Dragon Flatus

February 24, 2012 at 12:28pm

The Year of the Dragon is off to a very blazing start in terms of juicy news and scandals. For once, Singapore may be outdoing our neighbours to the north on this front. Of course, local healthcare cannot be seen to be left out on the cold either. We have our fair share of dragon flatus, some of harmlessly odorous, while others are plain noxious.

Let’s start with the harmlessly odorous – the case of the new Parkway hospital located at Novena, just a few metres away from the Ministry of Home Affairs (which some wise guy has quipped should be renamed simply as Ministry of Affairs) headquarters. Controversy has erupted with it being renamed as Mount Elizabeth Hospital@Novena. Some doctors in the Mount Elizabeth@Mount Elizabeth are unhappy with this and are even considering taking legal action. This Hobbit thinks this is unnecessary. In fact given the exodus of specialists from the public sector (which the Lianhe Zaobao in a recent report has wisely attributed to the residency programme, among other things) as well as this naming precedent set, we can have a slew of new names for existing private hospitals: TTSH GS@Mount Elizabeth, KKH@Thomson, SGH Colorectal@Adam et Paragon etc. The possibilities are endless. We can even have a facility called Nobody@Residency in time to come.

More on the residency. It has come to light that some poor ASTs (Advanced Specialty Trainees aka Registrars aka Always Screwed Trainees) and BSTs (Basic Specialty Trainees aka Basically Screwed Trainees) are now forced to pay for and take Residency-related exams. The reason is that by making them pay, they will try their level best to pass the exams. Also, there is claim that they need to take these American exams because the UK exams have changed so much they are no longer good. This logic is astounding. It’s like making a GCE “A” Level student pay for IB exams so that they have a vested interest in passing the IB Exams. Or getting motorists to pay ERP charges even when they have chosen a route from Point A to Point B that hasn’t got any ERP gantries. Or charging hotel guests for room service they didn’t order so that they will order room service anyway. I believe if this was the commercial world where common sense and the law applied, it’s illegal. You cannot charge a person for a good or service he doesn’t need or want. And the geniuses who came up with this really believe that the UK exams aren’t good enough, that’s just too bad. You don’t change things mid-stream and make people pay for it. It’s not the money, it’s the principle. Can you imagine Ministry of Education telling students and parents “Hey, we let you enroll in the GCE system but now it’s not good enough. So now, you have to pay for the IB exams so that you will try to pass it and at the same time, you still have to pass the A levels?” If you messed up by offering a system that is now not good enough, that’s your business. Don’t mess with people in mid-stream. And people only pay for and take exams out of their pockets because they are relevant. Making them pay for the exams matters little to outcome if the exams are irrelevant. In any case, these BSTs and ASTs are already given a raw deal – they have to train junior residents and have heavier workloads to cover up for the residency system. Please don’t make it any worse

More disturbing is actually how much hands-on will these residents get. My old Professor of Surgery (arguably the most respected clinical teacher for Surgery in the last 30 years) said quietly to me that he was deeply troubled. He said residents only got to perform simple operations like hemorrhiodectomy as a Year 3 resident and they become qualified specialist surgeons after Year 4 residency! This professor is of the age that he probably won’t ever be operated on by a product of the residency programme. But there is no escape for the rest of us. I think chaps who are promoting the residency programme as a wonderful thing should stand up and be counted and state that they will only be operated on by surgeons who are trained in the residency system. Put your liver/gall bladder/stomach/colon/rectum where your mouth is. That’s intellectual honesty. In case you are wondering, this Hobbit has nothing against residents- these are poor chaps stuck in a situation that offers no way out besides quitting. They are stuck as victims of a cruel monopoly introduced by people with motives best known to themselves.

As you are well aware, the SMC has given us a nice New Year present by announcing on 4 Jan 2012 it is raising our annual subscription fees from $300 to $400, because it has been under-recovering and operating at deficit. These are seemingly standard and plausible reasons. For one thing, although SMC is run on our subscriptions, the accounts have never been shown in the SMC Annual Report. There is almost complete opaqueness in terms of SMC’s financial situation to the countless and nameless doctors working on the ground and paying subscriptions to keep SMC afloat.

There are two main functions of the SMC – maintaining a registry of doctors (including CME records) and the costs of running investigations and disciplinary actions against allegedly errant doctors.

We shall start with the first – maintaining a registry. Anyone who has run something similar to a registry or an association or a club will tell you that it’s all about scale. Except for initial processing costs, unit costs drop dramatically when the size of the membership increases rapidly. And considering that the number of doctors registered in SMC has increased dramatically in the last 6 years, one wonders how come costs have actually gone up for each member. In Dec 2005, when fees were last raised, there were 6748 doctors on full or conditional registrations. Be end of 2010, this number has increased to about 8600, an increase 27%, according the relevant SMC Annual Reports. By now the figure should be about 30%. That’s a lot of doctors in 6 years and a lot of fees paid. Maybe the SMC should why briefly explain why the principle of economy of scale doesn’t apply to the SMC registry.

The next big SMC function is that of investigations and disciplinary actions. We don’t have access to SMC records in this area but this Hobbit will hazard a guess that the biggest “customer” of SMC is actually MOH – in other words, MOH is the biggest referral source of cases to SMC. Some of these cases are obviously necessary and the doctor gets disciplined. But one must wonder – how many of these cases could have been unnecessary, in which the doctor is found not guilty? While SMC funds should be used to fund to process complaints from individuals, one must ask should these funds be used to fund complaints from MOH, especially when MOH is so well-funded? Shouldn’t MOH share the costs of such cases, especially for the ones when doctors are not found guilty?

