Angry Doctor

Wednesday, November 30, 2005

The 2005 Medical Blog Awards

Yes, it's not a Bonus Bogus Story.

Click here to make your nominations.

I'll make my nomination as soon as I get permission from the blog-owner; I'm not nominating myself, in case you are wondering...

Tuesday, November 29, 2005

Apology to Dr Pezzi

A few days ago I posted a story from Dr Pezzi's website, and also a follow-up post.

Dr Pezzi has made the following comment in response.

"Being the author of that story, I am compelled to make a few comments:

1. In regard to "It's too bad that your story is written in what sound to me as an African-American vernacular, and political correctness would require that the language be fixed up a little" and "Yes, I too detect a racist undertone in Dr Pezzi’s account." I never mentioned the patient's race, so if you reflexively assume that the quoted speech is indicative of a certain race, then you might question whether you possess some racial stereotypes that lead you to make that assumption. Second, I think it is ludicrous to suggest that I am racist. My site is huge, so it is understandable that you missed something in it, but in that site I presented a sure-cure for racism . . . or if not a sure-cure, then it is far better than the usual ineffectual approaches.

2. In regard to "This is quite disheartening. One would think that with all the intelligence & hard work that it takes to get accepted into medical school, the admissions comittee would at least choose people with a heart, some common sense, and the tiniest inclination of empathic understanding ..." You are missing the point. The idealism and good intentions of most medical students is decimated (at least in the United States) after years of practice, and years of butting your head up against the wall. I used to think that I could change the world, or at least my part of it, but the denizens would still shoot and stab one another for a variety of insane reasons, such as "I want your tennis shoes." It's wonderful to see (or infer) that some doctors retain that idealism, but most don't. Decimation of idealism is also a problem in nurses. I have several friends who are nurses, and when I hear them speak behind closed doors about patients and how they've "had it" (and more!), I think, "Compared to them, I AM idealistic!" Burnout is very common in healthcare practitioners, yet the onus for dealing with this is usually left to the individual. That's not a good approach, in my opinion. Many of these problems are systemic and affect virtually every practitioner, so why not do the logical thing and attempt to solve or mitigate the problem instead of bellyaching about practitioners who become burned out as a result of the problem?

3. Finally, a message to "angry doc": Copyright laws permit short quotations and comments, not lengthy reproduction of a story, as you did. It's standard practice and legally permissible in blogging to have a short excerpt and a link to the original source. Taking as much as you want and linking to the source does not absolve you of culpability, so please replace your posting of my material with an excerpt and link instead of expropriating the entire story. Thank you!"

I wish to apologise to Dr Pezzi for implying that he is racist.

I have also modified the first post as required by Dr Pezzi.

Sweet Deal?

OK, a bit of medical education today, prompted by this letter from the ST Forum:

Nov 29, 2005
Detect diabetes with free screening

IN THE report, 'Not-so-sweet truths about diabetes' (ST, Nov 24), it was stated that 160,000 people here do not know that they have diabetes because they have never checked. About one in 10 adults here has the disease, double the world average.

Before we look into the problem, we need to know why these people do not go for medical check-ups. Is it because some of them cannot afford the cost of the tests?

Early this year I was fortunate to get a free medical check-up - for blood pressure, cholesterol level, blood sugar, etc - near Jurong East MRT station. But that was the only free screening this year. Such screening should be held more frequently, and publicised at all MRT and bus stations.

Sng Ah Beng

Fact, however, is that screening for diabetes in the general population is not cost-effective, and does not give better outcome for the persons screened.

So why are there organisations doing 'free' screening? Well, because just because it’s 'free' to you, doesn’t mean there’s no money involved…


Got Heart?

OK, no gossip but a letter from the ST Forum:

Nov 29, 2005
Houseman makes fun of patients' plight

MY MOTHER, Madam Chong Kwoi Sin, was warded for a major stroke at Alexandra Hospital (Ward 5, Bed 19) on Nov 17 and died in the evening of the next day.

On the morning of Nov 18, a group of housemen in their early to mid-20s went on their rounds to examine the record of each patient.

When the group stopped by the bed next to my mother's, a male houseman commented in an amused manner to his peers that the patient, who was not in her bed then, was of very light weight at 38kg. He laughed while repeating the comment loudly several times. 'I've never seen anyone so light!' he said.

Later, in the corridor just outside the ward, this same houseman held up my mother's CT brain scan and commented, again in a jocular way, this time to another houseman: 'She's still alive, meh?' He repeated the same insensitive remark without realising that I was within hearing distance.

