Gray

I've blogged about this.

Mr Wang, Dr Huang, and Angrydoc have all blogged about it too.

This letter in today's ST Forum, together with several others, tells it from the viewpoint of the patient.

It's a tough call to make. As doctors, we tend to look at the world through rose-tinted glasses, where altruism is the best way to get things done (well, maybe not so much anymore in today's society). But till we can walk in the shoes of someone who is actually suffering through organ failure, are we equipped to moralize & lecture on what is right or wrong about $$$ being involved in organ transplants?

As I've said before, this needs to be looked at from different perspectives...

Feeling the Pain

I only read this article written by SMA President Dr Wong Chiang Yin this morning. Thanks to the wonderfully efficient China postal service, I only just received my APRIL SMA News yesterday afternoon. Grrr.

Anyway, Dr Wong gives a very detailed overview of what kinds of obstacles & risks GP's face when they take on Managed Care contracts. This article reinforces the disillusionment that I was starting to face when I first contemplated stepping away from clinical practice a few years ago. It makes me wonder how my GP colleagues can "tahan" the day to day slog of having to deal with all this c**p, & at the same time try to make a decent living. And I can see why the lure of aesthetic medicine is all the more appealing.

In another article in the May issue of the SMA News (which I had to read online, otherwise I would have to wait till July to get the hard copy), Dr Wong talks about the pain that is being felt by the Medical profession in Singapore. He writes optimistically that, with the SMA, we will be able to work through & learn from the pain.

Me? I think I am more skeptical than him in this respect. The SMA alone cannot do it. They have to get buy-in from The Powers That Be. Otherwise, they will fight a losing battle.

Hands On

Man, I wish this recommendation had come out years ago.

The one & only time I've ever done mouth-to-mouth resuscitation to a real-life human being was several years ago in my first month of work in a downtown GP clinic. Security had called up to inform us that someone had fainted & they were bringing up the lady. This was at lunchtime when I was one of two doctors on duty, the other one having gone out to lunch, & we were operating on a skeleton crew of clinic assistants.

As soon as I saw the patient's condition, I knew this was not a simple case of syncope, but that she was in cardiopulmonary arrest. She was blue, no pulse, no respiration, & probably had been in this state for at least 15 minutes judging from what the security guard told us.

Adrenaline kicked in immediately as I called for one of the nurses to help me give CPR & look for the crash cart which no one could find as the assistants in charge of "taking care" of the cart had gone out to lunch...so much for being prepared.

Anyhoo, given the urgency of the situation, I had no choice but to give direct mouth-to-mouth resuscitation while the nurse did chest compressions. Fortunately, the patient had a relatively dry mouth (could have been bad - use your imagination). Unfortunately, given that she had probably been down for at least 15 minutes, despite our continued attempts at CPR, there was no response. The ambulance medics continued CPR as they brought her to the nearest hospital.

Alas, this was not a happy ending.

Beautiful again

Well, it looks like the recent publicity over the regulation of aesthetic medicine (or rather, the lack thereof) has stirred up quite a hornets' nest. After the initial article which seemed to imply that MOH was going to clamp down on doctors performing scientifically unproven aesthetic procedures & prescribing what was referred to as 'snake oil', MOH has just put out a press release that seeks to clarify its position on this issue (implying that there was incorrect reporting before! I, for one, would have liked to know exactly what a certain reporter's interview notes contained when she obtained the information from MOH).

Dr Huang & angry doc have both commented on this.

It's a good thing, I think, that so much publicity has been generated by this. It serves as a cautionary alert to both patients and doctors:

Patients because, obviously (& hopefully), they would be more discerning & careful about seeking such treatment & (hopefully) do more research into the various options offered to them by their aesthetic physicians....a buyer beware kind of situation, if you like. Which is kind of sad really, when you think about it, because we are talking about that (supposedly) sacred doctor-patient relationship which previously was held at a higher level of esteem than it is now.

Doctors because now, those few black sheep who may previously have been lackadaisical & perhaps, even less than ethical about the kinds of aesthetic treatments & procedures they perform on their patients, have more eyes watching them & what they do. Which will (hopefully) discourage them from continuing with any inethical practices.


To me, (and this may be opening a Pandora's box) this whole debacle seems to highlight the woeful lack of patient advocates in Singapore. And I say this as a doctor: patient advocacy may very well be exactly what the medical profession needs to stay true to its ethical standards & conduct, and what is needed in order for it to "self-regulate" effectively.

