Broken Choices

 What kind of country is this

Where a woman's autonomy over her body

Depends on where she lives

Or if she can afford to execute that right

Where a doctor is not free to practice 

Good medicine

Depending on where he/she lives

Woah

I wonder what the response will be from the Ministry of Health to this mother's letter in the Straits Times....

Polyclinic doctors don't have it easy

PUBLISHED ON APR 10, 2014

PRINTEMAIL

 

I AM the mother of a polyclinic doctor and would like to give a different perspective to Ms Evelyn Ong Foo Chou's letter ("So hard to consult a polyclinic doc"; Tuesday).

After waiting for hours, some patients are likely to be frustrated and angry when they enter the doctor's consultation room. They want to get a consultation worth their wait.

But how do you expect the doctor to give them more "eye-contact time" when he has to document the patient's medical history, conduct the medical examination, reach a diagnosis and write the prescription - all within a matter of minutes - given that he has to fulfil a minimum quota of 60 patients a day?

Some patients express their frustration through anti-social behaviour, such as stealing the doctor's mobile phone, using abusive language when they do not get the prescription or medical certificate they want, or crushing the queue slip and throwing it at the doctor.

Many polyclinic doctors do not even have time for a proper lunch and often eat junk food from the vending machine.

Which doctor would want to work in a polyclinic when locum jobs in the private sector pay three times more, with one-third the patient load?

If there were no bond in place for Singapore's medical graduates, more than half of them would have already left the service.

Chew Ghim Lian (Ms)

How Doctors Die

I read this article some time ago.  It talks about a topic that many are uncomfortable to delve on.  It came to mind because a close relative of mine, who has been suffering from a chronic form of leukemia for the last several years, just found out that his condition is probably turning acute (not a good thing, where leukemia is concerned).  He is also a medical doctor and knows what this means with regards to possible scenarios.

We talked about what his options are now.  He has to live a day at a time, continuing with chemotherapy for a while longer, for what it's worth.  He is putting his things in order so as to make it "easier" for his loved ones (is it ever easy?) when he finally passes on.  There are three physicians in our family (including himself).  He has spoken about euthanasia (when the time comes) with his brother (the other physician), with me & with his own oncologist, knowing full well that the laws of the countries we live in prohibit it.   It is not an option, he knows, though he jokingly asks me to give him an overdose of propofol when he starts going downhill.  I laugh in response while trying to keep tears from rolling down my face (we are on the phone).

He knows what he is in for once the acute phase kicks in.  Fulminating infections, organ failures etc.  He doesn't want to suffer through all that.  The only option left at that point would be an induced coma until he finally passes on with dignity.

A Quarter Century

We last reunited 5 years ago.  My classmates from Medical School got together again a couple of nights ago to celebrate our 25th year post-graduation.

It was a good turn out: about 2/3 of the class showed up.  I think I did pretty well in recognizing people... better than 5 years ago anyway!  We've become older/greyer/fatter/slimmer/aesthetically enhanced/more wrinkled.  But when I say hello and chat, I see the same people I went to school with.  Personalities remain the same despite the additional prefixes and suffixes in their names.

Two have passed on, reminding us to seize the day.   We saw a slideshow comprising of old photos from our days as students, and photos of us now, with our families; so happy to see the smiling faces of my peers and their loved ones.

Our class may not have been the most distinguished nor the most intellectual, and it certainly has had its share of oddballs, and infamy.  But we are certainly an interesting lot.

Here's to 25 more years!

Looking back

I am looking through the pictures of my medical school classmates in our old university directory, preparing a slideshow that will be screened during our coming 25th year reunion (!!!), and I wonder at some of these familiar faces - some are/have been heads of departments in hospitals, most have families, many are GP's with established practices in Singapore.

I remember some of them as awkward teens, having attended the same junior colleges as several of them.  They were uncomfortable with the opposite sex, umm-ing & aw-ing when trying to have a conversation.

I remember some as the "bad boys" of the class, smoking, having "adventurous exploits" with the opposite gender.

I wonder what they are like now, as I have lost touch with most of them over the years.  It's hard to picture them as Heads of Departments or Senior Consultants or to address them as Prof.  In my mind, they are the same old classmates whose photographs look back at me from the directory.