As my heart was heavy and my mind preoccupied with the imminent death of my mother, I pulled her doctor, who was also a 20-something houseman, aside and told him how hurt I was with the insensitive remarks of his colleague.

I told him to tell his colleague that should I complain to the hospital's CEO, the young trainee doctor's record would certainly be blemished.

More importantly, I also told him to remind the young man that he also has a mother. He apologised profusely on behalf of his colleague and, to my surprise, was honest to admit that he, too, had made the same mistake of passing crude remarks, albeit innocuously, about his patients. However, he promised that he would not do it from then on.

Two hours later, my mother's doctor informed me that my message had been relayed to the houseman. I expected the culprit to come up to me to thank me for not reporting him and apologise for his loose tongue.

But this was not to be.

Thereafter, I noticed that he continued with his chatty arrogance, as if nothing had happened.

The haughty houseman demonstrated a high degree of thoughtlessness and a total lack of compassion and ethics, completely out of line with the noble medical profession. If he exemplifies the future of Singapore, my heart bleeds for the nation.

It is such an irony that Alexandra Hospital has this on its website: 'AH has promised to place heart, soul and mind to caring for the patients. Our staff are our best assets, central to the work we do and the level of success that we attain. We are prepared to commit the resources necessary to recruit, develop and retain the best staff. We take pride in providing them the best in training and development, and also in imparting a sense of empathy and care for our patients and community.'

Terrence Shan Chee Hoong
Hong Kong

I suspect the 'housemen' may really be medical students, but I won't be surprised if they were not.


Monday, November 28, 2005

Money for Nothing?

Came across this blog entry on Technorati, which discusses this study on the differences between public and private sector doctors in India.

I’m not sure how seriously to take a study titled “Money for Nothing - The Dire Straits of Medical Practice in Delhi, India”, but it seems like a topic worth looking at.

From the abstract:

First, what doctors do is less than what they know they should do - doctors operate well inside their knowledge frontier.

Second, competence and effort are complementary so that doctors who know more also do more.

Third, the gap between what doctors do and what they know responds to incentives: Doctors in the fee-for-service private sector are closer in practice to their knowledge frontier than those in the fixed-salary public sector. Under-qualified private sector doctors, even though they know less, provide better care on average than their better-qualified counterparts in the public sector.

These results indicate that to improve medical services, at least for poor people, there should be greater emphasis on changing the incentives of public providers rather than increasing provider competence through training.

Interesting. The scientific circle often goes to elaborate lengths to conclude something that seems self-evident.

The study seems to suggest that care (note that I say care, not service) in the private sector is better than that in the public sector. I wonder if the same can be said of the local healthcare system.

Firstly, do all doctors practise inside their knowledge frontier? Certainly in the public sector the doctors are under closer watch, although I have heard of a doctor being reprimanded for introducing unproven therapy in a major restructured hospital. But what about the private sector?

Secondly, while doctors in the private sector will try harder to please the patient, but that is not to say that the quality of care given is necessarily higher. Again, without any audit, the doctors may simply end up just trying to please patients rather than to provide them the best care. This state of affairs is possible because patients cannot and sometimes do not want to know the difference between good service and good care.

Conversely, doctors in hospitals and polyclinics are audited and their performance indices monitored. Being on fixed pay plus performance bonus, the incentive here seems to be pleasing the paymasters rather than the patients.

I don’t think one can say that fees correlate well with quality of care in the local healthcare system, or that it doesn’t, but I would certainly be interested to see a study done.

Angry doctor on the web 4

Found another angry doctor blog.

Hopefully the author will update it soon.

Saturday, November 26, 2005

The Stupidity Factor

Once in a while a poster makes a comment that I think deserves a new post in reply. This time it’s Anonymous’ comment on the post on stupid patients.

I’ll deal with the comment in parts.

"This is quite disheartening. One would think that with all the intelligence & hard work that it takes to get accepted into medical school, the admissions comittee would at least choose people with a heart, some common sense, and the tiniest inclination of empathic understanding…"

Like I said before, it is vain to imagine that you can in fifteen minutes tell if a teenager has the makings of a good doctor. Or that he or she has not, for that matter. If someone is intelligent enough to get the grades to qualify for an interview, he or she is probably also smart enough to fake sincerity for fifteeen minutes.

"… whether it be towards one's own culture, or the remotest culture on the face of this globe."

