Part 2: About That $100,000 Fine For An Injection

The practice of medicine must evolve with the times, and is necessarily ever-changing. How we change the practice of medicine is heavily dependent on new evidence gleaned from scientific discoveries as well as subjective factors such as patient expectations and even doctor’s expectations. These are not necessarily bad things

But change in medicine is never ever a good thing when the change is driven mainly by a change in medico-legal climate. Especially when these changes are fueled by fear and anger, whether they may be on the patients’ part or from the doctors’ perspective.

As we all know, fear and anger are two of the most powerfully evocative emotions in the gamut of feelings that the human race can muster. Fear and anger are two emotions that are often used by populist and irresponsible politicians to get more votes in election campaigning. Fear and anger, together, has a life of its own and spreads like wildfire.

But this is exactly what doctors are experiencing now in Singapore in the wake of the $100,000 fine by SMC on Dr Lim Lian Arn. Fear which has led to anger which in turn is feeding the original fear.

On 30 Jan 19, SMC issued a public statement of clarification of case, stating that “Doctors are not expected to inform patients of all possible complications”. This is helpful. But it is not enough. Let this Hobbit elaborate. We need to directly address:

  • Fear and anger over what is expected of the doctor to obtain an effective informed consent
  • Fear and anger over the magnitude of the fine ($100,000)

Fear and anger over what is expected of the doctor to obtain an effective informed consent

In short, the laundry list described in the charge and the Grounds for Decision was perceived to be setting a new standard of care. Thankfully, the 30 January 19 Statement by SMC has addressed this by saying a doctor doesn’t have to inform his patients of all possible complications. But it does say that “however, the DT indicated that it would be good clinical practice to document in the case notes that a patient had been informed and was agreeable to the injection, a proposition which no doctor would reasonably disagree with……; the Decision merely reminds doctors that they should document the fact that they have explained the treatment or procedure and the patient’s consent”.

Questions from this (also reasonable) Hobbit for the genius who drafted this document:

  • Must I document every “treatment or procedure” that I had explained to the patient and that he had consented? Treatment includes simple stuff like prescribing drugs, CRIB (complete rest in bed) and applying dressings. Every time you remove a urinary catheter, chest tube or drain, it is a procedure (let alone inserting one).
  • How does a junior doctor in charge of say, half the ward (about 15 to 20 patients) do this and have time for lunch and go to the toilet? Remember, every drug is a treatment, and practically everything you do in a ward is a procedure other than bathing and feeding the patient and bringing the patient to the toilet.
  • Does the person who drafted this understand what resources it entails just to achieve his one landmark sentence of “the Decision merely reminds doctors that they should document the fact that they have explained the treatment or procedure and the patient’s consent”?

Essentially, there are three “Categories” of activities a doctor prescribes or performs in vast numbers every working day:

  1. Treatment and procedures that require written consent from the patient
  2. Treatment and procedures that require documentation of verbal medical advice and patient consent in the casenotes
  3. Treatment and procedures that do not require written consent or documentation

In the past, the vast majority of treatment and procedure belonged to the last Category. We don’t document that we had explained the possible complications of most simple procedures or drugs and that the patient had consented. Now it appears that the default option is Category 2 instead – we have to document almost everything.

Can someone in SMC have a discussion with the Ministry of Finance on how Singapore will fund the resources needed for this new level of documentation?

For the avoidance of doubt, this hobbit thinks a H&L injection should fall under Category 2. But most daily procedures and treatments actually should remain in Category 3 and not be pushed up to Category 2.

One should not make sweeping statements like “a proposition which no doctor would reasonably disagree with” unless one really understood the practice of medicine as it happens on the ground given the resources this country allocates to healthcare. This new standard of documentation may already have happened in Beverly Hills, California, but it doesn’t happen here often at all, and certainly not in the public healthcare system.

Experts and “Expertism”

Much has been said about the expert opinion in this case. The Complaints Committee (CC) and DT accepted the expert opinion of what is the standard of care to be applied. It has been said often that the CC and DT did not act without expert advice and opinion.

This hobbit believes:

  • The answers you get depends on the questions you ask
  • People behave differently when they are labelled as “experts”. They have to display behaviour befitting that of experts (I call this “expertism”).
  • The SMC DT should concern itself with what constitutes basic or minimal behaviour that can be considered as NOT being guilty of professional misconduct, and not apply standards of good or best practice in disciplinary proceedings.
  • The SMC lawyer should likewise concern itself with establishing that the doctor failed to meet minimal standards consistent with professional misconduct and NOT good or best practice

The laundry list of complications that appeared in the charge and the Grounds of Decision was that of good or best practice, but not minimal ethical standards. Were the experts asked to give minimal standards or good or best practice? Even if they were not so asked, did the experts feel inadvertently compelled to give good practice standards because they were asked as “experts” – i.e. they had to display “expertism” in their answers?

Perhaps, when next time an expert is consulted, it should be specifically stated he is being asked to give minimal standards, below which, the doctor should be considered to be guilty of professional misconduct.

We should take a leaf from licensing of healthcare institutions. MOH licenses healthcare institutions such as hospitals so that they can provide health services. These are minimal standards. If these hospitals want to do better, they can go for accreditation such as the JCI accreditation scheme. But the two are different and we should not conflate them. Licensing ensures a minimal standard, accreditation puts in place good or best practices. Similarly, doctors are licensed because they are fit to practice and they are fined or they have their practice license suspended or taken away because they fail to meet these minimal standards of ethics and competence, not for higher or aspirational standards.

Paradoxically, “expertism” is easier to put in place than setting of minimal standards. One doctor describes this as “Google Medicine”. An expert can search for the list of complications on the Internet and furnish it to SMC in a matter of minutes. It is actually more difficult to decide what are the minimal standards one must achieve to obtain and maintain licensing. A good comparison is that of a Head of Department assessing residents: It is easy to decide who are the good residents who regularly impress you, but it is difficult to decide whether you would want to sign up and pass a marginally or poorly performing resident or not.

Fear and anger over the magnitude of the fine of $100,000

In this hobbit’s first column on this matter, he failed to mention a very important fact – statutory fines, such as the $100,000 fine by SMC, are not covered by medical indemnity schemes. Whether the fine is $1000 or $100,000, the doctor has to pay the full amount to SMC. A $100,000 fine is painful for even the richest doctor in Singapore, but it is financially crippling to many junior doctors such as residents and junior specialists.

Don’t get me wrong, fines should be punitive in nature. That’s why they are fines and the threat of this fine drives a person to behave correctly. But when the amount is so large such that it becomes an existential threat to the professional and the risk-reward ratio doesn’t makes sense to the professional, then a different type of behavior ensues.

In a market economy like ours, what options does any rational person do when he is faced with a financial penalty that is so large it becomes an existential threat? Let’s take the H&L injection as an example –

  1. He tries to insure it away. As aforesaid, this is impossible, and he has to pay the fine out of his pocket
  2. He tries to price-in the risk. The correct risk premium is probably out of reach of at least 70% to 80% of Singaporeans. For doctors in the public sector, they have no pricing power, because prices are set by the hospital or polyclinic administrators and doctors are paid a fixed salary and not paid for office procedures. The only people who can price in the risk and who have patients who are willing to pay the risk premium risk are the private specialists, who probably only serve the top 20 to 30% of Singaporeans. H&L injections will continue to be offered in this limited segment.
  3. He avoids the risk by not offering this service altogether. This is probably what has happened and most Singaporeans will find it more difficult to get a H&L injection nowadays than compared to a few weeks ago.

In case people in power do not understand (because they are probably the most well paid people in this country, let this hobbit state clearly – a $100,000 fine is an existential threat to a medical officer or resident, a GP or even an Associate Consultant.

The vast majority of people living on this island will now be deprived of a simple procedure  that is effective, very safe and was cheap.

Frankly, if I were still a young polyclinic Medical Officer with student loans to pay, I would stop giving H&L injections because a $100,000 fine would bankrupt me. It doesn’t matter if the $100,000 fine was for lack of informed consent or lack of documentation of getting an informed consent. The fact is, I cannot take the risk. Ask any professional risk management consultant and he will tell you that assessing any risk is not just about assessing the probability of incurring punishment but also related to the severity of the consequence (in this case, the punishment of $100,000).

The same goes for other junior doctors who perform all these high-risk procedures in the wards on a day-in, day-out basis. Fortunately, our junior doctors continue to display high degree of professionalism and dedication to their patients.