Lastly, we really have to look at SMC operating costs. Especially at manpower, which probably forms the largest chunk of costs. One example will illuminate this concern.

There are now two executive secretaries in SMC- (link: http://www.sgdi.gov.sg/; accessed on 24 Feb 2012). Executive Secretaries are very senior doctors and they do not come cheap. Let us look at Section 10 of the MRA – “The Medical Council may appoint an executive secretary and such other employees on such terms and conditions as the Medical Council may determine”. That means Section 10 of the MRA states there is only ONE executive secretary at any one time, together with an indeterminate number of other staff. Let’s leave it to Attorney General’s Chambers to advise on the legality of this arrangement of having two executive secretaries since we doctors know nuts about such legal stuff and also the AG Chambers is the government’s legal advisors, but surely this duplication of posts and manpower must lead to increase in costs? Why have two when the law provides for one? No doubt the bureaucrats in MOH will advise the politicians to amend the MRA on this aspect and it will probably be done, but the point is, who is really looking at costs?

In case you are wondering if “a” or “an” can mean more than one – Let’s look at the law again – the Medical Registration Act (MRA) that provides for the existence of SMC. Section 18 (1) and (2) of the Act states that “For the purposes of this Act, there shall be a Registrar of the Medical Council. The Director of Medical Services shall be the Registrar of the Medical Council”

That means there is ONE DMS and ONE Registrar at any one time and they are one and the same person. Of course, there can be an Acting DMS or Registrar when the DMS is on leave etc. But at any one time, there is only one person holding (and presumably paid for) the two jobs on a long-term basis. In this case, it’s our very esteemed and well-loved Prof K Satku. No one has any problems here with this arrangement or assumes there can be more than one Registrar or one DMS, this Hobbit included. So how can it be that there are two executive secretaries? By the way, if you do go to the online government directory (as given above), in addition to 2 executive secretaries, there are about 36 other staff that of executive level and higher, including one legal counsel. That’s some serious manpower there.

This is enough flatus already for 400 bucks. It’s getting kind of hard to breathe in our little shire hut. Gotta go out and get some fresh air. Bye for now.

Lessons from 2011 for the New Year

January 2, 2012 at 8:08pm

2011 was a tough year for the medical profession. Legal and ethical precedents were set which made the environment more difficult for doctors. Eventually this will impact on patients negatively as well. There were no winners in the long run. As we go into 2012, let’s look back and take stock of the lessons 2011 offered. It’s not a pretty sight, but we have to face reality. These are the lessons and values others are foisting on us. The younger doctors especially will probably easily come to accept these values as accepted and established norms of medical practice even as we old coots adapt to these – the “new normal” of healthcare

Lesson #1

It’s better to decide on the specialty before you graduate (if not why offer the option at all?).– What those big-shots say – it’s only an opportunity for you to apply, you don’t have to apply for a residency before graduating if you are not sure of what you want and you can take your time – once you know what’s happening on the ground, you would know this argument is all rubbish and devoid of intellectual integrity. Take-home message – Kiasu-ism pays. If you choose later, all the places in the popular specialties may have been taken up. You also don’t want to be the non-resident doing all the unwanted postings (or even if you are working in the same posting as residents – to end up working harder than residents).

Lesson #2

It’s OK for residents to work less than non-residents. Take-home message – Those that are given more will be given even more. Again, the lesson is – be a resident! And be one fast! But should you end up in a specialty you don’t like, tough luck.

Lesson #3

If you have exceeded your workload limit as a resident, do not log-in the additional cases or hours worked. It’s OK to lie to the training auditors. After all, telling the truth may get your whole department into trouble. Take-home message – don’t rock the boat, and to hell with honesty

Lesson #4

Signed consent is not good enough, even when the patient actually gave consent after two consultations and had a cooling off period before the operation. Take-home message – maybe it’s advisable to make an audio recording of your consent taking with the patient. Basically, you can’t trust your patient not to screw you royally later on.

Lesson #5

It’s OK to reveal residents’ names even when guilt is not proven. Take-home message – the days of your boss covering for you and taking the bullet for you, the junior guy, are OVER.

Lesson #6

Consultants have to review patients in person and you cannot trust your residents to make a clinical judgment. Take-home message – there is no team-based responsibility in reality even if the big-shots pay lip-service to promoting team-based practice. Better go into private practice when workloads are lower and you can do everything yourself and don’t have to trust junior doctors. Also, when in any doubt, cover your gluteus – order a CT scan/MRI etc.

Lesson #7

CMBs and Division Chairmen going into private practice. Take home lesson – do your own career planning, if even the CMB or Div Chair hasn’t got a life in the public sector after being CMB, you certainly don’t have one in the public sector either

Lesson #8

As long as you tell the patients beforehand and they agree, there is no such thing as overcharging. Take home message – Free market fundamentalism triumphs over professional ethics.

Lesson #9

When a patient/family member is unhappy with a SMC verdict, he can always appeal to the Minister to re-open the case with SMC. There is a significant chance the Minister will ask SMC to re-open the case and the doctor then be found guilty by a second panel. Take-home message – patients have multiple bites of the cherry including SMC, appeal to Minister, appeal to courts, civil suits etc.

Lesson #10

SMC wants to know sensitive stuff about you – Be careful about your past – e.g. whether if you have ever seen a psychiatrist. And then there can be an abrupt change of mind with SMC. Take home message – flip flops are possible with SMC. Hold on tight for the roller coaster ride. And even if we welcome the change in mind from SMC, one must wonder, what was the thinking behind the initial act of even asking all those strange questions in the first place?