A couple have passed on & when I see those old pictures of them in the prime of their lives, I wonder what the me of today would say to the them of yesterday if I could speak to them.   Would I tell them to enjoy life to the fullest & appreciate their loved ones while they can?

A few have gotten into trouble with the law & with the medical council.  What would I tell the young them?

What I DO know is that for me, there have been no regrets.  And I couldn't have asked for a better life.

:)

In Retrospect

After reading this article, I look back at my decision to stop practicing clinical medicine & realize that I was, indeed, suffering from burnout.  Someone did ask me, at the time, if this was the reason for my decision, and, at the time, I said No.  Perhaps it was denial.

In any case, when I examine my life over the last several years, I know now that it was the right decision.  

The Radical Notion that Doctors are People, Too

This article was written by one of my favorite doctor bloggers.

She says what I've always felt about people's (as in non-doctor people) perceptions of what doctors are/should be.

U Turn

TODAYonline | Commentary

Bring back medical fee guidelines

Concerns about over-charging highlight the need for a guide to

private doctors' fees

by Conrad Raj

04:45 AM Mar 22, 2011

In the wake of the Susan Lim saga, it might be time to review the ban by the Competition Commission of Singapore (CCS) on medical fee guidelines.

Without going into the merits or demerits of the ongoing court case involving Dr Lim, many among the public have become concerned over the high charges being levied on medical services here in Singapore.

Singapore's reputation as a medical hub and its medical tourism business may also have been adversely hit by the court revelations and the testimony given by many in the medical field to overcharging by the profession.

In June last year, the CCS ruled that the guidelines were anti-competitive, on the grounds that price recommendations by trade and professional associations might harm consumers because they "distort independent pricing decisions" as there may be no incentive for cost-effectiveness or innovation.

The Guidelines on Fees (GOF) for services and procedures in the private sector were put in place in 1987 by the Singapore Medical Association (SMA) - which represents the majority of medical practitioners here - after complaints of overcharging for medical services by doctors who were more interested in squeezing their patients than in curing them.

The GOF is a set of recommendations on private doctors' professional fees, which includes fees for consultations, surgery, preparation of medical reports and court appearances.

But the CCS felt that the GOF was now redundant as other benchmarks had become available - namely that of government hospitals, which provide hospital care and medical services for 80 per cent of the population. And the CCS noted that since these restructured hospitals do not refer to the GOF when making pricing decisions, patients could use their charges as a basis for price comparison when going to private hospitals.

The CCS had also pointed out that the Ministry of Health (MOH) requires patient medical bills to be itemised and financial counselling be provided and that hospital bill sizes are made public on MOH's website.

The commission urged the SMA to "work with MOH and hospitals to further improve the delivery of pricing information ... so as to allow patients to make more informed choices".

"In general, price recommendations by trade or professional associations are harmful to competition because they create focal points for prices to converge, restrict independent pricing decisions and signal to market players what their competitors are likely to charge," the CCS said. "This is a common position adopted by many competition agencies in the world, even for the medical sector."

But now, in response to a recent article in Today, the CCS has suggested that the SMA could provide information on actual pricing.

"In general, CCS recognises that information on actual pricing, and transparency in the reporting of prices actually charged in the market, are useful for consumers to make informed choices in their purchases of goods or services. CCS, therefore, supports the publication of historical price information to help consumers.

"However, this is very different from issuing price guidelines, which by their very definition, are intended to influence what prices should be set rather than merely providing historical price data," the CCS said in its letter.

Although the SMA had voluntarily scrapped its pricing guidelines in 2007, in October 2008, it wrote to the Ministry of Trade and Industry to request that the GOF be excluded from Section 34 of the Competition Act. After consulting with MOH, the ministry declined the request last year.

But it may be time now for the SMA to restore the public's faith in the medical services by bringing back guidelines, perhaps with the proviso that these are only guidelines and not mandatory charges binding all doctors.

These guidelines could provide a range, as suggested by the CCS, rather than a specific price that those in the medical services could charge. However, they should avoid the extremes which could give a distorted picture and could include overcharging by the unscrupulous.