Yes, I too detect a racist undertone in Dr Pezzi’s account*. However, to expect us to have an understanding of "the remotest culture on the face of this globe" is probably asking too much.

(* - Please read Dr Pezzi's comment and my apology for this remark.)

"I, on the other hand, may be part of the intellectually vacuous group of people who hope, forgive how utopian this ideology may seem,"

It may not be an ideology, but your expectation is utopian. Not so much in that you expect all doctors to be compassionate, but that you expect heart, some common sense, and empathic understanding to allow us to do our job well in the face of a patient who cannot provide answers to straightforward questions. Empathic understanding only gets you so far. With some patients what is needed is telepathic understanding.

" … that physicians are capable of creating change in the world around them without disregarding all those around & below them."

I don’t think Dr Pezzi is hoping to change the world by disregarding those around him. Note also that while Dr Pezzi was angry, he did not (as far as the account went) let that affect how he managed the patient.

Politically-incorrect as it is, I think I agree with him that 'stupid patients' do exist, and they are a risk to themselves and a drain on the healthcare system because they tend to need more healthcare (because of stupid decisions they make, be it lifestyle choices or non-compliance to treatment and medical advice) and take up more time of the healthcare providers.

It doesn’t sound like your problem until the day you are waiting to be seen at the A&E and the guy before you is someone who is suffering from the result of non-compliance to a medication and it’s taking the doctor fifteen minutes just to find out what illness he is taking them for.

So my first question is: do we have the moral courage to admit that some patients are stupid and that they consume more healthcare, at the expense of the others?

If we do, the next question is: what are we prepared to do about it?

Well, my theory is that there are two main classes of stupid patients: those who can’t help it, and those who can. Let’s call them Type I and Type II.

Type I patients can’t help being stupid, but most of the time they are allowed to go through the healthcare system repeatedly with no remedial action taken because no one bothers about them. They can’t really be held responsible for their own choices and actions, so someone must.

Who? The family, I say.

Because so long as we allow them to carrying on getting their prescription and going through the follow-up visit without any way to check if they are compliant with the advice or medication, so long will the family continue to allow themselves to think they are not being negligent.

Yes, negligent.

I think it’s negligent to let an elderly parent who is not in the best state of mind to take care of himself or herself to see a doctor on his or her own. (Experience tells me that these children who neglect their parents are the same ones who will kick up a fuss when something goes wrong, in an effort to compensate for their own guilt of neglecting their parents.) But those who live alone and without support? I guess that’s when we have to do the best we can and hope for the best…

And in some cases, I believe the doctor himself becomes negligent.

I once saw an old man who kept coming to the clinic every two months to get three months’ worth of medicine. When asked, he claimed that he was taking the correct dose. I could have just turned a blind eye and let him take another three months’ worth of medicine and possibly overdose himself (I'd be in another posting by then), but instead I told him I would not prescribe him any more medication unless he came with a responsible relative. The son came later loaded for bear but after I explained my reasons he agreed to collect the patient’s medication and parcel it in weekly doses to him and check on him to make sure he is not taking an overdose.

I think we as a profession must acknowledge that some patients are a danger to themselves and should be supervised, and that we should have a right to refuse to continue seeing them unsupervised if their care is compromised. Controversial, I know, but we don’t let children sign consent forms for surgery either.

As for Type II patients, they are the ones I typically deal with in my stories. They are not really stupid, but choose to persist in immature thought patterns because they get away with it. Because doctors do not challenge them when they persist in unhealthy lifestyle choices, or remain non-compliant to treatment or advice.

Different doctors deal with them differently, and of course each patient calls for a different approach. I don’t think there is a universal solution here, but admitting that they are a problem and that we should not reinforce their immature thinking would be a start.

I know in the private sector standing your ground may mean a loss in business. That is unfair to the doctors who try to 'change the world', but that reality may soon change when the Health Ministry starts auditing all practitioners.

As for Anonymous, my last words are for you:

From my point of view, there are a few things you can do to help improve the situation:

1. Continue to demand that doctors should be people of heart and common sense. Yes, it is your right.

2. Take responsibility for any stupid patient in your family, if there is one. Go with him or her to the doctor to make sure he or she gets the best care.

3. Go to medical school and make a difference.

Thank you.

For the longest time

Came across this site while googling 'stupid patients'. I'm not endorsing any of the products on sale on the site, but I thought this story was worth reading.