In Summary

They may say they want to promote stuff like doctor-patient relationship, team-based care etc but actual incidents seem to suggest otherwise. All these stuff require trust – trust between doctors and trust between patients and doctors. But people in power don’t seem to understand that. Or maybe they do, but they rather not stick their necks out to foster such an environment of trust. It’s easier to hang a chap than to stick out for someone, that’s for sure.

So we have to distinguish politically-correct hype from harsh reality. As a doctor, trust no one. You can’t trust your boss or the hospital administration, and you certainly can’t trust your junior doctors. You cannot depend on SMC for consistency and you certainly can’t trust your patient. Better look out for yourself more, even if it means being defensive in your practice. To quote former Intel boss Andrew Grove – “Only the paranoid survive”

2011 may well be remembered as the year trust quietly died in Singapore healthcare. Welcome 2012…

Residency Thanksgiving Turkey

November 4, 2011 at 2:26pm

Thanksgiving Time

As you read this, it’s near the end of the year and the holiday season is again upon us. Time flies. As with all things healthcare in Singapore recently (like Duke, JCI, Residency and Board Exams, the Hobbit goes American and celebrates Thanksgiving. For a start, here’s a recipe for a good Residency Thanksgiving Turkey:

Residency Turkey

One 7kg turkey, preferably caught from around College Road and slain by brute force with the bare hands of a simple-minded orthopaedic surgeon. If not, then get a frozen one imported from America that is suitably defrosted with naivety and bewilderment. Whatever the case, remember – remove the brain, heart and guts COMPLETELY! If not, this recipe will NOT work.

Seasoning

Juice of 2 BIG Singapore lemons

5 tablespoons of stupidity

5 tablespoons of single-mindedness and myopia

One cup of deafness

One cup of blindness

Stuffing

Mixed the following:

One cup of hubris

One cup of white flour (Made from pure American Wheat)

Common Sense, boiled for 2 hrs, cooled, peeled and then finely chopped

National Pride – pounded violently and minced to paste

A finger of Local Tradition, grated to a fine dust

A sprig of parsley

One carrot finely chopped

One onion diced

Salt and Pepper to taste

Gravy

A sprig of acceptance

A stem of blissful ignorance

3 tablespoons of cornstarch

2 cups of water

Salt and Pepper to Taste

Instructions<p> </p>

Clean turkey. Remember to remove guts completely. Squeeze juice of two big Singapore lemons into cavity. Season skin and cavity with stupidity, single-mindedness and myopia. Stand for 30 minutes to soften muscle. Rub deafness and blindness onto skin and cavity liberally. Stand in roasting dish for 3 hrs in the DARK. This is to ensure that when the bird is cooked, it is soft, compliant, tasty and quite divorced from reality.

Stuff Turkey with Stuffing. Close neck cavity and tail openings with string (not Prolene sutures, you idiot!).

Line roasting pan with lots of grease, preferably from Chicago or North Carolina. Roast Turkey in pan (breast-side down, to restrain/contain national pride). For a 7kg turkey, 200C (or 400F, for the residents familiar with the American way of measuring things) for the first 30 minutes, then reduce to 175C (or 350F) for 2 hours, then reduce to 110C (225F) for next hour to hour and a half. Then raise temperature to 260C (500F) for 5 minutes to brown skin.

Remove bird to cool. Collect Oil and drippings into saucepan, add cornstarch and other gravy ingredients, flavor (Not “flavour”) with ignorance and acceptance. Bring to a boil and over low heat, reduce to a suitable opaque consistency.

Note – Residency Turkey usually tastes better when carved by senior medical administrators on footstools (never both feet on the ground). So do invite them for your next Thanksgiving Dinner!

Things to give thanks for over the Residency Turkey Dinner

We give thanks for

The fact that, like their American counterparts, our house officers (or R1) can only work continuously for 16 hours (i.e. no more over-night calls) and other residents will be entitled to 5 hours of uninterrupted sleep. They can only clerk several cases a day on call. In other words, they will probably stop work at 3pm when their quota is filled up.

And for all this, they will not get a pay-cut

We also give thanks that somehow with the residency programme, productivity and efficiency will seemingly be unaffected and healthcare costs will not go up, even though USA spends 16% of their GDP on healthcare and we spend 4%. Presumably, consultants can pick up the slack for free.

Finally, we also give thanks to the British training system that had more or less served us well but can now rest in peace.

Footnote: This article was actually written one year ago and submitted to SMA News but never published. Now published on FB – One-up for social media.

GPs and Primary Care: Today and Tomorrow

October 7, 2011 at 7:01pm

Today is the eve of tomorrow. Tomorrow 8 Oct 2011 will be an important day for GPs and primary care in Singapore. Hand to heart, I wish the best for the new Minister for Health tomorrow.

After tomorrow, we will know if the MOH will truly embark on renewal and rejuvenation of primary care in Singapore. Or, if it’s another round of GP engagement which like previous rounds, have promised much, but delivered little on the ground.

The event held tomorrow in MBS underlines the intent of MOH under the new Minister to bet heavily on primary care, and private GPs in general to address the healthcare needs of Singapore. He is right to say we cannot go on building more and more general hospitals. This hobbit reckons, each subsidised bed in a general hospital requires about $100,000 of subsidies to run a year. Each subsidized bed put into use is in effect an expensive commitment. The SOCs are also expensive to run as well. And it is plain for all to see that the public system is way overworked.

We need primary care to deliver the goods and deliver quickly it must. This must fall largely on the private GPs which constitute the lion’s share of primary care in Singapore. But to do so, we need to step out of certain psychological straitjackets and slay certain sacred cows. Let’s see what some of them are:

A Great Plan or Policy is One that Practically Eliminates the Possibility of Abuse of Subsidies and Medisave.