The guidelines are a useful frame of reference: Patients should not be asked to buy a pig in the poke - a service they do not know the true value of. Dying patients may not be in the proper frame of mind to make the right judgement call.

And foreigners could use a guide to the range of charges they can expect in Singapore, enabling them to compare the expense with that of other medical hubs.

Perhaps private clinics should be requested to post their range of fees, either at their premises or on their websites, so that it would be possible for patients to shop around, like in the case of restaurants. Some doctors might feel it beneath their dignity to post their service and price menus - but then, being unscrupulous is even worse.

More importantly, such a move would not be anti-competition.

Well.

I guess it takes sensational headlines to make the CCS wake up to what the original price guidelines were supposed to do for patients. Call it "historical price data" or call it guidelines. It's semantics, really. What they have suggested was really what the guidelines were meant to do in the first place.

Light Bulb moment

Finally, a bright spark.

(Letter to the editor, Straits Times Forum, March 19)

Ban ineffective screening tests

I REFER to the reply from the Ministry of Health ("Why Medisave can't be used

for all screening tests"; Thursday) to Mr Arthur Lim's letter ("Allow use of

Medisave for more screening tests"; Monday). In the name of medical ethics,

the Ministry of Health should perhaps consider a ban on tests that are of

questionable effectiveness when used as screening tools.

Going by the phenomenal growth of some medical centres, and the increasing

complexity of some packages they offer, medical providers must be doing

a roaring business.

With some packages costing as much as $9,000, could it be that a large

proportion of tests in the packages are probably not recommended as screening

tools? And if they are, why are they even allowed to be there? Shouldn't

the public be protected from such practices?

(Addendum: I am not advocating banning these tests, some of which are useful

for patients recovering from cancer, to check for recurrences. I just hope that

this is a wake up call for both patients and doctors - patients to start asking

intelligent questions about the tests & procedures which they allow themselves

to be subjected to; and doctors to stop pushing some of these health screening

packages to laymen who may have the false impression that these tests magically

detect early cancer.

Wake up, people.)

Why Aren't Doctors Allowed to Care About Money?

Read this.

And this.

These two articles articulate very well the reality that has to be faced by all.

No, not all doctors are altruistic, nor should they be. Neither should they be ashamed of wanting to be rewarded financially for the work they do, same as anybody else, be they a banker, or engineer or waiter or plumber or bus driver.

Do not put us on pedestals and think that we are noble creatures who would work for less than what we are worth. We don't deserve to be on that pedestal. We do what we do because it's our job. And we should be paid for doing that job. We are not God. We have families to support, dreams to aspire to (some more expensive than others), children to educate.

We are human, after all.

Manage 'managed care'

THE Jan 6 report ("Docs may face changes in ethics rules") highlighted the three ethical issues which the Singapore Medical Council (SMC) is grappling with, namely, organ donation under suspicious circumstances, overcharging by doctors and the possibilities for manipulation by managed-care companies.

The American Medical Association recently revealed that two-thirds of 200 doctors polled in the United States said they would misstate the reason for a diagnostic test for Medicare insurance reasons.

A recent survey revealed that most American doctors support a "single payer" plan that will eliminate the central role of private insurers.

Doctors in many countries are resenting the iron hand of large companies as they are held to ransom by insurers and large hospital chains. The corporatisation of health care is producing a seismic shift in the way doctors look at public health care.

They are experiencing a sudden loss of control at the hands of the insurers and hospital networks, while being snowed under by paperwork and bureaucratic battles with insurance companies over authorisation and payments.

The SMC should consider these global trends and tread carefully lest our health-care system is hijacked by the insurance companies.

Heng Cho Choon

Perhaps unbeknownst to the author, this has already started to happen in Singapore....

Wise Words from a Wise Man

Oh, Prof Feng, I love you...


Good health not just about weight, says a 'lighter' doctor

I AGREE with Dr Yik Keng Yeong ('Excellent doctors despite wide girth; July 19) that doctors should look their part.

Since my girth has been mentioned, your readers may wish to know that I have lost 10kg after three years, but am still trying to lose another 5kg, which so far has proven to be mission impossible. This is because I enjoy food, in particular, roti prata, cheesecake, char kway teow and ice kachang.