But the bottom line is – when the penalty is cripplingly great and the reward remains small, (because you cannot price-in the risk), most doctors (and most human beings actually) want CERTAINTY of avoiding the penalty. This is basic and rational behaviour. And the only certainty is not to offer the service. Any human being with average intelligence will come to this conclusion.

The fact is the Lim Lian Arn case has set a new standard for penalties. This issue has not be addressed at all by the 30 January 19 Statement by SMC.

It is interesting to note what Finance Minister Heng Swee Keat wrote today in the major newspapers “(a Zaobao reader) is right to caution against creating a public service culture where “Doing more means making more mistakes, doing less means making fewer mistakes; and if we do nothing we will make no mistake”. That would be the most serious mistake we could make”.

This is probably what has already happened in the ‘medical’ service culture now with regard to H&L injections given what has happened in the Lim Lian Arn Case: Do nothing, and so make no mistake.

Externality Effect

That brings us to  the issue of externality effect or “externalities” in short. This is a commonly-used term among policy wonks and economists. Wikipedia describes externality the cost or benefit that affects a party who did not choose to incur that cost or benefit.

We are where we are today because of the Externality Effect. If everything that happened in the Lim Lian Arn case only applied to Dr Lim, no one would be flustered. But in the Common Law system that we inherited from the British, precedents and case law matter a lot to all of us. While SMC is not exactly a court, but their Grounds of Decision serve as precedents and “case law of sorts” for future SMC cases.

Therefore these aspects of the LLA case have externalities (whether cost or benefit) that we, the medical profession at large, did NOT choose to incur:

  • How the charge (the laundry list of complications) was drafted
  • The suspension of five months that the SMC lawyers asked for
  • The fine of $100,000 which Dr Lim offered and which was accepted and the reasons for not imposing a suspension
  • The reasoning for the conviction and sentencing as given in the Grounds of Decision, including the effectiveness of any mitigation factors, if any
  • The need to document almost everything as given in the SMC Statement dated 30 Jan 19.

To this hobbit, the ONLY benefit or positive externality effect the profession derived from the Lim Lian Arn case is that not all cases of (lack of) informed consent will end up with a suspension and a fine may suffice (albeit a big fine).

The externalities of this case extend not just to the medical profession, but to ALL healthcare professionals that carry out procedures and prescribing and dispensing of treatment, including dental surgeons, pharmacists, physiotherapists, TCM practitioners etc. The magnitude of fines may differ, but the principles and effort of getting an effective informed consent should not vary much. For example, the TCM practitioner-patient cannot be less deserving of a less patient-centric advice process than a patient seeing a Western Medicine doctor, right?

The Limitations of SMC and the Government

A lot of criticism has been levelled at the SMC members, the SMC lawyers, the Complaints Committee, and the Disciplinary Tribunal recently. The four parties are often conflated in discussions but actually they function quite independently.

The first question to ask is, what gives SMC the right to even exist, and to investigate and punish doctors? The answer is the Medical Registration Act (MRA) which is passed by Parliament. Parliament passes laws like the MRA. Then the MRA is administered by MOH and SMC. The SMC’s power to publish the Ethical Code and Ethical Guidelines (ECEG), to punish and extent of punishment is provided for in the MRA. So in a sense, the SMC’s DT also has the power to interpret the SMC Ethical Code and Ethical Guidelines as well as the MRA itself. But like all laws in Singapore, the FINAL power to interpret any law or the final arbiter of any law does not rest with a ministry or a statutory board but the Courts. That is why the patient, doctor or SMC lawyer can all appeal to the Court of Three Judges (Sometimes five) if they are unsatisfied with the DT’s judgement. The Court of Three Judges always consist of High Court or Court of Appeal Judges, and sometime may even include the Chief Justice himself.

So in a sense, the SMC DTs and  the SMC lawyers must take guidance from the learned Judges when they pass judgment on SMC appeal cases brought before them. In recent years, a few precedents or case laws which may or may not have a bearing on the Lim Lian Arn include:

  • The Courts have on more than one occasion asked that SMC metes out more severe sentences to doctors
  • In the SMC vs Ang Peng Tiam case, a lifetime of good clinical practice record is NOT an effective mitigation plea. In fact, being senior may work against you. The only effective mitigation plea in this case was that there was a delay by SMC in processing this case.
  • In the Hii Chi Kok vs London Lucien Ooi case (Which is NOT an SMC Case, but a case brought by the patient directly against the surgeon through our Courts), the Modified Montgomery (MM) Test was first confected and applied. The MM Test will apply to all medico-legal cases (including SMC cases) in this country to test how medical advice is offered.

Of course, what these cases demonstrate and instruct are principles. Whether these principles are correctly applied (as the Judges would have wanted it) on the ground is a big question.

For example, is the five-month suspension or $100,000 fine appropriate in this case, given that “ there is nothing to suggest that the complications experienced by the Complainant were in any way permanent or debilitating” (Grounds of Decision, Para. 57)?

In the Grounds of Decision, it was recorded that the SMC lawyer asked the DT members to “not to give any weight to the mitigating factors such as the potential hardship to the Respondent (i.e. Dr Lim) arising from the conviction, the testimonials, character references and acts of community service and the Respondent’s long, distinguished track record”. (Para 33 of the Ground of Decision). In fact, it was recorded in para 27 of the same Grounds that had Dr Lim not submitted an early plea of guilt, the SMC lawyer would have asked for six to 8 months of suspension.

This hobbit wonders if this severe stance by the SMC lawyer was in some way influenced by what had happened in the Ang Peng Tiam case that was brought before the Court of Three Judges?

Also, in the indirect application of the MM Test through the drafting of the charge, should a laundry list of complications of a H&L test be listed out?

On 7 Feb, The President of the Pharmaceutical Society of Singapore, Ms Irene Quay wrote in a letter to The Straits Times, “it is important for the Ministry of Health (MOH) to provide clear guidance on the extent of informed consent for low-risk medications or medical procedures if the modified Montgomery Test is to be applied”.

To be fair to the government, MOH did not ask for the MM test to be confected or applied. That was the decision of the Judges. In fact, the Attorney General (AG) Chambers specifically asked for the Bolam Test and Bolitho Addendum to be retained in their submission to the Court of Appeal in the Hii vs Ooi case. But the Court of Appeal decided that the MM test will replace Bolam and Bolitho in Singapore on matters pertaining to medical advice.

I guess MOH and SMC are as much trying to understand what stiffer penalties mean and how should the MM test be applied in day-to-day medical advice situations when they administer the MRA. They can issue guidance, but it will be very challenging to have “clear” guidance when they didn’t come up with the MM test in the first place.

Who And What Are We Trying to Deter?

The main purpose of the SMC is to protect the public from bad doctors and in doing so, also serve justice. At the individual level, patients who have been harmed by doctors guilty of professional misconduct deserves justice from the SMC.  Justice has to be done, and has to be seen to be done.

Some have argued that stiffer penalties are necessary today to deter more doctors from practising medicine such that public confidence in the medical profession is not eroded. This is called deterrent sentencing. It is meant to deter others from committing the same act of professional misconduct and the objective of this is termed “general deterrence”. General deterrent sentencing is an intended potential externality. This is in contrast to “specific deterrence”, in which sentencing is targetted at preventing the specific doctor from erring again.

If you look at the latest SMC Annual Report, 12 doctors were given letters of warning and another 23 were given letters of advice. 12 cases were brought before Disciplinary Tribunals and concluded in 2017, of which two are pending appeal before the Court of Three Judges and two cases were concluded without any punishment for the doctor. Eight were actually censured and/or punished in some way. These numbers have been rather stable in the last 10 years. Even if we assume the worst-case scenario in which the two cases pending judgment before the Court of Three Judges will actually be punished in the end, the number for DT cases in which doctors will be found guilty of professional misconduct is 10.

Assuming that general deterrent sentencing is effective, how many doctors do we think we may have deterred from behaving in a bad way? Let’s give this a generous multiple of 10. 10 times 10 is 100. In other words, we have deterred 100 doctors from behaving in a bad way such that he is guilty of professional misconduct. By the same factor of 10, another 350 doctors or so would have been not served with letters of warning of advice because of the deterrent effect of stiff penalties.

The rest would not have committed the offence anyway, because this hobbit would like to believe most doctors in this country are still ethical and professional ones.

But in the fallout from the Lim Lian Arn case, thousands of doctors are now deterred from giving a H&L injection, a safe, simple and cheap procedure that would have benefited many tens of thousands of patients: Just because one patient wasn’t properly counselled and hence did not give an informed consent and thereafter she suffered complications that were not “permanent or debilitating”?