This great psychological straitjacket has really been one of the factors that has greatly hindered previous attempts to involve the private GP in tackling chronic diseases in a big way. Because of the lack of trust and the fear of abuse by policymakers, previous attempts involved many rules and reporting that were too burdensome and complicated for mass adoption by GPs on the ground.

If we want to do something that involves the masses, then some degree of abuse will be take place. By all means, reduce the abuse as much as practically possible, but recognize that the end is to get decent care delivered to many people by the GPs; the end is not to eliminate abuse. Indeed, the cost of eliminating abuse may far outweigh the benefits of mass adoption of a system. The police will tell you that there are compromises to be made even in tackling crime. The police has to tolerate and accept that there is an “ambient” level of petty crime that exists in a community while they practice a no-tolerance policy on major and violent crime. But the aim of eliminating all crime, whether petty or major, is impossible as the costs of implementing such an approach are prohibitively high.

So, hopefully, with whatever new policy that is going to be put in place or olds ones such as PCPS that will be broadened and enhanced, I hope the bean counters cut the GPs some slack so that the system is not stuck in bureaucratic gridlock because they want to eliminate abuse.

The Need for Accountability through Immediate Data Collection and Measurement of Improvement.

This is a corollary of the first sacred cow – which is elimination of all abuse. It is true that for every public dollar spent, there must be some accountability. And the default mode seems to be that accountability is best evidenced by showing some improvement. Hence the need to capture all kinds of data to facilitate the measurement of improvement, if any. And it seems the data must be collected repeatedly and in real-time.

Unfortunately, this is not one of the private GPs highest priorities. The GP’s highest priority is to treat his patients well so that he keeps his patients and gets new patients to support a viable practice.

There are certain simple age-old adages we should remember when we approach this data collection business:

Never collect data you don’t use. Many folks collect data just so they can sleep soundly at night. They may never look at the data later on.
There is a cost to collection of data, which is so far, never explicitly stated in the use of subsidies or when Medisave is used. The GPs know this but somehow every policy so far doesn’t recognize this. 5 minutes of data entry is equivalent to about $10 of lost professional fees to a GP.
Never force someone to adopt an IT system for your convenience or for control. Unless you are paying him an arm and a leg to do so. This is because it will cost the GP a lot of pain probably akin to an amputation for him to move out of his system to yours. In other words, it will not happen.
You can always collect data later. This is why the case-control study was invented.

People Have Short Memories.

A wise lady once told me – Never make people unhappy if you can’t make them happy.

The GPs are a very confused lot. On one hand, MOH and its agencies keep wanting to engage them. On the other hand, MOH also keeps making life tougher for them through ever tighter regulation. For example, the introduction of the Family Register is supposed to be a happy event, but somehow along the way, it has become controversial because of the issue of the use of the word “family”. Many clinics will have to change their names because of this unnecessarily puritanical approach to the idea of differentiating a family physician from other GPs. The new CFPS President has also said as much in the latest issue of the College Mirror. In the same breath, the GPs are told they are important people and GPs need to be engaged. Another case in point is the statutory requirement to stock 2 weeks of PPEs at GP’s own cost.

The GPs are receiving too many conflicting signals from the powers that are. And the natural response to these conflicting signals ranges from indifference to cynicism. You may think you can get their cooperation now by giving them a goodie or two when you had just inflicted pain on them a while ago because people have short memories. That’s wishful thinking. Especially when it comes to doctors. You don’t graduate from medical school by having lousy memory.

Define the Role of the Polyclinics

At the risk of irritating my polyclinic colleagues, I will say this again – what is the role of the polyclinics? Are they supposed to provide cheap and good-enough care to the poor, or they are to be centres of excellence in primary care or both? If it’s both, then its about time the polyclinics adopt a classed system like the restructured hospital or to introduce means testing. The current FP clinics are still subsidized. If not, we have to recognize that polyclinics giving more and better and subsidized care will stifle the development of the GP sector. Good enough care is different from being excellent.

The Way Ahead for Training of Family Physicians: Residency?

Good training will ensure that the future of primary care is bright.

Family Medicine is highly contextualized and based on local factors. It is very different, say from “harder” disciplines such as Pathology or Radiology or even Anaethesiology. A Chest Xray is a Chest Xray, whether reported in Singapore or Sweden. But family medicine is different. The practice of family medicine is based on contextual factors peculiar to the local cultural, socio, economic and health system factors. A family medicine practice in Singapore is quite different that say in USA. For example, in USA, it is common practice for a GP to see his patient in the hospital after the patient had been admitted. In other places, it is common also for a GP to practice some obstetrics. This is rarely, if ever done now in Singapore.

The next thing to note is that the training of family physicians has evolved largely as a community effort over the years by many people working tirelessly in CFPS. The large public institutions came into the act later. Even now, for example, the number of GDFM enrollees outnumber the M.Med enrollees to the tune of about 4 to 1 each year. So while we need to focus on developing family medicine professors and institution leaders through the M.Med or residency route, the greater impact to society will lie from the products of the GDFM system.

For years, the GDFM route has coexisted well with the M.Med system. But with the forced adoption of the USA ACGME-I system, the equilibrium is disrupted.