However, obesity is only one of the risk factors of poor health. Recent research has shown that about 20 per cent of obese people are perfectly healthy with normal cholesterol and blood sugar, and a good family history. They also live a long and healthy life.

My late friend, Professor Chao Tzee Cheng, used to tell me that 30 per cent of people who die suddenly of heart attacks are not obese, but they indulge in unhealthy habits such as smoking, excessive alcohol intake, lack of exercise and risky sexual behaviour, and have a poor diet and poor family history.

Good health is a lifelong journey and you start when you are young. Parents must instil in their children healthy lifestyle habits such as having a good diet, regular exercise, not smoking and not drinking alcohol, as well as prevent childhood obesity.

Good health is not a number, be it your age, weight, body mass index, how often you jog or the number of kilometres you run. It is a sense of well-being physically, mentally, socially and spiritually.

In this regard, the National Arthritis Foundation, together with a geriatrician, is organising a number of seminars and talks in the latter part of the year and next year to address issues of health literacy, active ageing and patient empowerment.

We need to change the whole concept of health, focusing more on prevention and self-management. The present debate of 'girth and health' is simplistic and does not address the more important issues of good health.

Professor Feng Pao Hsii
Chairman, National Arthritis Foundation

Prof Feng was one of our professors in medical school. Like the late, great Prof Chao (mentioned in his letter), he was (still is? Have not seen him in years) rather rotund & a wonderful teacher.

I wish that more people could appreciate the truth of what he has to say about health being more than just a number. Today's society is incredibly obsessed with appearances especially how heavy one is. Look at how popular weight loss drugs are, to the point that many doctors have been charged (in Singapore, anyway) with indiscriminate dispensing of appetite suppressants like phentermine. I used to have patients with BMI's of 18 coming to my clinic asking for weight loss medication!

Open your eyes, people. Good health is not just skin deep.

Being a doctor is a tough business

ST Forum Wed April 7, 2010

"Being a doctor is a tough business

DR GARY Ang's reply ("More doctors may drive up costs", March 30) to Mr Choo Kay Wee's Forum Online letter ("More doctors, lower health bill?" March 25), suggesting that more practising doctors may drive up total medical costs, seems to fly in the face of conventional market wisdom.

Among other things, because we are now training three times as many doctors as in the 1970s and the doctor-to-patient ratio has dropped dramatically, doctors as a commodity have relatively depreciated in value and they command a lower asking price for their services. The increase in medical charges almost always is down to the escalating cost of medicine and other costs of doing business, with doctors' incomes stagnating.

That enterprising doctors create little niches for themselves to generate income is a sad but realistic reflection of how market forces have driven the practice of medicine to become a commercial trade.

Mr Choo delights in the prospect of having a trained doctor in every family, seeing this as a way of bringing down medical costs. A few years ago, the Government estimated the cost of training a doctor with a basic degree to be about $500,000. From a pecuniary point of view, Singapore would be far better off importing doctors of other nationalities; it would be far more cost effective and feasible than training a doctor in every family.

As it is, many patients have noticed that the medical staff in polyclinics and hospitals have turned into a veritable United Nations of sorts."


Let's see how long it will take before the snide comments come up in response to this letter to the ST Forum....

Bugs, Bugs, and more Bugs

This has been a brutal Winter, health-wise. Our family has been attacked left, right & center by various viruses (in all likelihood including the swine variety) since October, with sniffling, sneezing, coughing, wheezing, fever, copious mucoid production, congestion (not necessarily in that order) affecting one or more of us almost consecutively.

My usually ample supply of meds ( I keep a good stock of pharmaceuticals at home as I find it a pain to go to the local clinic where they charge exorbitant rates for consultation & end up giving medication which I could very well have prescribed myself) has been almost depleted & I will need to replenish it on my next trip to Singapore next month.

We all had the flu shots (the regular one, not the H1N1) - whether or not it helped, who knows. For some reason, I seem to be the least affected one of the lot. Yes I still get the symptoms but to a milder degree than the rest of the family. Maybe it's because of my previous abundant exposure to all the URTI patients that I had had to see in the polyclinics/general practice that has fortified my immune system so that I have the immunological memory of literally, a thousand & one types of antibodies . I guess some good came out of that. :)

Now if only my brain memory was that great...