Beautiful no more

STRAITS TIMES
March 20, 2008
Ministry wants doctors to stop 'aesthetic' treatments

It will act against those who persist with unproven beauty treatments
By Salma Khalik

THE Health Ministry has decided to put a stop to doctors offering patients a range of controversial, unproven beauty treatments.
Banning these treatments threatens to wipe out millions of dollars in business for countless doctors engaged in the lucrative 'aesthetic medicine' scene.
Dr Tan Chor Hiang, the ministry's head of regulations, told The Straits Times last night that they will be advised to 'stop these practices immediately'.
'Recalcitrant doctors will be referred to the Singapore Medical Council,' she warned. The profession's watchdog is already investigating the aesthetic medicine practices of six doctors, including a specialist.
The ministry has been concerned about the booming aesthetic medicine market, estimated to be worth $200 million a year.
Over 1,000 general practitioners (GPs) and specialists have taken to offering a wide range of unproven treatments - everything from fat-busting injections and skin treatments to remove flaws or 'whiten' the complexion, to applications of growth hormones or stem cells for a more youthful appearance.
'This is not medicine,' Dr Tan said. 'Such services should never be offered on the pretext that they are medical in nature and are medically beneficial.'
The ministry began cracking down on such practices from September last year, telling about 20 of the bigger operators to stop.
Prominent plastic surgeon Woffles Wu and anaesthetist Christine Cheng were among those targeted. They complied immediately.
Dr Cheng was unhappy to have been singled out, and asked why the ministry did not inform all doctors.
The ministry explained that it did not realise earlier how widespread aesthetic medicine had become.
'Doctors are also advertising these services more aggressively,' Dr Tan said.
An online check showed close to 30 clinics still promoting the treatments, including mesotherapy which involves multiple injections of drugs to dissolve fat. This treatment is not allowed in some countries.
Madam Halimah Yacob, head of the Government Parliamentary Committee for Health, welcomed the ministry's ban, saying people trust doctors to provide approved and safe procedures.
But she wanted more action to regulate such treatments 'or they may end up in unauthorised beauty salons which could be worse'.
Dr Tan said the ministry's main concern is 'doctors performing unsubstantiated procedures, being unethical and subjecting patients to unacceptable health risks'.
'Without having proper scientific evidence, it is not known whether these practices can cause harm in the medium or long term,' she said.
The ministry is in talks with the Academy of Medicine and the College of Family Physicians to draw up proper procedures and the minimum training doctors need before offering them.
'Once these standards are ready, they can be used for regulating the practice of such procedures,' she said.
salma@sph.com.sg
Copyright © 2007 Singapore Press Holdings.

I can hear the collective flush of money going down the toilet after reading this today. Many a GP will feel utterly depressed, I think, seeing their profit churning procedures "banned".

My question is: What about TCM? It even has its own regulatory branch within MOH. Using the same words as the ministry's head of regulations: 'Without having proper scientific evidence, it is not known whether these practices can cause harm in the medium or long term'.

Why the discrepancy? Why is it OK for this type of non-evidence based "medicine" to be practised & not another?

Don't get me wrong, I wholeheartedly support MOH's efforts to clamp down on unproven procedures being used on patients. But what I don't appreciate is the double standards.

Mile High SOS

So, the excitement of the day for me was being called to render medical assistance to a passenger on the flight from Singapore back to Beijing.

Fortunately, turned out to be nothing too serious...syncope due to mild dehydration, due to excessive alcohol intake(!!!).

When the flight attendant first approached me to ask for help, my panicked mind was thinking about the case a few weeks ago where a passenger suffered what sounds like a heart attack while on a flight and died. The inner me was saying, "Oh sh*t, don't let it be a heart problem!" while outwardly appearing as cool as ice.

Anyway, all's well that ends well. That's my adrenaline rush for the day.

Hmm

TODAY ONLINE
When losing fat gains you a whole load of trouble

Tuesday • March 11, 2008

ALICIA WONG
alicia@mediacorp.com.sg

THEY offer shortcuts to weight loss at cheaper rates. But as more general practitioners (GPs) enter the growing market for liposuction in Singapore, the problems that arise are proving a costly burden for unwary consumers.

Today understands that the number of complications following liposuction procedures — such as patients going into shock from too much blood loss — is on the rise, with at least one near-fatal incident.

Last week, Health Minister Khaw Boon Wan told Parliament that the Ministry of Health had "unconfirmed feedback" of complications from liposuction done in some outpatient clinics. When contacted, the ministry said it could not comment as "there is a case which is currently under Singapore Medical Council investigation".