So we need to ask, who and what are we deterring? Do the cost-benefit numbers add up and make sense for the greater good of society?

Conclusion

The Chief Justice said in his speech at the opening of the 2016 Legal Year: “Medical care is of direct concern to all Singaporeans and we must act to avoid a situation where the practice of medicine comes to be adversely affected by the medical practitioner’s consciousness of the risks of malpractice liability.”

This “consciousness” has already come to pass in Singapore. The “situation” is already unavoidable.

This hobbit does not see any conclusive way out of the current problematic situation unless new laws are drafted by MOH and passed by Parliament to restore a more sustainable practice environment, not just for doctors, but for all healthcare professionals, and ultimately for the patients as well.

 

 

 

About That $100,000 Fine for An Injection

So, this is how the practice of medicine, as we knew it, dies in Singapore.

Not quietly or softly in the arms of compassion and empathy, but throttled inadvertently by the hands of a $100,000 fine.

Interesting Points

There are many interesting points about the case.

Firstly, there is the patient who complained against Dr Lim Lian Arn. It is interesting how the incident of the H&L injection took place on 27 October 2014 but she only complained against Dr Lim on 11 January 2016, some 14 months later. Especially when she was purportedly unhappy with the adverse effects and complications which are quick to surface and temporary: – pain and inflammation, discolouration, paper-thin skin and loss of fat and muscle tissues. What took her so long to complain?

Secondly, the SMC lawyer asked for a 5-month suspension for Dr Lim. This is mightily interesting. The ill effects suffered by this patient are far less serious than the one suffered in the Eu Kong Weng case. In the Eu Kong Weng case, also a case involving informed consent, the patient suffered serious complications. Dr Eu was suspended for 3 months and he appealed to the Court of Three Judges. The Judges upheld the (minimum) 3 month suspension but commented that had the law provided for less than a 3-month suspension, then a shorter period would have sufficed. But since the minimum period was a 3-month suspension, then the Judges had no choice but to uphold the 3-month period since they felt a suspension was indeed warranted. If so, on what basis did the SMC lawyer from Drew and Napier ask for a 5-month suspension? This hobbit does not understand. I hope SMC President, Registrar and members understand at least retrospectively why a 5-month suspension was warranted to be asked for by their lawyer.

Thirdly, we come to the doctor himself and his lawyer. Faced with the SMC lawyer asking for a 5-month suspension, this Hobbit speculates that chief on their mind is that they want to avoid a lengthy suspension. So, they pleaded guilty at first instance and offered to pay the maximum $100,000 fine or the minimum 3-month suspension. This is perfectly understandable because for a senior and successful orthopaedic surgeon in private practice, he probably makes more than $100,000 in 3 to 5 months. A 5-month suspension would mean he has no income in that period and worse, he has to bear the fixed costs of running a clinic, e.g. the rent and the pay of his clinic assistants and nurses. A secondary concern (if they think far enough) is that should they offer something low like $5,000 or $10,000, and should the SMC Disciplinary Tribunal (DT) accept, there is no guarantee that the SMC lawyer will accept and instead, he may choose to appeal to the Court of Three Judges. In other words, in trying to avoid what they deem as undesirable consequences, Dr Lim Lian Arn has to make a generous-enough offer such that BOTH the DT and the SMC lawyer will accept. In his self-interest, Dr Lim did as he was supposed to do. Nothing wrong with that. Perhaps this Hobbit would have done the same, given similar circumstances.

Fourthly, we go on to the Disciplinary Tribunal (DT) itself. Faced with an offer of $100,000, they had three choices – they can either accept or lower the fine, or still suspend Dr Lim. Thankfully and rightly, they decided that Dr Lim should not be suspended. They certainly couldn’t raise the fine, since the $100,000 was already the maximum amount allowed under the law. It would look very strange if they decided to lower the fine since the defendant already offered $100,000 even though the DT thought the closest comparison to this case was that of Dr Eric Gan, in which Dr Gan was fined $5,000. So, as expected, they decided to fine Dr Lim $100,000, the amount that Dr Lim himself offered. This Hobbit does not think the DT did anything questionable up to this point.

What is indeed questionable is the appropriate standard of care that this DT promulgated for taking an informed consent for an H&L injection.

They said that for the patient to give an effective informed consent, she should have been told of

(a) post-injection flare, in particular, that:

(i) the Complainant may experience increased pain and inflammation in the area injected that can be worse than the pain and inflammation caused by the condition being treated;

(ii) the onset of the post-injection flare is usually within two hours after the injection and typically lasts for one to two days;

(b) the post-injection flare can be treated by rest, intermittent cold packs and analgesics;

(c) change in skin colour including depigmentation (loss of colour), hypopigmentation (lightening), and hyperpigmentation (darkening);

(d) skin atrophy (thinning);

(e) subcutaneous fat atrophy;

(f) local infection; and

(g) tendon rupture.

To me, this is exactly the kind of “Information dump” that the Judges said should be avoided when they formulated the Modified Montgomery (MM) test for Singapore in 2017 in the Hii Chii Kok vs London Lucien Ooi case.

Fifthly, the MM Test itself, now obviously in full force in SMC trials, including this case.

The MM test replaced the Bolam-Bolitho (BB) test because the five Judges (in the Hii Chii Kok case) felt that in the provision of medical advice (which includes getting the patient to give an effective informed consent), the process must be patient-centric rather than doctor-centric. Nothing wrong with that in theory.

A few doctors, faced with disciplinary proceedings and medical negligence suits, relied on the Bolam test in their defence, almost to the point of abusing it. They would nominally come up with a few friendly “expert” opinions to justify their actions and pass the Bolam test.

This was the weakness of the Bolam test. But the Bolam test also had a strength – it provided for a reality check. The Bolam test required one to ask what was actually practiced on the ground by many doctors and took reference to such common practices.

This “reality check” element is somewhat missing in the MM Test. So, the DT accepted an information dump checklist as the required standard of care in giving medical advice when practically no one does this. The only reality check the DT was seen to undertake was that it accepted that it was not universal practice to get a written consent for a H&L injection.

Dr Lim Lian Arn was charged under the 2002 version of the SMC Ethical Code and Guidelines (ECEG). Many respected orthopaedic surgeons have been on the SMC as members since 2002. In fact, at least one of the current members is an orthopaedic surgeon. All the DT has to do is to ask these SMC-member orthopaedic surgeons if they routinely gave ALL such information to a patient going for H&L injection, and documented as such in the casenotes as well, to know what is the reality on the ground. This hobbit is quite confident that practically all orthopaedic surgeons who have been on SMC at any time since 2002 will fail this simple test. It’s just that none of their patients complained, unlike Dr Lim’s.

There is nothing in the published Grounds of Decision that suggests they did such a reality check. Indeed, the MM test itself does not include such an element of reality check except that it suggests that expert opinion could be taken into account when appropriate. The test of materiality (in deciding what information needs to be given) is solely from the patient’s perspective and nothing much about what was actually being practiced on the ground.

Nonetheless, the standard of care stated in the Grounds of Decision of the DT is Medico-Legal Reality.

What’s next

The H&L Injection

Lets’ get back to the procedure itself – H&L injection. This is a cheap, effective and common office procedure commonly done in the specialist and GP setting. But no more in the post $100,000 fine era. This hobbit would like to differentiate by calling the past the pre-LLA era and the current period as post-LLA era. (Dr Lim Lian Arn deservedly gets naming rights to such a momentous incident)

Ask any business school professor and he will tell you to price in the risk. Here is how you price in the risk:

Pre-LLA era price for a H&L injection by a GP – $50 to $150. Let’s take $100 as a reference price.

No of H&L injections you think you give before a patient complains: 100

No of complaint cases that will be successful (where you pay a fine of $100,000): 1 in 3

Estimate: 300 cases of H&L will result in 3 complaint cases, of which 1 will be successful

Economic cost: one $100,000 fine, AND estimated $200,000’ or about $70,000 a case of emotional distress, time lost, effort in preparing for the 3 cases of complaints etc.

Total price-tag for risk premium is $300,000 for 300 cases

Risk premium is therefore $1,000 a case

New Price for one H&L Injection: $1000 + $100 = $1,100

Conclusion 1: Price of H&L injection by a GP in the post-LLA era: ~$1100 (up from $100)

Of course, these numbers will only be significantly higher in the specialist setting. A H&L injection by a hand or orthopaedic surgeon may now cost $2000 to $4000 in the post-LLA era, after taking into account their own risk premiums.