Ignoramus

Do more to lower GP charges (ST Forum, February 19, 2010)

Another example of how the average Singaporean perceives a GP's work & his worth.

I wonder if he knows that even with the guidelines in place, GP's were still charging lower than recommended rates for consultation?

I wonder what his definition of "reasonable" is?

I wonder if he knows that the GP needs to pay rent for the clinic space, & that more often than not, this rent is exorbitantly high?

I wonder if he knows that the GP also needs to pay the salary of his clinic assistants and/or nurses?

I wonder if he knows that most GP's have to work day & night & weekends in order to support himself & his family?

I wonder if he thinks that the GP should aspire for a good life & standard of living for his family?

I really wonder....

"Don't Be Evil"

I read this article about Google's threat to leave China & for some peculiar reason, it reminded me about the doctoring situation in Singapore. I've been getting negative vibes from reading about complaints left, right & center about doctors' overcharging for their services, bad outcomes from aesthetic procedures, death from liposuction, doctors being late at their clinics, and so on & so forth. Being a doctor in Singapore does not seem to be something that is looked upon very favorably at the present moment.

Much of the negativity is probably justified. However, that doesn't take away the disheartenment I feel and even some sadness to see my profession being given a bad name. It seems like the media has focused on the bad apples rather than the good ones, which doesn't help matters at all.

I guess for me, Google taking a stand for their beliefs against the Goliath that is the Chinese government is akin to those family practitioners in Singapore who slog on & practise good medicine & not succumb to the temptation of the all mighty dollar by going into aesthetics exclusively, which many have done so.

Whether or not Google will follow through with this threat, who knows?

I, for one, am hoping that they will. Although it may not make economic sense, it would leave some spark of hope that for some, money is not the be all and end all of everything, and that standing up for one's beliefs and doing what is right is more important.

Don't Be Evil.

Do No Harm.

Sound very similar to me.

It's He...ere...

The H1N1 virus has reached my boys' school. It was a MOT anyway, I reckon.

One child has been diagnosed with it, so his whole class has to stay home for the rest of the week for observation.

I hope they won't have to close the whole school down.

We'll just have to wait and see if the madness ensues...

Homicide

Definition: a killing of one human being by another (from the Merriam-Webster's Online Dictionary)

Michael Jackson's death has been ruled a homicide by the coroner. Whether or not his physician will be criminally charged remains to be seen.

This is a sobering reminder of the power that lies in the hands of physicians, in the form of know-how & accessibility to drugs, equipment, procedures and technology, that, if used wrongly or negligently, can result in death. Sometimes, even when used correctly, patients die, due to errors or unforeseen circumstance. In techno-babble, when something like this happens, it is called an Adverse Event.

When does an Adverse Event become criminal? I don't know the answer. I am positive that Dr Murray did not mean to kill Mr Jackson. But if he did administer all those drugs as reported, IMHO, that would amount to negligence.

Someone once said: "With great power, comes great responsibility."
(No prizes for guessing which movie this came from & which character said it :)... )

Why this particular doctor chose to do what he did...we can only guess that it was likely to be a combination of the lure of money + the fact that it was the King of Pop himself who had demanded the drugs to be administered.

Wealth and Celebrite can be a deadly combination.
Heath Ledger.
Anna Nicole Smith.
And now MJ.

What a waste.

McAllen, Texas and the high cost of health care: newyorker.com

McAllen, Texas and the high cost of health care: newyorker.com

Shared via AddThis

This is an insightful commentary on the state of health care in the United States.

Dr Gawande's suggestions on how to cut costs certainly make sense. Problem is: how receptive would doctors be to improving quality instead of quantity (i.e. making less money).

I see parallels happening (or already happening) in the state of health care in Singapore. I wonder which direction our doctors will follow? Towards quantity where the money lies? Or towards quality?

Hah???

I read this and said "Hah???!!!"

So I searched and found this and said "What???!!!"

Only 87 responses.

I hope this doesn't mean that the proposed changes will be adopted in its entirety based on this feedback.

That would REALLY suck.