Echoing the view of most plastic surgeons Today spoke to, Dr Hong Soo Wan said liposuction was "safe if done properly under well-trained hands in a proper manner" but under inexpert hands, the risks increase.

Infection, for example, could set in if the facility is not sterile or well-equipped, or if the surgery is not done properly.

More common are patients who turn to plastic surgeons for revision surgery — on average, five or six cases in the past year, compared to one or two the year before. At the extreme end of the scale, plastic surgeon Dr Woffles Wu saw as many as 30 cases of botched liposuctions performed by GPs within the past year.

Results include irregular contours, scarring or skin rippling from too much fat removal, said fellow professional Dr Ivor Lim. His patients — women from their late-20s to mid-40s, some of whom are foreigners — were too scared to go to their original doctor and required "a lot of hand-holding" when they consulted him for revision surgery.

Said Dr Lim: "This is affecting our national credibility as a medical centre of excellence. Foreigners think because we are so tightly regulated, if a GP says he's trained, he should be qualified."

Prices advertised by GPs are one huge draw. While plastic surgeon Dr Martin Huang charges "well over $10,000" for a patient who wants "a lot of work done," he estimated a GP's fee would be half that.

But as one secretary in her mid-20s discovered, this can prove a costly gamble. She paid a four-digit sum to a GP for a liposuction procedure — then another five-digit fee to correct the results, after discovering uneven contours along her thigh.

"The doctor claimed he was trained in liposuction. When I raised the issue, the clinic kept saying it would go away," she told Today. It did not even after two years.

So, should GPs and other specialists be allowed to undertake plastic surgery? Or should Singapore go the way of France and Malaysia, which have made it illegal for non-plastic surgeons to perform such procedures?

Some say this call by plastic surgeons for more regulation is motivated by a turf war. There are 35 registered plastic surgeons here and more than 1,400 GPs.

"Plastic surgeons seem to think that GPs and other specialists are invading their turf," said a gynaecologist who also performs cosmetic surgery and liposuction.

"We need to move away from the mindset that you need years of training to perform plastic surgery. Doctors go for a weekend course, but also educate themselves at home. Some train overseas under plastic surgeons, some even practice on dead bodies."

Another GP with training in aesthetics said: "Complications can arise from all forms of surgery, sometimes from the doctor's lack of skills, other times from the suitability of the procedure for the patient."

He has "heard and seen first-hand" the problems arising at the hands of GPs and plastic surgeons.

He added that with newer drugs for local anaesthesia and newer techniques, certain liposuction procedures can be performed in the outpatient setting — with backup plans to evacuate to the nearest hospital if needed.

But Dr Wu is adamant — he points out that while specialists may have surgical training, it is not in plastic surgery.

Dr Huang noted that with many GPs now calling themselves aesthetic physicians or cosmetic surgeons, patients could be misled into thinking they are plastic surgeons.

"We are not saying you can't do this work, but get trained and qualified. Become a bona fide plastic surgeon."

Playing it safe

Check the list of registered plastic surgeons at the Singapore Medical Council website.

A qualified one should have a Fellow of the Academy of Medicine, Singapore (FAMS) in plastic surgery.

Get a fully qualified anaesthetist.

Understand what results to expect from the procedure, eg before and after photos of the surgeon's work.

Provide your doctor with a full medical history.

Copyright MediaCorp Press Ltd. All rights reserved.

Is this MOH's way of making their displeasure known? Let the media "expose" the GPs & stir up the masses before putting their foot down on aesthetics practice by GPs? I wouldn't be surprised. It seems to be the path they are taking .

Beautiful

Straits Times Feb 18, 2008
GPs quizzed on shoddy cosmetic treatments

Health Ministry is also looking at regulating aesthetic medicine
By Judith Tan

AT LEAST 20 doctors have been questioned by the Health Ministry in the last five months on their shoddy aesthetic practices.

This is part of a ministry clamp down to ensure general practitioners offering treatments such as Botox and collagen injections are appropriately trained.

A ministry spokesman told The Straits Times it is studying the regulation of aesthetic medicine - something the plastic surgery fraternity has been fighting for.

'Doctors who performed aesthetic or other health-related procedures need to substantiate them with scientific evidence on safety and efficacy,' she said.

GPs using unsafe practices will be referred to the Singapore Medical Council (SMC) for disciplinary review.