Firstly, the residency system will produce even fewer family physicians than the M.Med system. It is essentially a high-resource, low volume system. It is a system of training that our polyclinic and GP system cannot afford, especially in the face of higher patient loads and more complex casemix in the polyclinics and hospitals.
Secondly, it does not take into account local factors – which is why it demands that family medicine residents must visit inpatients and that each resident must be provided with two rooms or that first year residents are limited to seeing two patients an hour (no typo here!). This is also why our training centres were only given a one-year accreditation by ACGME-I instead of full accreditation: we are not Americans and hence we cannot meet their requirements. The family medicine delivery and training systems of USA and Singapore are different.
Thirdly, a system should ensure clinical competence. The residency system does not have an exit clinical exam. Is it any wonder there is talk that the FRACGP will not recognize the products of the residency system even though it recognizes the M.Med(FM) we now offer?
Fourthly, the residency is institution based and there is a lot of duplication of resources in setting up of different training centres in NUH, Singhealth Polyclinics and NHGP. Ultimately, this sucking up of resources will affect the GDFM and undergraduate teaching programs. There are only so many teachers. There are signs that for example, many teachers can no longer participate as much in GDFM teaching as before because of residency responsibilities. But again, we need to prioritise – will GDFM have a greater impact on primary care delivery than residency or the way around?

We can go on and on about why the ACGME-I residency system is a poor fit for us. But to summarise- what Singapore family medicine training needs is a system that is efficient and capable of mass deployment, and relevant to local factors and needs. The USA ACGME-I system is inferior in all these three aspects to the current system we have so arduously developed over the years and in which now we are tragically dismantling. We should have evolved our current system to a Singapore-type of residency which is relevant to our needs. But instead, we have imported a foreign system which seems to undergoing a host versus graft reaction.

We train for the future and with the ACGME-I residency system, this Hobbit does not think the future of family medicine is bright.

Managed Care can be Left Unregulated

Managed Care is part and parcel of most GP practices now. For some strange reason or other, while possibly every aspect of healthcare has seen tightening of regulation in the last decade of so, three aspects of healthcare have escaped this fate: fee-charging, medical advertising and managed care. And these three aspects have probably contributed in no small way to the over-commericialisation of medicine that we have seen in the last few years.

Managed care is basically free-for-all now. Managed care companies range from $2 companies to multi-billion dollar insurance companies. Managed care affects GPs more than specialists. As we all know, through subtle practices or otherwise, managed care companies tend to cherry-pick and influence participating GPs to shift the more complex work to the public hospitals and polyclinics. And yet, managed care companies are not regulated as healthcare entities like healthcare professionals, facilities or medicines even though they can impact greatly on healthcare delivery. It’s almost like benign neglect and with things proceeding the way they are, very soon it will be malignant neglect. Either that or it almost seems managed care has been given some form of divine dispensation from regulation.

Currently, most GPs can live with this because with a fast growing population, there is enough low-brow work to keep GPs alive, even if the public system is unnecessarily burdened. But the fact remains that GPs can do more and if we really want to develop GPs capabilities to do more so as to relieve the overworked public system, Managed care has to be regulated.

So this is Primary Care today as the Hobbit sees it. Will there be a better tomorrow?

Epilogue?: Questions and More Questions

October 4, 2011 at 1:25pm

Dear Hobbit

I am relieved. More relieved than holding my pee in for 4 hours while stuck on a coach on the Causeway and then finally letting go at the WC. Just when I thought I had made untrue declarations and my wife will find out about my enuresis problems, SMC now says some of the questions were inappropriate. The feeling is indescribably shiok….like a relaxed and emptied bladder…..

Thanks again for your advice.

I can now consult my psychiatrist friend again without fear – asking him if I should get a SUV or a MPV for my next car…

Yours gratefully,

Dr Tjio Pee Wee

p.s. You cannot have my favourite Ultraman toy. But I will pass you my old Seow Lang Geng baju, now collector’s item. On the way by UPeeAss courier to Middle-earth

Questions and More Questi0ns

October 2, 2011 at 3:46pm

Being a writer is tough. Let’s face it, inspiration doesn’t quite come simply all the time on tap like water or draft beer. Every writer goes through bouts of writer’s block. I was having one for the last couple of weeks. But just when I was vexing over what to write and wondering if I have lost my writing mojo or if the world has finally sorted itself out, the ever reliable SMC has come to the rescue of this hobbit again.

The latest letter from SMC on “Application for Renewal of Practising Certificate” to all doctors contained quite a few really tough questions that were never seen before and it’s no surprise that many doctors are confused/upset/constipated by these new questions.

I recently spoke to a SMC member and even he was seeing these new questions for the first time. Obviously the “new normal” of politics, policy and consultation hasn’t quite reached the folks running SMC yet.

Anyway, alert reader of this column, Dr Tjio Pee Wee has written in for advice. We reproduce his letter here, sans expletives and grammatical mistakes.

Letter from Dr Tjio Pee Wee

Dear Hobbit

I have just filed my application to renew my practicing certificate. I am now in deep, deeper and deepest trouble. (Original letter contained the phrase “cheam, cheamer and cheamest trouble”)

I am in deep trouble because I had carelessly ticked the “No” box in all six questions, not realizing the last question (i.e. Question 4) should be ticked “yes” when you do not owe the SMC any money. Yes, it’s my fault, I had fallen prey to the oldest trick in the MCQ business, that of not reading every question carefully and looking out for that old trick of putting in a question that should be answered “yes” after a slew of questions that should have been answered “No”.

I am in deeper trouble because of Question 3a, because while I have never been convicted of any investigation, I have been the subject of an inquiry. I think it was 25 years ago and I was a MO in psychiatry posting and some mad guy with a frontal lobe problem complained that I had assaulted his mother, stole his hospital baju and slept with his Hello Kitty toy. The psychiatric hospital conducted an inquiry into me and of course found his allegations to be baseless, especially when the hospital found that the patient’s mother had been dead for many years and that I slept usually with my Ultraman toy and it was the patient in the next bed (not me) that was sleeping with his Hello Kitty toy. He even tried feeding the toy hospital food in a vain attempt to pry open its non-existent lips…..he eventually borrowed lipstick from a female nurse and drew lips on it…..Lastly, and most importantly, of course everyone knows a doctor only steals doctor’s baju, never the patient ones…..