" The fact that a patient is "mentally challenged" is not an acceptable means of defense in a malpractice trial. In reality, it is obvious that there is an increased risk of a diagnostic error being made in such a case, when the patient can give a history that is no better than that which could be obtained from an earthworm. However, malpractice defense attorneys would be loath to suggest such a thing, as this might appear as if the physician were guilty of intellectual snobbery. Actually, it's just life in the real world. People who are stupid have an increased chance of doing stupid things, and making errors in judgement (as when they are driving a car, for example) for which they may pay dearly. It is an indisputable fact that they have a higher death rate, and no amount of liberal pressure to phrase their shortcomings in euphemistically acceptable terminology is ever going to benefit them. Actually, by attempting to mitigate the stigma of the intellectually vacuous, they are perpetuating their misery. A problem cannot be overcome unless it is recognized, accepted, and dealt with. Anyone's intelligence can be improved through effort. Coddling the incompetent merely predestines them to a life in which they will never reach their true potential. "

That sounds harsh, but after a few years in this job you get really frustrated with patients not being able to tell you how roughly long they've been having that cough/pain/bleeding. And you know what? Chances are, the longer they take to remember the answer, the shorter the duration is.

Friday, November 25, 2005

Slow week...

Not so angry this week... so a comic from TalkingCock to start the day instead...

Thursday, November 24, 2005

"I remember you!"

Thursday evenings are when I take in the week's episode of Scrubs with a generous dose of sherry and dark chocolate and reminisce about my first months as a doctor...

In this week's episode the interns get their own medical students to mentor. I don't think I was ever assigned any student to mentor, although we did have students rotate through our wards, and when we could we imparted what little knowledge we had.

I didn't think I was making any impression on anyone, until one day, many years later, a new colleague recognised me as 'the houseman who bitched about everything when he was supposed to be teaching me'.

What a thing to be remembered for.

Well, I'm still at it, now with a slightly larger and more varied audience, and with a little more anonymity.

So now you know: angry doc has always been a complainer.

angry doc asks – 4

Where are the Dental Blogs?

Doctors blog. Medical students blog. Nurses blog. Nursing students blog. Pharmacists blog.

But I haven’t seen any local dental blog.

Don’t dentists blog?

What about Medical Social Workers? I’d imagine they have the most interesting stories to tell.

Wednesday, November 23, 2005

angry doc asks – 3

How do you pick your doctor?

The thing about being a doctor is, short of you having a condition that requires the attention of a specialist, you don’t really have to pick a personal doctor.

Or rather, you never had to pick blindly. You know which colleague to go to if you needed an MC or some drugs, and you also knew which of your colleagues you wouldn’t trust.

So when a reader asked me how to be sure the doctor she was seeing would not be a quack, I didn’t have an answer.

Help me out here: how do you pick your doctor? What makes you stick with him or her?


Life's a Gamble 3

Now ev’ry gambler knows
that the secret to survivin’

Is knowin’ what to throw away
and knowing what to keep.

’cause ev’ry hand’s a winner
and ev’ry hand’s a loser,

And the best that you can hope for
is to die in your sleep.

- The Gambler

Tuesday, November 22, 2005

angry doc asks - 2

Tortoise or Hare?

Prompted by what Oz Bloke and uglybaldie posted, I decided to find out something about the patient load in 'the west'.

Here is an interesting article entitled 'Turtles and Rabbits' from the American Family Physician site, and the follow-up article.

Seems like the situation (at least in the US) is not a bed of roses either.

How many minutes do you think your doctor ought to spend with you per visit?

angry doc asks - 1

Business, or personal?

I’ve actually run out of things to say this week, so I thought I would listen while you guys talk (or rather read what you guys write) instead for a change, if you will be so obliging.

In my reply to TTG’s comment in an
earlier post I quoted this passage from The Godfather (novel not movie):

"Tom, don't let anyone kid you. It's all personal, every bit of business. Every piece of shit every man has to eat every day of his life is personal. They call it business. OK. But it's personal as hell. You know where I learned that from? The Don. My old man. The Godfather. If a bolt of lightning hit a friend of his - the old man would take it personal. He took my going into the Marines personal. That's what makes him great. The Great Don. He takes everything personal. Like God."

Of course, in the movie what Michael said was:

“It's not personal, Sonny. It's strictly business.”

I have no idea why Francis Ford Coppola decided to change the line, but I think you will agree that it gives a totally different spin to the whole story.

I’m not sure which version I prefer.

As doctors we deal with people. People whose ailments are very real and very personal to them. Every pain, every discomfort, every disability, every loss.