The medical watchdog told The Straits Times it received six complaints last year on aesthetic procedures performed by GPs.

Its spokesman declined to comment on complaints against specific doctors as investigations are on-going.

The MOH surveillance is a move away from its previous hands-off policy which favoured self-regulation by the medical profession.

Plastic surgeons, however, are up in arms over the leeway given to GPs to dabble in aesthetic medicine. They fear the public would be misled into thinking non-plastic surgeons are trained in surgery.

With a rise in the number of people wanting cosmetic treatments, some GPs have moved beyond coughs, colds and flus to performing cosmetic services.

Some have even become hugely successful in this field. Typically, a patient pays between $300 and $1,200 for Botox treatment to get rid of wrinkles. Treatments may be once every three months.

There are more than 1,400 registered GPs in Singapore. Although the number of GPs offering aesthetic treatments is growing, there is no official figure on how many of them are doing so, said the Singapore Medical Association.

The Straits Times understands that some GPs pay anything between $2,500 and $8,000 to attend online courses for which they receive the diploma a week later; or attend day-long seminars on procedures to be qualified.

Doctors say patients with botched treatments are unwilling to press charges because the procedures are private matters.

Another reason: GPs provide corrective surgery for botched treatment and patients are afraid payments would stop should they complain.

One patient, a 28-year-old woman who did not want to be named, had gone to a GP for fuller lips.

But she was injected with too much of the wrong type of lip filler and collagen, and ended up looking like a 'duck'.

Alarmed by the results, the GP - who the patient declined to name - brought her to a plastic surgeon who performed surgery to drain the filler. The GP is still paying for her follow-up treatments.

Dr Ivor Lim, consultant plastic surgeon with The Plastic & Hand Surgery, said aesthetic GPs are only trained in administering procedures like injecting Botox or collagen. 'But when things go wrong, they don't know how to correct the mistake or how to manage the complications. That is where the problem lies.'

MOH feels regulation would help ensure quality of treatment, its spokesman said.

Dr Chai Chin Yoong, a GP and medical director who started a clinic offering aesthetics and weight-management programmes at the Parkway Shenton medical group, thinks there are pros and cons to regulation.

'On the one hand, regulation will not only ensure quality of the work done, but also allows insurance companies to define a premium to cover the doctors,' he said.

But it would also mean that doctors will have to attend courses at approved institutions. 'This would mean higher fees, which would probably get passed on to patients,' he added.

It's about time for this to happen. It would only make sense that there be some kind of control over aesthetic procedures performed by GP's. I had never quite understood the Ministry's previous stand of self-regulation where aesthetic medicine was concerned.

I had been quite appalled to see "aesthetic practitioners" sprout up right, left & center all over Singapore, whether it be in the HDB heartland, or in the midst of the bustling CBD district or the residential enclaves of districts 9, 10 & 11. I wondered when the bubble would burst, and when the Ministry would realise that the ignorant public did not have the know-how nor the common sense to double check if the doctor he/she went to for their various aesthetic procedures had the training & the experience of doing a proper job, and more importantly, to do some research into what the possible complications of a botched job could be.

In the land of people willing to pay thousands of dollars for an aesthetic procedure & yet balk at coughing up $30 for a GP consult + medication to treat an URTI, I do not blame GP's for trying to make a living with aesthetic procedures. Some probably have gone for training. But a one-week course does not an aesthetic physician make.

As a doctor, I would be ethically bound to ensure that I have the appropriate training & experience in whatever invasive procedure I would perform on a patient. (And yes, chemical peels & Botox/collagen injections ARE invasive). In a prior job, I had been asked before by my boss if I would be willing to perform chemical peels on patients as this was a very profitable endeavour. I had always declined because I never felt that I had the qualifications nor the know-how to do it.

I am glad that MOH is starting to feel the same way too.

War of the Worlds

This & this does not augur well.

Signs of the coming of the feared pandemic? Maybe not quite yet. But this is just a small example of what could happen when vaccines don't work as well as they should.

And the ever-changing, ever adaptable influenza virus looks to be developing resistance against Tamiflu, which so far had seemed to be the last stalwart against it.

Not quite a "War of the Worlds" scenario, but just goes to show that no matter how technologically advanced or mighty the human race may be, the fight against these tiny microbes, who have existed much longer than the homo sapiens species, continues...and we may not turn out to be the victor.

Docs Outraged....

...and well they should. My initial reaction was also that of outrage. An insurance company wants US to squeal on our patients???