I had forgotten all this until now. I realise I had made a false declaration because at the time of my posting in this particular psychiatric hospital, the hospital was not restructured yet and it was a government hospital and a department under the ministry of health. In other words, it can be construed to be “an authority” as the hospital was run by government officers. Do I now have to report this episode in my latest SMC declaration?

In addition, I have been accused of overcharging in 2001 because I charged my patient $50 for a housecall requested by this patient. I understand this difficult patient wrote to the SMA Complaints Committee which decided my charging was entirely appropriate. Is SMA considered a “professional body” and hence, do I have to declare this as well?

Finally, I am in the deepest trouble because I have a deep dark secret which even my wife doesn’t know about. You see, when I was a kid, I used to wet my bed. This continued till I was in primary school. My parents were rather distressed and brought me to see the family doctor. The family doctor reassured my parents that I would grow out of it. But my mother would not be persuaded and brought me to the specialists. The specialist included a urologist and (sigh) a paediatric psychiatrist. So now, do I tick “Yes” to question 3c – Have you ever consulted a psychiatrist or are you currently undergoing psychiatric treatment?

This is driving me nuts. I have not wet my bed since I was eight years-old and even my wife doesn’t know about this. Do I have to tell SMC? This is deeply personal, embarrassing and irrelevant to my medical practice now. I may start bedwetting myself again with all this stress.

Please advise me, dear Hobbit!!!

Hobbit’s Advice

Dear Dr Tjio Pee Wee

Please do not worry about ticking the wrong box in para. 4 on money owed to SMC. First of all, no matter what you tick, civil servants always behave like you owe them money. Besides, at the rate SMC processes cases, it may be quite a few years before they get to you. By that time, you may well have retired

As to your second problem – You should report to SMC on the inquiry by the authorities and civil servants- mainly because you did steal the doctor’s baju, you bloody idiot. As to the complaint on overcharging made to SMA, don’t worry, I was told that some powerful but misguided soul has always thought that SMA is nothing more than a “trade association” and not a professional body. So you should be OK if you keep quiet on this.

As to your enuresis problem when you were a kid and your wife not knowing- I don’t think your wife will respect or love you any less if she knew you wetted your bed when you were 7 – Unless you are still sleeping with your Ultraman toy now.

I hope this helps.

Yours Shortly,

The SMA Hobbit

p.s. – can I have the Ultraman toy? Thanks!

Anyway, since SMC has added so many new questions to go with the renewal of practicing certificate application, let us be constructive. The Hobbit would like to suggest a few more questions for the administrators running SMC to consider –

Possible Additional Questions for Doctors

Have you ever harboured evil or impure thoughts against any SMC member, or the Registrar or Secretary of SMC?
Did you do your National Service in a military camp or in a laboratory?
Have you ever visited (accidentally or otherwise) any Internet pornographic websites?
Do you think we should introduce similar questions for lawyers, nurses, accountants and pharmacists when they renew their practicing certificates as well as to potential Elected Presidency candidates when these candidates apply for Certificates of Eligibility?

Possible Additional Questions to SMC

On the other hand, even as SMC introduces a plethora of questions, I think we, registered medical practitioners should also be entitled to ask the chaps running SMC a few questions, such as

Do you know what is the “new normal” in politics, government and policy implementation?
Have you heard of the subject of “questionnaire design” and “user-testing” before you threw up all these new questions for every doctor to answer?
Even though we know you know that you are empowered by the Medical Registration Act to do many things, do you have a clue what is “Stakeholder Engagement and Consultation” before shoving new stuff down our throats, such as these new questions?
Can you spell H-I-G-H – H-A-N-D-E-D?
Why do you need all these new questions when doctors treating doctors are already statutorily bound to report to the Health Committee of SMC if they think their patients (i.e. doctors) are possibly incapable of medical practice?
SMC is a statutory body “self-funded” by doctors’ license fees and MOH has a budget of billions. How is it that the biggest user of/complainant to SMC is MOH and MOH doesn’t pay practically anything to SMC to use SMC services? Do you or do you not consider this to be an utter irony?

For the avoidance of doubt, the SMA Hobbit advises all doctors registered with SMC to answer all those questions truthfully and to send in your application for renewal of practising certificates before the closing date.

Vote Ah Bock!!!!

August 24, 2011 at 11:00pm

Vote Ah Bock!

I say don’t just talk, vote Ah Bock

He can really jaga our reserves and be the second key and lock

His tree very big, not scared even when lightning forks

He said his piece on foreign talent and got mocked

I say don’t just talk, vote Ah Bock

That’s not because I own Chuan Hup stock

A man of principle, he believes – in politics no cincalok or belly pork

That’s why many times he stood his ground then kena knock

I say don’t just talk, vote Ah Bock

Just like last time in APMPS, he still rocks

He will get those fat cats to pull up their socks

Stop those guys from talking cock. Go Ah Bock, give them a shock!

Please note –

The SMA Hobbit is mythical in nature and has no right to vote in Singapore. So his support is quite virtual at best.
The Hobbit is also apolitical and is not affiliated to any political party.
This note does not in any way represent an endorsement by SMA Council or SMA News of Dr Tan Cheng Bock
APMPS – Association of Private Medical Practitioners of Singapore – merged with SMA about 20 years ago

Prof Tan Ser Kiat for Elected President (expanded version)

August 10, 2011 at 5:13pm

There is a time when your country needs you. To preserve and protect your countrymen from the tyrannies of disunity, fear and oppression. To battle evil, envy and aggression.