Many patients in the HDB heartlands cannot afford this thousand-dollar jabs and the neighbourhood GPs know this too. Most of these patients will then be treated conservatively with brace and medication, resulting in more unnecessary pain or suffering by the patient (and may cost more than $100 but less than $1100). Or these patients will be referred to the public sector. This is not to say that the public sector doctors can do a better job than private GPs with better outcomes and therefore attract less complaints. It is just a simple transfer of the risk premium to the public sector where much of the costs are subsidised by the taxpayer. The richer GP patients will be referred to the private specialists because they can afford to pay the prices charged by the private specialists. The private specialists too may refer their poorer patients to the public sector.

The patient that will complain to the private GP sector will also likely complain in the public sector or in the private specialist sector. In the former case, the state/taxpayer takes up the risk and in the latter, the risk premium is covered by higher private specialist fees.

Incidentally, fee benchmarks currently do not cover office procedures like H&L injections.

To summarise – there will be little demand for a $1,100 H&L injection in the HDB estates, and GPs are also unwilling to take up this new risk premium for a hundred dollars or so. In simple economic theory, the demand and supply curves do not cross and there will be little or no transaction (i.e no volume of work). Consequently, the standard of care given in the Grounds of Decision of the DT, while now is Medico-legal Reality, will also in all likelihood effectively become Virtual Reality in the HDB Heartlands. How interesting.

Conclusion 2: In the post-LLA era, not many HDB heartland GPs will offer H&L injections. H&L Injections will go the way of dodo bird in the heartlands

The expected repartee from people who are out of touch is that this is not about risk premium but about good consent-taking and documentation. If you take a good informed consent and document as such, you should be OK.

Frankly, not many doctors are interested in this spiel anymore. Certainly, after the Eu Kong Weng case, no doctor is really sure what will be deemed effective informed consent-taking under the scrutiny of SMC or the Courts. And if I have to take this kind of risk for a $100 job, I might as well not offer the service and refer to someone else to do the job (and take the risk).

This is probably the outcome that will take place in the next few months, if it has not taken place already. Please do not call this Defensive Medicine. As this Hobbit has said before, it is called Survival Medicine. It’s the only practical way to survive. For me at least.

But it’s not just about H&L injections. How about other simple everyday office procedures like Speculum Examination, Proctoscope Examination or Ear Syringing? The same principle applies and a heartland GP will transfer the risk premium to the public sector or the private specialists by referring to them.

Conclusion 3: In referrals we trust (to avoid taking on insufferable professional risks)

You may ask: How did we get to this situation?

Answer: because everyone behaved in a way that is expected of them

The Judges wanted to move from a doctor-centric to a patient-centric process when medical advice is provided. They promoted patients’ rights to autonomy through promulgating the MM test.

The lawyer wanted to do a good job as SMC’s lawyer by pushing for a deterrent 5-month suspension. He is defending a particular patient’s rights to autonomy as well as promoting patients’ rights in general by going for a deterrent sentence.

The SMC DT wanted to be seen to be defending/promoting patients’ rights as well by accepting Dr Lim Lian Arn’s offer of a maximum $100,000 fine. They also want to send a signal to all doctors that the standards (as they see it) as prescribed by the MM Test are well in force when they promulgated that long list of potential complications and side-effects for a H&L injection.

Dr Lim Lian Arn acted as he should, by offering to pay $100,000 or be suspended for only 3 months (Reasonable speculation: he wanted to avoid a lengthy suspension and also a possible appeal from the SMC lawyer should the punishment be deemed too low).

The patient-complainant is probably satisfied too that the doctor was fined $100,000. Whether she proceeds on to a civil suit or not, we don’t know.

Every party got what they wanted: The Patient, The Doctor, The SMC Lawyer, The Judges, and The SMC DT.

But this Hobbit cannot help but wonder if Singapore society deserves more.

Because the Likely End-Result is collectively, patients will find it either much more difficult to get a H&L Injection from a doctor or will have to pay significantly more for it. And the same goes for other common, cheap and effective office procedures. A situation of either scarcity of service providers and higher prices will result, leading to unnecessary higher healthcare expenditure.

Society will have to pay for this in the long run. Unless the politicians and senior civil servants step in soon with some form of tort reform for medico-legal cases, the practice of medicine, as we knew it, has truly died. And the biggest losers are the patients collectively and society. Not the doctors. I just earn a few hundreds less a month, but I’ll live. Don’t worry.

 

New Year Wishes For 2019

After a well-needed break last month, this hobbit is back with some New Year Wishes for 2019. Yes, some of these wishes are not exactly new stuff but hey, it’s like new year resolutions to lose weight. If it doesn’t happen, then you wish or resolve again in the new year!

 

Wish #1

MOH will finally fix all the lacunae in healthcare regulation – those “grey” area that have hitherto been deemed to be not worthy of direct regulation by MOH: Managed Care, Third Party Administrators, Medical Concierges and even Referral Portals that claim to represent all doctors.

These folks working in the shadows have been making a lot of dough because of MOH’s inattention and inertia!

 

Wish #2

Now that we have fee benchmarks for doctors’ procedure fees in place, it’s time to expand the scope and look at hospital, facility and implants charges etc. If not, private healthcare costs will continue to rise at an unsustainable rate.

 

Wish #3

Someone should look at public healthcare financing. The recent incident where an SNEC patient was only reimbursed for $4.50 from MediShield Life (MSL) is plainly unacceptable. Apparently, it’s because in this case, the patient went for the same procedure for both his eyes but MSL only allowed the claim to be made for one eye.

If possible, operating on both eyes actually is more cost-efficient and saves money in the long run. But if the funding mechanism cannot support such practices and generate bad press, then surgeons have no choice but to operate on one eye at a time. So much for innovation and efficiency.

 

Wish #4

The big healthcare news of 2018 was the Singhealth Cyberattack. We should learn from this incident and take a hard look at how IHIS is structured and governed. There is nothing much worse than a “monopoly vendor” whereby customers have to buy essential services or products from only ONE vendor. That’s what IHIS is – the public healthcare clusters have to buy essential IT services from ONE vendor – IHIS. Think about it, if you had to buy rice or toilet paper from only ONE supermarket operator….

 

Wish #5

Also arising from the ashes of the SInghealth Cyberattack – new laws should be passed that spell out clearly and safeguards patients’ privacy, confidentiality and security rights. The current situation whereby a National Medical Record (NMR) is exempt from PDPA requirements and the MOH/MOHH/IHIS guys “ownself regulate ownself” is unsatisfactory. Even if there are no new laws enacted, the whole NMR programme should be placed under PDPA to instill public confidence. Only with public confidence restored will public buy-in be re-established and the NMR initiative be put back on track.

 

Wish #6

Leadership renewal should be managed sensitively and transparently, especially in public institutions with a sizeable pool of talent and experience. In choosing a leader, one must balance the need to have a person who is perfectly aligned and loyal to the masters, as well as having a record of excellence and service to the institution. If it is too tilted towards one way or the other, either the larger system suffers or the institution in question suffers. If this sounds rather cryptic, just look at one of these institutions, resignations are spreading faster than a poorly differentiated cancer. The pool of talent and experience there is evaporating faster than a puddle in a dessert. Even neutrals will quit quickly when they realise meritocracy is a distant second to alignment.

 

Wish #7

The Courts are setting the pace in medical negligence, with their landmark rulings in the last few years. The Modified Montgomery Test is one such example. The recent judgment on the liposuction death is another. This hobbit hopes the SMC can also say something on important medical legal matters before the Courts issue definitive judgments (by which ‘case law’ is made). If SMC speaks up and provide guidance beyond the Ethical Code and Ethical Guidelines as well as the Handbook of Medical Ethics, the Courts will certainly have to take into account what the SMC has said on a certain subject before judgments are made and new case laws are set in stone.

The advantage SMC has is that it can say a lot of things about a medical-legal subject at any time even when there is no existing SMC case ruling, with the objective of educating the medical profession. The Courts on the other hand, can only develop new case law when there is a case before them to judge.

 

Wish #8

Someone should really look at the number of people studying medicine, whether locally or overseas. We all can feel it in our bones that too many doctors are being trained. The legal profession and Ministry of Law have taken swift steps to address their glut. What about MOH and SMC?

The same principles must apply downstream to specialty training. The boom and bust in residency positions in recent times is really embarrassing.