I'll be the first to admit that among my patients in one of my past jobs included those sent by insurance companies for checkups before they buy insurance. These were patients who KNEW why they were going for the checkups & signed declaration forms saying that they were basically telling the truth & allowing the examining physician to reveal whatever medical condition they had to the insurance company. This is very different from the case mentioned in the above article, where the insurance company in question wants physicians to tell on patients who are already insured, hoping to catch them in a lie. This goes against the very grain of doctor-patient confidentiality. And all in the name of profits (for the insurance companies & their shareholders).

The issue of health care costs & the uninsured is one that is & has been in the news, whether in the US or Singapore.

FACT: EVERYONE will need health care sooner or later.
FACT: Health care IS expensive
FACT: Not everyone can afford the best quality care
FACT: There are grey zones as far as what is considered "best" quality care is concerned, & we can argue till the cows come home over what constitutes good, better or best care.

Bottom line is: how do we address these problems? The Singapore government is promoting means testing, which, if you think about it, makes a lot of sense. If you can afford it, why not pay for it? The problem then arises with how one gauges whether one can afford it or not.

I am no economist; but I can understand the concerns of the middle class who may fall into the cracks of means testing because they make just a bit too much income to pass whatever test they need to pass to get 'x' amount of subsidy. I'd like to see the means by which MOH will do the means testing (pardon the pun).

I don't think health insurance is a bad thing. But when the $$$ sign becomes more important than patient care, the alarm bells start to go off.

Getting Healthy

It's been over 2 months since I've started going to the gym on a regular basis. As in really regular, 3 times a week without fail, with at least 30 to 45 minutes of cardio workout, & a bit of weight training on targeted muscle groups, the latter to strengthen muscles that support joints like the knees & shoulders which I've been having problems with.

As I get older, health matters become more of a concern. I know it sounds strange coming from a doctor, but doctors can be the worst patients. I know in my case, I haven't exactly been the paradigm of health as far as my weight & eating healthy was concerned. And I had my VERY FIRST HEALTH SCREENING just over a month ago. I know, I am very bad. So my LDL is slightly high, but HDL is at a nicely high level too. But my TG's need to come down - so I guess that means trying to eat fish & perhaps taking omega 2 (Jan 28 -correction: should have been omega 3) fatty acid supplements.

(The good news is that I have been religiously regular with the female checks like the PAPs & the Mammos & the US scans).

In my schooling years, I had always been active, with ECAs (as it was known then) & in university, with representing the medical faculty in various sports. So my activity level had always been decently healthy. Then after graduation from medical school, housemanship & MO ship started & I needed to find time for other things (like sleep!). Although I had had sporadic periods of time during which I went to the gym or played various kinds of sports once or twice a week, I inevitably found myself stopping due to either lack of time or different priorities coming up (like children!). I am sure many working parents succumb to the same trap; whether or not it's avoidable, that's arguable.

The turning point came after my thumb injury last year, as I became terribly sedentary during the recovery & rehab period, & felt myself getting more & more lethargic. It's a vicious cycle, really. The less you do, the more lethargic one becomes. So I decided - that's enough lazing around, aliendoc. You need to get off your butt & get healthy again.

In the months that I've become more active, I have found myself with more energy, & feeling less lethargic. If I miss out on a day of exercise, I find myself feeling uncomfortable, & bloated. Perhaps its the endorphins & adrenaline doing their jobs. Whatever it is, I need to continue working on it, not so much to lose weight, but for the sake of my cardiovascular health.

I hope I can persevere.

Better

“Better” is a book written by Atul Gawande. He is a general surgeon working in Boston & also an assistant professor at Harvard Medical School & the Harvard School of Public Health. He writes about performance in Medicine, what it takes to be better at what we do as doctors, and how do we measure this ‘goodness’, for lack of a better word.

He uses real-life examples to explain his points of view, which is one reason why this book is so immensely readable, especially for doctors. It could be you or me that he is talking about.

An interesting issue he raises is that of litigation. As we all know, it has become an almost nightmarish situation for doctors practicing in the USA as far as litigation is concerned. Malpractice insurance premiums have skyrocketed especially for specialties like obstetrics & neurosurgery.

On the other hand, there ARE patients who have suffered as a result of medical errors. What recourse do they have if not for malpractice suits? Gawande highlights an approach that has been used by vaccine manufacturers which seems promising.