Oops. Wrong subject. We are not talking about Captain America, Thor or Hal Jordan and his ring shooting out green goo.

We are of course talking about the Elected Presidency and the President’s role to safeguard our country’s reserves; approve key government appointments which surprisingly does not include the Director of Medical Services (sigh); and, according to a speech given by the honorable Law Minister, to perform all public acts (including giving public speeches) according to the advice of the Cabinet which the Elected President is obliged to follow and cannot reject, except for powers specifically vested in the office of the Elected President. [1]

Now the Hobbit understands why we need to be careful about how we choose our Elected President and why he needs a relatively big paycheck. It is obligated that the poor chap does everything publicly on the advice of the Cabinet, advice which cannot be rejected. That’s a real tough job. I may be wrong but I think some SAF recruits in Tekong, apprentice sushi chefs in Ginza or adolescent orcs in Mordor may have more liberties publicly than the Elected President.

This recent Presidential race has thrown up several interesting if not exciting candidates. I think the field can be widened to include another doctor as well, other than the well-known six-term MP and SMA Honorary Member Dr Tan Cheng Bock.

The Hobbit thinks the very respected Prof Tan Ser Kiat should run for the elected presidency as well for the following compelling reasons:

He has run SingHealth for some 11 years as Group CEO – which owns SGH, KKH, CGH, several national centres and many polyclinics – surely that must be >100M in terms of paid up capital
He’s older than 45
He is a “Tan”, like Dr Tony Tan, Dr Tan Cheng Bock, Tan Kim Lian and Tan Jee Say
He is from RI – like Dr Tan Cheng Bock, Tan Kim Lian and Tan Jee Say
It’s been a long time since we had a doctor for President – 30 years to be exact, since the passing of President Sheares in 1981
It’s a money-saving President – all the government offices only need ONE photo and not two. On top of that, he doesn’t need an accompanying physician to follow him when he makes overseas trips – he can heal himself.
He’s already got one hospital named after him – Sengkang General Hospital (i.e. SKGH)
He doesn’t have worry about his political adversaries raising questions about his son’s NS record
Salma Khalik can hopefully finally leave the health beat and move on to do the Istana beat in The Straits Times.
No more bad Hokkien jokes about insane canines from Prof Tan’s old classmates and colleagues

One wise guy suggested to me in my original facebook note that it is not a good thing to have only Prof SK Tan’s photograph alone in government offices. It’s kind of lonely being so. That’s not really a problem. Since Prof Tan is an orthopaedic surgeon in body, soul and spirit, this hobbit suggests that the accompany photograph would be that of a vertebral column. After all, he has a stiff spine to stand up to the Cabinet when the occasion requires. Note: it’s a whole vertebral column and not just the coccyx to sit through 6 years.

Yet another doctor who has been proffered as a possible candidate for the job of Elected President is Prof Chee Yam Cheng. But this Hobbit thinks Prof Chee is not quite as suitable as Prof Tan due to the following considerations:

He’s been Group CEO of NHG for less than 3 years
He looks like 44 although he is way more than 45 years old
He’s obviously not a “Tan”
He’s from (oh dear) ACS and not RI
He will make all civil servants wear a tie. What the heck, he will buy a tie for the civil servant who doesn’t (like what he did for his housemen and MOs)
All the Istana’s speechwriters will resign or commit suicide because if elected, Prof Chee’s public speeches will have an average of 54 words. The televised opening of Parliament will last only 40 seconds with no time for commercials.
His autobiography post-presidency will be longer than the Harry Potter series, Winston Churchill’s Nobel Prize-winning six-volume Second World War or past-PM Mr Lee Kuan Yew’s memoirs. Just look at Prof Chee’s voluminous writings on SARS in SMA News and you’ll get the picture
Like Prof Tan Ser Kiat, he can heal himself. But the problem is, if Prof Chee ever becomes Elected President, no doctor would want to be his personal physician. It would be like going through mock MRCP every two weeks. Imagine the Elected President Prof Chee looking at you with that look of his as you palpate his abdomen. Damn stressful…
Prof Chee is really quite politically incorrect in this day and age. Imagine how are the smart cookies in MOH promoting ACGME-I Residency going to explain to our final year medical students it’s perfectly OK to apply for a residency even before they take their MBBS finals when the Elected President decided on his choice of specialty ONLY after passing Part 1 of FRCS, MRCOG and MRCP.
Finally, Any hospital named after him will sound like it’s been donated by a famous tailor and Dr Tan Cheng Bock may just object again.

Finally some wise doctor actually suggested that this Hobbit run for President. That’s a very bad suggestion: –

This hobbit will look absolutely ridiculous reviewing the National Day Parade and especially when he walks down the line posted by Guard of Honour with the Chief of Defense Force. I haven’t learnt how to walk on stilts yet.
I have always (perhaps erroneously) thought that advice is discretionary, command is compelling. I have never taken a job whereby I cannot reject advice from someone who is not my boss. So being an elected president, whose job description includes being unable to reject the Cabinet’s advice (unless for powers specifically vested in the office of the elected presidency) is definitely not a job I want.

Anyway, Prof Tan, go for it!!!!!