 

Wish #9

ACGME-I Residency – Kill it or keep it? This is a tough call politically even if logic dictates otherwise. Even if no one wants to press the kill button, at the very least, we should really remove the double-yoke from our residents immediately – of having to fulfill ACGME-I requirements and passing the UK exams. Just let them choose one or the other. Stop testing them or examining them to death.

 

Wish #10

Family Medicine should be made a specialty and those with the FCFP qualification should be recognised as specialists by the Specialist Accreditation Board (SAB). Plain and simple

Random November Pickings

Heng ah.

The one key issue that has troubled if not bedeviled the whole nation in recent years has finally been resolved. Yes, I am talking about the fee benchmarks released by MOH Fee Benchmarks Advisory Committee.

“Kee Chiu” if you do NOT agree.

This hobbit will not talk again about how the SMA GOF either was killed by CCS or died after neglect by MOH. That’s all been discussed in previous columns. For the avoidance of doubt, CCS stands for Competition Commission of Singapore, not Chan Chun Sing.

A quick glance at the benchmarks gave the impression they were modestly generous. Some of the figures were better than what some TPAs and insurance companies were willing to pay previously. Of course, the figures were also substantially less that what some “star” surgeons and proceduralists were charging.

I met up with a few old classmates recently: an ENT surgeon and an interventional cardiologist. They lamented that their actual charges were even lower than the lower end of the benchmarks. This experience reinforced my belief that all my life I have been hanging around too many Cheap Charlies. I gotta stop mixing with such dubious company. But not before I get this ENT classmate to dig my ears first. He sucks our more ear wax from me than the cyber-attackers had exfiltrated data from the IHIS EMR.

Having the doctors’ fee benchmarks is a good thing. But it is not enough. There are two aspects to runaway healthcare costs: over-charging and over-servicing. Fee Benchmarks only deal with over-charging by doctors. How about healthcare facilities like hospitals and day surgeries? There should be fee benchmarks or guidelines too for healthcare facilities. And then there is over-servicing, which is often subtle and therefore harder to prove. Poor insurance design is often the problem behind over-servicing. All these have to be dealt with before healthcare inflation in the private sector can be brought down to manageable levels again.

Speaking of the cyberattack on Singhealth, the Committee of Inquiry (COI) hearings have more or less ended. We now await the Report by the COI. But the hearings were quite a shocker to say the least. It was literally such a jaw-dropping experience that my TM joint is now permanently subluxated. Let’s face it, IHIS makes SMRT’s “deep cultural issues” look as thin as popiah skin or tissue prata. Each day of hearing was met with cries of incredulous disbelief “Did the guy really say that”? There is so much head shaking and jaw-dropping, the healthcare community looks like a bunch of people high on designer drugs.

But we should have known better. Come on, the signs were all there all along in IHIS or its predecessors:

  • GP IT systems that never really worked well and went down well with GPs despite spending millions and millions on  their development
  • Many years ago, EMRX was launched based on implied consent and nothing much else (the patient was presumed to have read a poster and agreed to have his data shared on EMRX)
  • A NEHR design that did not give the patient privacy rights to NOT store data on the NEHR initially (this has now been apparently fixed, we don’t know for sure)
  • An IHIS Board that changed from having restructured hospital CEOs on it to other folks, that while the latter appear qualified on paper, they would not directly experience the pain when IHIS IT systems broke down
  • An IHIS CEO who also headed IT strategy and policy work in MOH

All these boils down to the fact that IHIS is an organisation that is designed culturally and structurally to achieve its aims with brutal singlemindedness. And the aims are often determined internally.

If you ask around, restructured hospital administrators will often tell you quietly that IHIS is not a joy to work with. You get the feeling that this organisation is not particularly enthusiastic about good governance or stakeholder engagement and empowerment. IHIS answers to MOH Holdings, not to the public healthcare clusters the IHIS was set up to serve.

So when a massive cyberattack occurs, the initial actions and responses of its key people on the ground reflect the culture and structure of the organisation. It’s as simple as that.

Finally, we come to the subject of web-based referral services. Apparently, there are companies that set up websites claiming to be able to help anyone get appointments to see doctors. Often this is ostensibly for free. And interestingly, their websites list just about every doctor registered with the SMC. Most of these doctors have never agreed to have their names listed on these websites. Some of these doctors have not practiced medicine for a long time, like doctors who are now full-time politicians (including ministers, no kidding).

Of course, many doctors are upset about this. The question we need to ask is what is in it for these companies and how do we regulate them. Apparently, by boasting a large database of doctors (i.e. practically the whole list of SMC-registered medical practitioners), they can tell potential investors they have buy-in from lots of doctors. This helps these companies to get richer valuations and raise money from unwise investors. The next thing is the patient’s request to see a particular doctor will likely prove to be unsuccessful (since 99% of the doctors on the list did NOT sign up with the company) and the patient will be given the recommendation to see the 1% that did sign up (“would you like to see Dr ABC instead of Dr XYZ?). In such instances, these companies will probably collect an admin/referral fee from Dr ABC.

The next question then is – how are these companies regulated? Answer: They are not. They are like TPAs (Third Party Administrators) or Managed Care companies. They are not regulated as a healthcare institution under the PHMC Act since they are not a licensed or licensable entity like a hospital or clinic. The Medical Registration Act, which regulates doctors through the SMC, also has no powers over such companies. Again, this is a lacunae in our health regulation framework that needs to be addressed.

For now, to the 99% doctors who did not sign-up with them, these companies are more of a nuisance than a problem like TPAs and Managed Care. But doctors should be aware of the pitfalls. For example, one such company provides video consultation services for patients 24-7 with a SMC-registered doctor. The SMC doctor should be very familiar with SMC Ethical Code and Ethical Guidelines’ position on telemedicine before he agrees to take part in such activities.

But still, there is apparently no law against a company publishing a “directory” of doctors’ names and claiming they can get an appointment for a member of the public to see any of these doctors on the list (which is essentially a directory of SMC-registered doctors). Even when I didn’t “kee chiu” for this.

I don’t know about you, but this somehow comes across like someone stuffed me like a Thanksgiving turkey.

 

 

 

 

 

Trick, Entreat

It had to come. Sooner or later. Like head lice or scabies when you live in the tropics and you don’t bathe for three months. “Making it harder for errant doctors to cheat” (The Straits Times, Opinion Page A28, 25 October) looks like another Salma Khalik hit job. It is also timed to be the journalistic equivalent of a Halloween trick or treat; designed to scare doctors and dentists by entreating the authorities to witch-hunt. She wants someone to clean up the houses of the medical and dental professions by writing this long opinion piece when all that is needed is for someone to pass Ms Salma a broom. This Hobbit happens to think she will look decidedly befitting with a broom. Preferably an anti-gravity one placed between the adductors.

Let’s first go back a little to 15 October 2018; in the article “Penalties are lower if doctors own up”, she wrote, “There is a big difference between tax avoidance and tax evasion. In avoidance, the person fully declares his income, but tries to pay lower taxes by using possible loopholes, such as setting up a company simply for tax breaks, or claiming personal expenses as legitimate business expense. The penalty for an “omission” is two times the taxable amount”

She moves seamlessly from tax evasion, tax avoidance to “omission”, giving the impression that the omission refers to avoidance. But actually, are they the same? Tax avoidance is NOT a crime or an offence. The person deemed to have committed tax avoidance by IRAS will be asked to pay up the difference between what he would have paid and what he actually paid and not “two times” the taxable amount.  The reasonable student of the English language on reading this, would probably infer that tax avoidance (like “omission”) is a crime and that it may be punished with a penalty of two times the taxable amount. No one really knows what is this omission she is talking about. Does omission equate to avoidance, or is she referring to evasion? Only she knows.

As for tax avoidance, the principle is simple – no one wants to pay more taxes if he can avoid doing so legally, just like you wouldn’t want to pay more for a pair of shoes if another shop offers the same pair at a lower price. IRAS is merely asking for information from some doctors and asking a few others to pay up for tax avoidance. If you agree to pay up, it stops there. There is no criminal record if you pay up. Has IRAS charged a doctor for a tax crime yet this year? Not that this hobbit knows of. And certainly, no doctor or dentist has been convicted of tax crimes this year yet.

In any case, with the obfuscating word “omission” in place, she launches her major offensive 10 days later with the aforesaid long opinion piece. Highly predictable; almost boring already.

Her strategy is to use the highly evocative and bewitching word “cheat”. She suggests many doctors and dentists are cheating, and gives a litany of examples: cheating Medisave money, cheating CHAS, cheating taxes, cheating insurance etc.