See, previously, the vaccine manufacturing industry was threatened by lawsuits from patients who had suffered from side effects of vaccinations. Out of the millions of patients helped by vaccination, one in ten thousand is affected by side effects. Like anything in medicine, there are always risks involved, even for the most mundane procedure. These victims would then file for damages (talking billions of US$ here). Because of these lawsuits, some vaccine manufacturers went out of business, prices of vaccines hiked up, stockpiles dwindled (you get the picture).

So the US government came into the picture. A 75 cent surcharge was imposed on each vaccine. This money went into a fund for children who are harmed by the side effects. A panel of experts had come up with a list of known injuries from vaccines, & whoever suffers from any of these injuries would be compensated, whether the injury is due to negligence or bad luck. Those still unhappy can still sue but apparently, few have.

Putting this in practice for physicians is a monumental task. Who would qualify for compensation? How do you put a dollar amount to an injury or disability or death due to medical error? Would doctors buy into such a scheme?

Another interesting issue he raises is that of falling income of doctors, mostly due to the fact that health care costs are managed mainly by insurance companies. Doctors not only have to deal with managing their patients, but now are faced with having to tread through the oftentimes obstacle-ridden course of managed care. End result: they lose money. Unfortunately, this seems to be happening in Singapore as well. Ironically, without insurance, many, including the well-to-do, would have a hard time covering health care costs. Medical care IS expensive. I don’t know the answer to this dilemma.

Picking & Choosing

This is an interesting article about recruiting & retaining physicians.

This was written by an American author for the US scenario, but I wonder how much of this would be applicable to the Singapore situation. With the "shortage"of doctors here, can the employers be so picky & use the guidelines listed in the article? ("Employers" here meaning the large group practices in the private sector & the two clusters that run the government polyclinics, which all seem to have a perpetual shortage of doctors).

I really doubt it.

Tree Man

This is the worst case of warts I've ever seen!!!

A real-life Ent - poor guy...I hope he finds a cure. Or at least some way of keeping it under control.

Oldies but Goodies

"There is no age limit for applications."

I was pleasantly surprised to see this in a recent mass mailing I received from a certain medical association calling for applicants for specialist traineeship.

2 years ago, in a similar letter (I guess they send one out every year), I noticed an age limit in place for applicants. When asked by a director in the public health institution I was working in at the time whether or not I was going to apply for traineeship, I gave him a wry smile & said that I was too old. Admittedly, I was flattered by the look of surprise on his face when he realized that this lowly M.O. was already the mother of a teen & a pre-teen (at the time) & already over-aged for such lofty ambitions (sarcasm intended).

So why the change in policy now? If I had to make an educated guess, I would say it is to try to make up for the perceived lack of doctors in the public sector. Whether or not this will make more senior doctors step up to the plate...we can only wait & see.

I am glad the age limit has been abolished (for now, anyway). After all, in this day & age, 40 is hardly considered over-the-hill. Yes, the eyes may be starting to go a bit, & some of us need reading glasses to read the small print; and the reflexes may not be as good as, say, a decade ago. But the brain power is still there. Plus the added years of experience of practising general family medicine I think is a huge advantage.

But I wonder how this will affect the teacher-trainee relationship, especially if the trainee is one who was already practising medicine when his teacher was still struggling with the PSLE! It will be interesting, to say the least!

So does this mean that I am considering applying? Nah...not right now. But who knows? Five years from now, when I am an empty-nester, I may reconsider it. But by then, the policy may have changed again...

Zagat for Docs?

Hmmm....what next? Michelin stars to rate doctors?

I have no issue with rating doctors...as long as it is done fairly. But when this is driven by an insurance company, it becomes quite suspect, really. After all, the bottomline (i.e. $$$) counts A LOT for these companies.

Plantar Fasciitis

Boy, what a pain this is.

I just read this article from Medscape about Plantar Fasciitis.

I am sure GPs will agree with me that this is one of the most common foot problems seen in their clinics. And treatment can be difficult as well as it tends to drag on or become a recurrent condition in some patients.

The article mentions most of the modalities of treatment we would generally use (although now, I tend to discourage patients from getting steroid injections into the affected area....damn painful, & also not advisable) but seems to have left out NSAID’s for symptomatic relief.

Oh, and I think they could have mentioned CROCS as well…. :)

Tough Calls

How does one make such a decision?

Oct 22, 2007

Weigh options when saving premature baby

I REFER to the article, 'Saving tiny tickers' (ST, Oct 11).

It is indeed heartening that medical advances allow the babies mentioned to enjoy a new lease of life.