[1] http://www.news.gov.sg/public/sgpc/en/media_releases/agencies/minlaw/speech/S-20110805-1/AttachmentPar/0/file/Speech%20by%20Minister%20for%20IPS%20Forum%20on%20EP%20-%20FINAL.pdf; accessed 8 Aug 2011

Prof Tan Ser Kiat for President

August 4, 2011 at 12:24am

The Hobbit thinks Prof Tan Ser Kiat should run for the elected presidency for the following compelling reasons:

a) He has run SingHealth for some 11 years as Group CEO – which owns SGH, KKH, CGH, several national centres and many polyclinics – surely that must be >100M in terms of paid up capital

b) He’s older than 45

c) He is a “Tan”, like Dr Tony Tan, Dr Tan Cheng Bock, Tan Kim Lian and Tan Jee Say

d) He is from RI – like Dr Tan Cheng Bock, Tan Kim Lian and Tan Jee Say

e) It’s been a long time since we had a doctor for President – 30 years to be exact, since President Sheares

f) Its a money-saving President – all the government offices only need ONE photo and not two

g) He’s already got one hospital named after him – Sengkang General Hospital (i.e. SKGH)

Go for it, Prof Tan!!!!

Doctors’ Day???

July 29, 2011 at 11:15am

It’s the time of the year when we celebrate Nurses’ Day again. And the President will give out the much anticipated President’s Nurse Awards to several nursing leaders each year on Nurses Day. In every hospital in Singapore there will much revelry and gaiety. Hospital administrators and doctors alike will have to demonstrate their affection for the nurses in some way or the other. These include serving food, singing a song or maybe swallowing a live cockroach (especially if Nurses Day falls near a JCI audit). Huge bouquets of flowers will be sent between each and every hospital. I have seen a hospital give out one stalk of rose to each and every nurse. This is no mean feat as some large hospitals have more than a thousand nurses.

Naturally, this begs the all important question, what on earth is the male nurse going to do with all the flowers and bouquets.? Instead of roses for male nurses, can we just give the guy a can of beer? Just kidding.

I don’t know, call me skeptical, my take is all this fanfare and gushing of goodwill on this one day every year is but an annual short-acting anaesthetic to the fact that nurses are still underpaid and overworked in the other 364 days. Of course, seeing Prof Chee Yam Cheng playing the piano may be balm that lasts more than a day but that is only once-off for TTSH.

So we have Nurses Day. We also have others like Teachers Day, SAF Day, Mothers’ Day, Fathers’ Day, Children’s Day, Youth Day, and maybe in the near future Harry Potter Day and Flood Day. This Hobbit thinks we should also have a Doctor’s Day. I hope respectfully the newly Elected President will take up my humble suggestion.

The reason for having a Doctor’s Day is obvious. It is to remind everyone that some doctors think they can make miracles and cure every father-mother-son like Harry, talk like teachers, behave like children, work like nurses, dress like youth and of course earn money like a tropical rainstorm flood.

What can we actually do to celebrate Doctors’ Day?

First, we can conduct an Unlucky Draw whereby the unlucky winner gets to be CMB for one day to see and understand actually how sucky a life of CMB is. The winner will get to sit in the CMB’s office for one day. In the morning, he will hear non-stop different doctors coming into his office to complain about poor pay, promotional prospects, lousy patients and the residency programme. In the afternoon, he can then try to feedback to the higher authorities his problems and of course the unlucky winner will either get no response or be criticized as being “not progressive”. Finally at 5pm, there will be a simulated incident whereby one of his heads of department comes in to hand in his resignation letter. Lunch is not provided, but his personal assistant for one day can buy a kopi and red bean bun from the hospital canteen for this unlucky winner (at the winner’s expense). If we are really going to have serious fun, we can even get this guy to give a talk to 200 doctors in the auditorium on why JCI audits and residency ACGME accreditation are necessary.

And then we can also have Singapore Doctor Idol where folks show off their talent. Possible items on show could include

A GP trying to do a liposuction on a guy with a BMI of 23
A residency program director trying to explain why his department fulfills ACGME’s requirements even when obviously everybody is working 101% everyday trying to clear the patient loads
A foreign trained surgeon who only speaks English trying to take informed consent in accordance with SMC’s standards (warning – long performance hours lasting >2hours)
Two very senior surgeons meeting after 30 years and dancing the tango till midnight

Next, similar to nurses, we can of course also have the President’s Award given to outstanding doctors for their outstanding contribution to medicine and health. Immediately, at least three possible candidates for the award come to mind:

The doctors on the disciplinary committee that set new standards for informed consent, specifically for purportedly running hearings from 2pm to 2am on a few days and on one occasion to 4am and for deciding that obtaining consent in a suboptimal place is a critical factor in deciding what is professional misconduct. Such dedication and prowess cannot be ignored, including the great ability to give and hear sound testimony, think clearly and decide fairly at around 2 to 4am. It is interesting to note that while most resident housemen (PGY-1) cannot work past midnight but DC can run till 4am, bearing in mind folks have been working since the morning (of the previous day). This hobbit stands in awe of the stamina and incisive thinking being displayed…

The doctor that was rumoured to have paid ~$6,000 per square feet for clinic space also deserves an award. After all, he has gone where no man has gone before and has showed that clinic space prices have joined the realm of other gravity-defying manifestations such as COE, Superman and push-up bras.

Finally, we should give the President’s Award to the doctor who decided Singapore should adopt the ACGME Residency system. He symbolizes what a great leader is all about, a man/woman who dares to go it alone, without prior consultation with the professional bodies/stakeholders and goes for a vision that many think is impossible to achieve. This sheer improbability and audacity of thought ranks up there with Singapore in World Cup – Goal 2010 vision, Mao Tse Tung’s Great Leap Forward and Dr Evil’s plan for world conquest in Austin Powers movies parts 1, 2 and 3.

And of course, as part of the pomp and pageantry of the Presidential Awards for outstanding doctors, we must get Chee Yam Cheng to play the piano again at the award-giving ceremony.