At last count, there are some 15,000 doctors and dentists in Singapore. Is there a cheating epidemic?  In the same article of 15 October, it was mentioned the last time a doctor was jailed for tax evasion was 2011 and he was subsequently suspended by SMC for four months. One case in 7 to 8 years doesn’t sound like an epidemic to me.

Then what is the whole point of her latest tirade against the medical and dental professions? Is she asking for

  • Stricter or better laws or ethical codes?
  • Better enforcement?
  • More punishment?

She seems to be saying that doctors and dentists should be held to higher standards when they commit tax offences because they are “not ignorant” and doing so out of greed. The first principle of law is that the law shows no preference to any group of persons. All men are equal under the law. The same standards and burden of proof applies to everyone. A doctor should not be more easily convicted of tax offences just because he has a MBBS degree. Likewise, a doctor or dentist should not be punished more for tax crimes versus say a banker, journalist, accountant, lawyer, hawker or taxi driver.

As for ethical codes, the latest SMC Ethical Code and Ethical Guidelines (ECEG) as well as the accompanying Handbook of Medical Ethics (HME) are two of the lengthiest and most detailed publications of this sort in the world. And SMC is already empowered to strike-off a doctor. What else is there? Lengthen the SMC ECEG and HME some more? Empower the SMC to give 10 strokes of the rotan?

The doctor or dentist already suffers from “double jeopardy” of being punished by the professional board for bringing the profession into disrepute after he has been also punished by the other authorities. If a journalist is found cheating on taxes, he pays the fine, and he maybe goes to jail as well. He doesn’t have a Journalist Board or Council to suspend or strike him off the Journalist Register because there isn’t such a thing.

As for cheating CHAS, well, last I looked, I signed a CHAS contract with a public sector Polyclinic Group. It is what it is – a contract. If I am found to have filed claims wrongly, they can claw-back the monies as per contractual terms. There is no specific legislation for CHAS (unlike Medisave, which is covered under the CPF Act), so enforcement of a contract between contracting parties is quite different from enforcement of a law.

Then she complains about doctors who do not give adequate MC to foreign workers. Well, they should be punished. But do notice that she is completely uncritical of the other elephant in the room – the employers and supervisors. Is this just purely a doctor problem?

As for insurance, yes, she claims insurance patients with full first-dollar coverage may be over-serviced or over-charged and that compulsory co-payment will be introduced to address this. Well, evidence and experience around the world have shown that insurance claims are always higher when there is full first-dollar coverage. This is bad insurance design leading to bad doctor and patient behaviour. These outcomes have been replicated time and again all over the world. What does Ms Salma Khalik expect? Are Singapore and its doctors expected to be so different from the rest of the world?

Over-servicing is not just a doctor thing. Over-servicing can also originate from the patient. The patient, with full and first-dollar insurance coverage, often requests for more expensive services from the doctor. The doctor, being a patient-advocate, will happily oblige. For example, why should a doctor not use the best implant for his full-cover insurance patient and choose something inferior (but adequate)? After all, if my patient has paid for it through his insurance premiums, I will use the best. In fact, if I don’t use the best implant (which is often also the most expensive), the patient may be unhappy with me afterwards. He may tell me “Doc, what didn’t you use the best Brand Z pacemaker for me and instead used the cheaper, inferior Brand Y one when my insurance covers everything?”. Is that dishonesty on the part of the doctor? In fact, in the era of the Modified Montgomery test, I better use the best, lest I be accused of not considering a relevant consideration from the patient’s perspective that should lead me to offer the best pacemaker later on. You never know. Better safe than sorry.

Bad insurance product design probably drives patient and doctor behavior more than human greed, so to speak. Fear of the new medical legal climate also plays a part too.

As for her example about the probability of getting a procedure for unspecified gastritis, it really depends. There are more foreign patients in the private sector. They come here wanting to get a definitive diagnosis and treatment as quickly as possible and then go home, hence the bigger demand for “a procedure” (probably a gastroscope). Also, many patients seek treatment in the public sector first for gastritis, and when the problem recurs, they often wrongly lose faith in our public hospitals, and seek care in the private sector, where again the pressure on the doctor to come to a diagnosis quickly results in more scopes. Yes, money does matter and some doctors do more procedures to earn the dough. But one must realise that in the private sector, there are also other factors that favour doing a scope which are not pecuniary. When you are the first doctor dealing with the problem, the patient is more patient (pun intended). When you are the second, third or fourth doctor dealing with the same problem, the patient has often run out of patience and is already very emotionally distressed. In addition, private hospital bed charges are a lot more than public ones and observing a patient for a few more days in the private hospital may cost as much as doing a scope. And even after observing the patient for a few more days, you may still not get a definitive diagnosis.

Shouldn’t a senior health correspondence with decades of experience in healthcare reporting give much more balanced analyses than this shallow sweep of “cheating” doctors and dentists?

Actually, she seems like a sulking kid who refuses to admit a mistake. “Salmatologists” (This hobbit is one) will recall that she wrote another long opinion piece on 26 March 2018 (Sunday Times) where she made the claim, “Drilling down, the MOH concluded that much of the higher claims was the result of overcharging and overtreatment by doctors in the private sector”. (“Diagnosing the cause of rising costs”).

This was clearly refuted by MOH and guess what, The Straits Times itself! On 30 March, the newspaper clarified that “This is incorrect, the Ministry of Health did not draw such a conclusion”. It was a mistake by her, pure and simple.

And now, once again, she is again asserting essentially the same erroneous claim, only albeit in a more convoluted way, and wisely not attributing this to MOH but to the insurance industry instead, presumably to “one insurer” and the COO of AIA, Ms Melita Teo.

So what’s the message here – that like Ms Salma Khalik, the “one insurer” and AIA’s Ms Melita Teo disagrees with MOH – overcharging and over-servicing by private sector doctors are the main reasons for rising insurance claims?

There is a pattern to all this of course. Her usual and favourite trick is to drive a wedge between MOH and the medical profession; then she entreats the government to come down hard on the medical profession. This can be seen on at least three occasions:

  • FIn 2005, she made the assertion that the then DMS will remove dispensing rights from medical clinics, which the then DMS refuted.
  • Then in March this year, she made the claim that MOH is of the position that higher insurance claims was the result of overcharging and over-treatment by doctors in the private sector, a position that the Straits Times has since said MOH didn’t arrive at.
  • Now, she is asking MOH and other authorities to go tough on cheating and unethical doctors and dentists. And she has also apparently roped in the insurance folks to beef up her claims (pun unintended).

You have to give it to her. As an object of antiquity, she has enormous energy. Apparently, she’s 63 years old (give or take a year or two), and this hobbit can only wonder how long more can she keep going like this. But seriously folks, other than Salmatologists, no one really reads these long opinion pieces anymore in the age of Instagram and Twitter.

In the meantime, will someone give her a broom? This hobbit is thinking of giving her a hat as a year-end gift. The two gifts will go nicely together. Hopefully they will come in handy when she finally retires.

Happy Halloween

 

Urgent Skin and Eye Blue Letter

Even as the dust on the SingHealth cyberattack has barely settled, another piece of bad news has surfaced on healthcare IT systems offered by Integrated Health Information Systems (IHIS). IHIS is the IT arm of MOHH that oversees IT development and implementation in the public healthcare sector, and increasingly influences the private sector as well. It involved the mis-labelling of drugs affecting 400 GP patients who saw GPs who are using the GP Connect software that IHIS offers. Two days later it was reported that the affected number of affected patients is more likely to be double that of the original number – 836 patients seen in 104 clinics.

An egregious example given was that a patient who was supposed to take 10ml of cough mixture would be asked to take 10 bottles in instead. For codeine addicts, that’s like hitting the casino jackpot.

When such an incident happens, we need to ask a couple of inconvenient questions. First- if the patient indeed was dispensed 10 bottles and worse, took the amount as stipulated, who will be responsible for the unfortunate consequences?

The short answer to this question is “YOU, the GP”. (are you surprised?) As a GP in the private sector using GP Connect, it is quite unlikely you had hired a pharmacist or staff nurse to perform dispensing. If you did, then the pharmacist or staff nurse, both registered with the state and licensed to perform dispensing duties independently, has to bear the brunt of the responsibility. If not, the dispensing staff are dispensing under your supervision and you will have to take professional responsibility even if the IT system had printed out the labels wrongly. This is because you are supposed to have checked and realised the labels did not reflect what you had prescribed earlier on. You may be punished by MOH, Health Science Authority and/or SMC for dispensing the drug in wrong dosages.