Infant mortality has been reduced drastically because of the excellent medical care and services provided by Singapore's health-care workers.

However, we should not use the plain vanilla number of initial infant survivals as the basis of a job well done by health-care professionals.

This holds true, especially for extremely premature babies.

With advances in medical treatment, younger and younger 'premmies' are able to survive.

However, some will have disabilities, from minor to major, because of their early arrival and subsequent damage to their brain and under-developed organs.

If a baby is severely brain-damaged, where his quality of life in future is likely to be almost non-existent, should the doctor go all out to save the baby, just so he is alive for another painful day?

Or should the doctor let the baby die with dignity, through compassionate inaction?

Who should be the one to make such an important judgment call on the treatment (intensive, moderate and just enough to prolong the life, letting go) for the tiny patient?

For parents, this dilemma can be very much be like that of the relatives of a brain-dead patient.

It is therefore important that a clear standard set of rules and guiding principles be provided and adopted for extreme premmies' treatment, as this is a sensitive and grey area where emotions, and personal and religious morals and convictions play a big part.

It is important that the parents have a say in the premmie's treatment and can make informed decisions.

This is because, as parents, their decisions will be based on what is best for the baby.

Doctors should not be biased against their young patients' parents, even when the parents' views and opinions differ greatly from theirs.

Doctors should also respect parents' decision on treatments offered to the baby, even if they disagree with the parents' decision.

At the end of the day, it is the parents, not the doctors, who will have to care for the disabled child.

Thus, treatment options should be scaled towards what the informed parents want.

Olivia Siow Yan (Ms)

As a resident working in the NICU, I grappled with such dilemnae almost daily. Why save the premature, especially the severely premature, when the child eventually develops disabling conditions like cerebral palsy, bronchopulmonary dysplasia, ROP, all requiring long term medical care, with questionable quality of life. And the caregivers, having had to deal with the heartbreaking situation, are now saddled with a huge hospital bill, & look forward to a life time of probably repeated hospital stays & visits & seeing their child suffer.

But as a resident, one sworn to save lives, we pretty much did our damnedest to save even the most premature of babies until we knew that there was nothing much else we could do for him. I don't remember any one of the parents trying to stop us from doing so. I sometimes wondered why.

But then I became a parent. I then realized that the love one has for one's child, even unborn, is undescribably all-encompassing. I understand now, why these parents would want the doctors to try their damnedest, no matter how disabled or how much suffering their child might end up with. In a way, it's a selfish kind of love.

In any case, it's a tough call to make. To save or not to save. You tell me.

Mountains & Molehills

A case of who knew too much about Clooney

By Gina Piccalo, Los Angeles Times Staff Writer October 11, 2007

A New Jersey hospital is at the center of a storm over its suspension of 27 staffers. The action, over viewing of the actor's file, seems 'a little harsh,' his publicist says.

George Clooney's medical records and the hospital staff who may or may not have leaked them to reporters have caused quite a dust-up at a North Bergen, N.J., hospital this week, leading to a month's suspension of 27 staffers without pay and thrusting Palisades Medical Center into the rigorous churn of the worldwide celebrity news cycle.

The story was bested this morning only by Lindsay Lohan's whereabouts since rehab, and naturally hundreds of bloggers debated the hospital's actions. Camera crews flocked to the Palisades Medical Center, and reporters flooded the phone lines of the hospital and the union representing some of the suspended staffers.

"It is just sickening," said one hospital receptionist of the newshounds. "There's more important things going on in the world."

Indeed. But -- spoiler alert! -- those things won't be covered here.

Clooney and his girlfriend, Sarah Larson, took a spill while riding the actor's motorcycle in northern New Jersey on the afternoon of Sept. 21. Clooney suffered road rash and a cracked rib, and Larson injured her foot. They were treated and released from the hospital the same day.But news of the incident ricocheted around the Internet and made headlines around the world (as did subsequent footage of Clooney escorting his paramour as she teetered along on crutches).

Palisades Medical Center found itself at the heart of the news story and launched an investigation into staff access to Clooney's records. So far the hospital hasn't accused its staff of leaking the information to the press, but the investigation revealed that as many as 40 hospital staff members accessed the actor's personal medical records in apparent violation of federal law that bars staff members who are not directly connected to a patient's treatment from consulting a patient's medical records.

Since then the story has gained momentum, leaving the hospital struggling to go about its daily work while at the eye of a celebrity news story. The 27 staffers were suspended on Friday. The hospital released a statement today, emphasizing that its staff "adheres to a strong code of ethics that respects the privacy and confidentiality of all of our patients.