What about the IHIS and the IHIS folks? Presumably, the people in there who developed GP Connect are NOT state-registered doctors, pharmacists and nurses. So, the most you can do is perhaps sue them for civil damages and get some money back. The people won’t be suspended or struck-off by some authority regulating the IT profession (IT professionals are not state-licensed).

This is what the financial and business world calls “skin in the game”. You, the doctor, have a lot more skin:- epidermis, dermis and hypodermis, in the game then the IT folks. This inequality or asymmetry in risk exposure leads to the inevitable cultivation of unhealthy behaviour. That’s not to say IT people are evil people, they are not. It’s just that if that is how the system is badly set-up, then suboptimal behaviour and outcomes are sure to follow. This phenomenon is pretty well described in famous economist Nassim Nicholas Taleb’s new book “Skin In The Game”. (He also wrote The Black Swan which sold 3M copies)

On 6 Sep 18, 2 days after the news first broke, it was revealed that this glitch was due to a “planned system update”. Frankly, this sounds terrible and this hobbit is not sure what is the messaging aim here. If a “planned” system update could mess up life like this, one should ask what if the update was unplanned? Would it have been far worse? Is it being “planned” a mitigating factor or an exacerbating factor? Are we supposed to commiserate with the patient, the GP, or get angrier with IHIS? Would the mess have been less if there wasn’t any update, whether planned or otherwise? I don’t know about you, but this hobbit is really confused.

Next on the radar screen are the anaesthetists in the private sector. Apparently, many of them have been targeted by the taxman. Let this hobbit be clear from the onset: he firmly believes the taxman is to more feared than the hitman. The hitman can’t do anything after you are dead. The taxman will get you, in this life or the after-life: he will hit your estate. They are even more powerful than forensic pathologists.

As we all know, most anaesthetists set up companies. Professional fees are paid to and recognised as revenue in these companies, and anaesthetists then get their income from these companies in the form of salaries, dividends and directors’ fees after expenses have been deducted.

Apparently, the taxman now thinks that because these companies who have no office, hire no staff other than the anaesthetists, they are nothing more than tax shelters providing tax avoidance for the owner-employee anaesthetists. The taxman now wants to claw back the difference in taxes the doctors have paid to the government had the doctor been taxed as an individual only when the doctor had paid taxes as a blend of different tax schemes (personal income tax for salary of up to 22%, 22% for director’s fees, 17% corporate tax rate for dividends).

This problem arose because the maximum tax rate for income tax now (22%) is significantly higher than for corporate tax (17%). Certain amounts of dividends are also given tax breaks and certain cost items can be “expensed off”, such as meals with colleagues or the purchase of your Ipad which you need for your work. Some people have received letters saying their claw-back will be up to 5 years. So now, an anaesthetist may now find himself owing the taxman hundreds of thousands of dollars.

It is therefore no surprise that many private sector anaesthetists are up in arms. I know many of them, and they have sought professional accounting and tax advice in the past to set up these companies to avoid paying more tax. They did so in good faith under professional advice. Why should they be penalised for something in the past, just because the taxman applies new rules of interpretation of (purportedly) Section 33 of the Income Tax Act? Who wants to pay more tax than what one is supposed to legally and in good faith?

In any case, tax avoidance may not also be the main reason why doctors set up companies. A private limited company, as the name suggests, is a way of limiting one’s exposure to damages arising from business activity. If you work for and under a company, your business liability is limited to the assets of the company, even though your professional liability is not. For example, the damages, say, your supplier, can get from you is limited to the company’s paid up capital and assets. Your supplier cannot touch the assets that you own personally which are not part of the company, such as your home or your personal-use car. As this hobbit sees it, this is the main advantage of setting up and working under the umbrella of a private limited company.

This liability limitation objective can be evinced by the fact that some companies set up by older anaesthetists have been in existence for decades. In the 80s and 90s, income tax was actually lower than corporate tax. These senior anaesthetists probably paid more money than they could have had they not sought a company structure to house their activities. Can they now claw-back the excess money from the taxman? In the name of fairness, surely there is is some merit in this argument?

Even if the taxman wants to take a new interpretation and get anaesthetists to pay more taxes, this new interpretation should not be applied retrospectively in claw-backs. It should at best be applied to current and future income. And the fact that because the anaesthetists don’t have an office and hire staff, they are then penalised to pay more taxes doesn’t make much sense. If 30 anaesthetists hired 5 receptionists and a tea lady and housed them in a 500 square-foot office in Yishun at $2 per square feet means paying much less taxes, then they may just do it. But what does that do to Singapore and the government’s drive for more productivity? Nothing. It may just mean more low productivity jobs that the Singapore economy doesn’t need.

Someone needs to see the Big Picture here. Obviously the taxman’s visual field and visual  acuity in the context of the Future Economy needs to be questioned here. If not, the road to lower taxes through lower productivity will surely be taken.

 

 

Sacred Cow or Golden Calf?

SingHealth Cyberattack 2018

The cyberattack into Singhealth dominated healthcare news not just in Singapore, but in the world as well. News of the attack was made public on 20 July 2018, exactly 5 months to the day when this Hobbit published “NEHR: A Patient’s Perspective from A Doctor’s Eyes”. In the section on “Security” in the aforesaid article, this Hobbit wrote:

“The last point I would like to deal with is that of security. Security can basically be defined as measures put in place to prevent breaches of confidentiality. How secure is the NEHR? I am confident that the planners and implementers have tried their reasonable best to ensure best practices in IT security have been put in place or are being put in place. After all, the NEHR, being backed by government, has enormous resources to do so.

Even then, no IT system, especially one that is internet-based and cloud-based, with literally unlimited number of entry points (every clinic or hospital computer that is linked to the internet is an entry point into the NEHR) is hack-proof. If it were not so, there would be no need for the government to delink civil servants’ work computers and intranet from the internet last year. It was reported this affected all 143,000 civil servants. That is a tacit admission that no security system is fool-proof or hack-proof. I suppose this shows cyberthreats cannot be wished away, but they can be effectively partitioned away.

This hobbit is sure the NEHR is as secure as can be, but not quite more secure from the civil servants’ work computers before they were delinked from the Internet. In fact, the fact that the NEHR exists must in itself be a very tempting trophy database for hackers from all over the world to try and test and breach.

In the event a breach happens and records and medical information are stolen, what is the liability of the NEHR or the government with regard to this breach, and what are the rights of the affected patients? Can he seek redress, compensation, damages etc.?”

Sometimes, this Hobbit wishes he isn’t so spot-on, although he was referring to the NEHR and not the current IHIS-Singhealth Electronic Medical Records (EMR) that had been hacked into. But if you replace “NEHR” with “IHIS-Singhealth EMR”, everything else pretty much applies. In fact, DPM Teo Chee Hean pretty much said so too when he said in hindsight, that internet surfing separation for public hospital separation should and could have been done earlier.

And it was just as well that this attack occurred before the NEHR was rolled out to the private sector. If that had already happened, then the cyber-attacker would have even more access points to hack via any computer in any of the 2000+ private clinics and laboratories all over Singapore.

This hobbit supposes that all the computer terminals in the three public healthcare clusters are well maintained with up-to-date antiviral software, server firewalls and robust security measures such as high security passwords etc. The public healthcare sector has dedicated IT teams and resources to ensure this. The same cannot be said for the private clinics. Do they have anti-viral software? Let alone up-to-date ones? And what about passwords? I won’t be surprised if many passwords are “qwerty”…

So, it was fortuitous that NEHR hasn’t been made mandatory yet in the private sector, if not the cyber-attackers would have found it even easier to launch a cyberattack, and probably an even more massive and debilitating one.

The authorities also said that the data that had been exfiltrated was “not sensitive”, and were “basic demographic data”. This was an attack on 1.5 million people, which is about 25 to 30% of the populace on this island. It is really an attack on Singapore, plain and simple. Singhealth was probably chosen because many, many influential people seek care in SGH, and the Outram Campus, which are part of SingHealth. If you want to dig out medical information on most of Singapore’s VVIPs and CIPs, the most ‘rewarding’ place to look would be SingHealth. It wouldn’t be NHG or NUHS. Anyone in healthcare long enough knows this.

I am not sure downplaying the impact of the cyberattack is the right strategy here. Sure, someone needs to strike a balance between unnecessarily pressing the panic button and euphemising a clear and present danger. I can decide what is “sensitive”, thank you. My birthday and my NRIC number are sensitive data alright.

In addition, the 160,000 medication records that had been exfiltrated was surely sensitive information. Any healthcare worker, be it a doctor, pharmacist or nurse can quite easily infer from the medication records with reasonable accuracy what disease(s) the patient is being treated for. And if you think about it, this is the most efficient way to know about a patient’s medical status. If you go and look at his investigation results, there will be many ‘uninteresting’ normal results. If you look at the record of procedures done, you may miss the pure medical diagnoses the patient has. But when you look at the medication records, almost everything there is sensitive and ‘useful’. This is a medically-intelligent cyber-attacker.

The externalities of this attack are significant. The attack does not only affect the 1.5m people or the 160,000 medication records. The Monetary Authority of Singapore (MAS) has already instructed all bank to take more steps to verify the identity beyond the basic demographic data that was exfiltrated. Unless you do not have a bank account or use only human teller services, we will all have to answer more questions to verify our identity, beyond name, NRIC, address and birthdate. In other words, practically everyone is affected adversely.
NEHR

Since we are on the subject of NEHR, let’s discuss security of the NEHR in the wake of the attack. The authorities have categorically stated that the move towards NEHR is inexorable. There is NO turning back. It is true that the move away from paper cannot be avoided. But it is also true the NEHR has many issues that need serious re-thinking and ironing out.

This Hobbit senses that there is an almost religious fervour amongst those in power to developing a monolithic glorious NEHR that will be the pride of Singapore and establish the country amongst the pantheon of IT gods as soon as possible. To be in the pantheon of IT gods is the geek’s ultimate fantasy. But we need to face up to reality beyond geek-ish obsessions. Perhaps it is wise to take a leaf from Steven Spielberg latest directorial effort, the hit movie “Ready Player One”. In this movie set in the future (2045AD), most people in the world are living in slums and finding happiness only in a virtual reality gaming world called OASIS. The founder James Halliday becomes the richest man on the planet, with a fortune of $1trillion. But at the end of his life, he realised that “reality is real”; not OASIS.

Indeed, reality is real. Reality involves looking at the NEHR with detached objectivity. But it is difficult. The people right in the thick of things can get easily enamoured with the whole idea. Even a tech giant like Facebook is not immune to such failings. In the wake of the Cambridge Analytica scandal, Facebook CEO Mark Zuckerberg said in an interview on 18 July 18 that “we were too focused on just the positives and not focused enough on some of the negatives”. When you make a Golden Calf and worship it, you seldom look at its negatives.

If you look at the NEHR publicity so far, it is all about the positives: continuity of care, ease of care, more efficiency, patient safety etc. It’s terrific spin. Nobody talks about the potential negativities. But one must wonder if the people driving this believe in their spin? As the saying goes – never believe in your own spin.

Former editor of The Straits Times, Han Fook Kwang had his finger on the pulse when he wrote, “(NEHR is) A no brainer for the medical fraternity? You would have thought so. But doctors are divided over it”. (Singapore needs to get smarter about digital world, 5 Aug 2018)

He also said’ “It is easy to be seduced by the appeal of placing everything in a common system under one control: It can be more efficient and is easier to manage. Very Singapore Inc, you might say”. The key word here is “seduced”. Mr Han goes on to explain the pros and cons of a centralised system versus a distributed one. He used to be an elite Administrative Officer with experience working in MOH so he obviously knows more than a bit about healthcare.

For sure, many doctors in the private sector, like this Hobbit, don’t buy the spin. Many have quietly voiced their reservations about the security dangers, loss of privacy rights and costs of maintaining the system etc. But the feedback has always been “We are going full-steam ahead”. Until this massive cyber-attack happened and Smart Nation projects was paused for a total of 14 days (20 July to 3 Aug). A cyberattack that affected 1.5 million people did not quite put a dent in the Charge of the NEHR Brigade beyond 14 days.

This hobbit hopes someone in authority is finally looking at the negatives seriously even as we continue to brandish the positives. For one, if internet surfing separation is going to be permanent, does it mean that there will be at least one computer terminal in each clinic dedicated to just NEHR and which is not connected to the Internet? Who pays for that and its upkeep as well? Even if that happens, what is there to prevent hackers from physically breaking into a GP clinic located in the HDB heartlands at night and launching a cyber-attack from there? Does it mean we have to physically secure each clinic to the same level as SGH?

Regulation of the Public Sector

On 4 Aug, NUS Law Dean Simon Chesterman wrote eruditely in The Straits Times that we should not waste the opportunities afforded by this Singhealth cyber-attack crisis and take a good look at revisiting the issue of privacy on top of addressing the obvious issue of security. He was obviously not enthusiastic of the fact that the entire Singapore public sector was exempted from the “relevant legislation” (i.e. the Personal Data Protection Act or PDPA in short) that governs data protection. (Singhealth breach may give privacy new life, 4 Aug 2018).

Many official sources have said that the NEHR is subject to even higher standards than what the PDPA requires so no one should be worried. But that is NOT the point. The point here is when the public sector fails the public and fails the standards that it is supposed to meet, what happens? The PDPA provides for clear penalties to be meted out and the rights of the private individual is clearly spelled out. What is the equivalent of that in the public sector? Can the patients now sue IHIS or Singhealth? Who regulates IHIS and Singhealth under which piece of legislation when a cyberattack is successful and patients’ privacy and confidentiality suffer?

A private hospital administrator said to this hobbit that if this cyberattack had happened in the private sector, the PDPA would have been enforced and in all likelihood, the party involved, say a private hospital, would have been punished under the clear provisions of the PDPA with hefty fines etc. But since the PDPA doesn’t apply to the public sector, it’s anyone’s guess.

The SMA-AMS-CFPS Survey on Patient Perspectives of NEHR

This point is in fact quite well echoed in the results of a survey which was commissioned recently by the Singapore Medical Association, College of Family Physicians and Academy of Medicine, Singapore which has been released to the members of SMA and AMS. Out of the 2100 people surveyed, no less than 81.7% were concerned that the NEHR was not subject to the requirements of the PDPA. A whopping 82.9% (1741 of 2100) were concerned that their medical information would be used for matters of public interest by the Ministry without their consent.

Other significant findings include:
• 581 of 2100 (27.7%) definitely wanted to have their records maintained in the NEHR
• 1175 of 2100 (56.0%) would like their records maintained in the NEHR but did not want any healthcare provider to access it without their explicit consent except in emergencies. (i.e. privacy concerns)

On the issue of security:
• 77.5% (1627 of 2100) of the respondents were confident that their data in the NEHR was secure,
• 70.8% (1487 of 2100) were confident that their data would not be misused by others.

This survey was done before the cyber-attack. Will 77.5% of people still be confident of the security of the NEHR now?

But there is good news for the authorities. Singaporeans understand the importance of having a NEHR. 92.2% of those surveyed were supportive to varying degrees of having an NEHR. But of course, the devil is in the details. And as this Hobbit has said some five months ago, the concerns and dangers are lurking somewhere in the alleys of privacy and security which need to be faced squarely and addressed adequately.

As you can see, many people who had been surveyed were already concerned with some of the potential negatives of the NEHR, even though they saw the need for electronic medical records. The findings are not surprising.

Time For A Rethink, Repositioning and Redirecting ?

This hobbit feels that the NEHR urgently needs a re-positioning. In the wake of the cyber-attack, it is not just enough to say the NEHR is good for continuity of care, efficiency, cost-effectiveness, patient safety etc. Yes, the NEHR works for the patient’s interest in these areas. But the NEHR must also work for the patient’s rights and interests in other equally important areas such as privacy, confidentiality and security. And it is not just spin. The public that is now “sensitised” to such issues will want to know what are the concrete policies and measures taken to do so.

The public will also want to know what are their rights to redress, compensation and damages if their privacy and confidentiality rights have been compromised. This is still unclear in the context of the Singhealth cyber-attack and even more nebulous with regard to the NEHR.

What has happened in the last few weeks with the cyberattack calls for deep reflection,  serious repositioning. It may even need some redirecting – a change in course if necessary. But this hobbit doesn’t think there will be much of these. Instead, the focus is still on achieving rapid deification through the NEHR.

Come to think of it, this hobbit feels the NEHR is turning out to be something between a sacred cow and a golden calf…..

Perhaps it is time to revisit Lord Alfred Tennyson’s famous poem, “Charge of the Light Brigade”, in particular, the 2nd stanza:

“Forward, the Light Brigade!”
Was there a man dismayed?
Not though the soldier knew
Someone had blundered.
Theirs not to make reply,
Theirs not to reason why,
Theirs but to do and die.
Into the valley of Death
Rode the six hundred.