"Eurice Rojas, the hospital's vice president of external affairs, could not be reached for further comment.

A spokeswoman for the Health Professionals and Allied Employees union, which represents seven of the suspended workers, has publicly criticized the suspensions as premature until the hospital's investigation is complete. Some suspended employees may have been legally permitted to view the records, said union spokeswoman Jeanne Otersen.

"I'm looking at the Web and seeing how widespread [this story] is," she said. "Whether you are John Doe or George Clooney, you have the same rights to privacy. The same goes for the staff. They have rights too. Now you have a tenfold violation of his privacy. . . . I think there's a different way to handle it so that you both protect patients and educate workers and make sure that, while people are held accountable, there's due process."

For his part, Clooney -- known for his lively debates with the media on its treatment of celebrities -- has taken this latest security breach in stride.

On Tuesday afternoon, he issued a statement in defense of the staffers and emphasized that he had nothing to do with the investigation of the alleged leak.

"This is the first I've heard of it," Clooney said, referring to the suspensions. "And while I very much believe in a patient's right to privacy, I would hope that this could be settled without suspending medical workers."

"This is not our issue," Clooney's publicist Stan Rosenfield added today. "This is between the hospital and their employees . . . . This was not anything we instigated. We felt that perhaps suspending medical workers was a little harsh."

gina.piccalo@latimes.com


Yes, patient confidentiality is important & is well understood by health care workers.

But suspending 27 hospital staff for one month with no pay??? That's a bit much, isn't it?

I wonder if the same punitive action would have been imposed if the patient happened to be John Smith, plumber instead of George Clooney, movie star?

White Coats No More

This is a great move by the UK Department of Health.

White coats off, UK docs told

LONDON — British hospitals are banning neckties, long sleeves and jewellery for doctors — and their traditional white coats — in an effort to stop the spread of deadly hospital-borne infections, according to new rules published yesterday.

Hospital dress codes typically urge doctors to look professional, which for male doctors, has usually meant wearing a tie. But as concern over hospital-borne infections has intensified, doctors are taking a closer look at their clothing.

"Ties are rarely laundered but worn daily," the Department of Health said in a statement. "They perform no beneficial function in patient care and have been shown to be colonised by pathogens."

A 2004 study of doctors' neckties at a New York hospital found nearly half of them carried at least one species of infectious microbe.

Last year, the British Medical Association urged doctors to go without the accessories, calling them "functionless clothing items".

The new regulations, which will take effect next year, mean an end to doctors' traditional long-sleeved white coats, Health Secretary Alan Johnson said.

Fake nails, jewellery and watches, which the department warned could harbour germs, are also out.

Johnson said the "bare below the elbows" dress code would help prevent the spread of Methicillin-Resistant Staphylococcus Aureus, or MRSA, the deadly bacteria resistant to nearly every available antibiotic.

Popularly known as a "superbug", MRSA accounts for more than 40 per cent of in-hospital blood infections in Britain.

Because the bacteria is so hard to kill, healthcare workers have instead focused on containing its spread through improvements to hospital hygiene.

Doctors and nurses who do not adequately wash their hands pose a far bigger risk to patients warns Dr James Steinberg, an Emory University infectious disease specialist. — AP

When I was an intern, then an MO doing hospital postings, we had to follow a dress code, which meant ladies had to wear skirts (no pants allowed unless on night call), & covered shoes (meaning court shoes, not thongs or Croc-like sandals!) while the guys had to wear ties or bow ties. It was a pain especially when, as an intern, you had to do all the scut work, running around the wards, doing multiple rounds a day, setting drips, taking blood (no such thing as phlebotomists in my day :( ).

I don't know about other doctors, but I find it less of a strain on my back to squat next to the patient's chair or bed when setting drips or taking blood (& also less risk of exposing my chest to the male patients!!!). Try squatting in a skirt. If it's a slim cut one, damned difficult. If it's a flare skirt , you end up sweeping the floor with it. And the shoes...OMG, talk about plantar fasciitis & bunions!

I used to envy the docs I saw on TV wearing those oh-so-comfortable scrubs. I wonder why doctors in Singapore can't change into scrubs when they get to the hospitals (even if they are not working in the OR), & at the end of the day, leave them for the hospital laundry to wash so that they don't bring home all those nasty hospital germs.

Besides, I think scrubs are sexier looking than street clothes.

:)