We sometimes take the bad outcomes that patients encounter as the 'natural history of the disease', or 'known complication of the procedure'. We keep a clinical distance from the emotions. We accept them as part of our job and we move on. We call it 'professional'. But it can be personal as hell.

I once watched a colleague cry after the death of a patient, a death which he thought he ought to have been able to prevent. There, in the presence of other doctors, both junior and senior, he wept. The guilt and grief were real and palpable. At that moment there was no worry of legal implications, no thought about setting up review committees. Just raw human emotions. I didn't think him any less of a doctor then, or now.

Do you?

I end with another quote, this time from
House, speaking to Foreman about him and his former mentor:

"You took a chance, you did something great. You were wrong, but it was still great. You should feel great that it was great. You should feel like crap that it was wrong. That's the difference between him and me. He thinks you do your job, and what will be, will be. I think that what I do and what you do matters. He sleeps better at night. He shouldn't."

Thank you.

Sunday, November 20, 2005

Recurring Nightmare – End Notes

Please read Foreword first.

Recurring nightmares have a quality of their own. While you are in them, you find yourself experiencing the same bad emotions even though you know you are in a dream and the events don’t really affect you in ‘real life’. And even though you know how the story will pan out, there is nothing you can do to stop it from happening the same way it always does. The only thing you can do is to wait for it to be over so you can wake up again.

I end the series with a real (non-recurrent) nightmare I once had.

This happened when I was in O&G posting. I was a 'conscientious objector', which meant I didn’t perform any procedure related to abortions. They offered us the choice way back when, and at that time I chose it as a 'default setting' despite not having very firm views on the pro-life/pro-choice issue. I wasn’t trying to make abortion illegal, but I didn’t want to have a hand in it.

However, I did see patients asking for termination of pregnancy at the clinic for one reason or another. All sorts of women. Schoolgirls in JC uniforms accompanied by their classmates, professional women who wanted the abortion done 'yesterday' because she had to fly off for a meeting, women who used abortion as a means of family 'planning', and grandmothers who thought they were no longer fertile.

I saw them, did the initial assessment and tests, booked the dates for them, and then left the work to others. I thought I was being professional and that the emotional aspects of it didn’t touch me.

Then one night I had a dream that my best friend was pregnant and she wanted to get an abortion. I was pleading and begging for her to reconsider but to no avail.

I woke up with a cold sweat and a thumping heart, and I knew I had been kidding myself.

The next morning I asked to be exempted from seeing women seeking abortion in the clinic.

Saturday, November 19, 2005

Maybe a campaign will make you change your mind?

"The workgroup has identified inadequate patient education as a key obstacle to live donor kidney transplant... Families of patients with kidney failure often do not come forward to donate a kidney for transplant, even to someone they care for, out of fear that donating a kidney may be dangerous."

- Dr Balaji Sadasivan, Senior Minister of State for Information, Communications and the Arts and Health at the launch of National Transplant Awareness Campaign and Donor Appreciation Ceremony 12 Nov 2005

I am sure the intentions are good but I really wonder about the relevance of a campaign to 'raise awareness that living donor kidney transplant is safe for both the donor and recipient'.

You'd imagine that when a patient needs a transplant, the family members are informed about it and educated by the transplant team regarding the benefits and risks. A small, personal, thing. Doctors, transplant co-ordinator and medical social worker sit down together with the immediate family and they discuss the patient's care, the costs, details of the surgery, prognosis, etc. Misconceptions are dispelled, fears are allayed.

Or are our transplant teams doing such a bad job communicating with them on a face-to-face level that we need a publicity campaign to let them know all that?

I just can't imagine someone who has refused to donate a kidney to his brother after seeing him suffer and being educated and counseled at length by the doctors will suddenly change his mind after seeing a poster about how safe the procedure is.

Or a TV ad.

Or a show on which TV personalities perform stunts to persuade people not to opt out of the HOTA.

Nor can I imagine people rushing down to the 'Kidney Bank' after this campaign to donate one of their kidneys, since we only need one (or one-fifth of one, to be precise), even though I am sure that is not the intention of the campaign.

I think it's sad that something as personal as donating a kidney to your family should become the subject of a nation-wide awareness campaign, as if Singaporeans cannot be trusted to make such a decision of sacrifice for their loved one unless it is 'de-personalised' into a media event.

Labels: ,

Recurring Nightmare 4

Please read Foreword first.

Recurring Nightmare – Internal Medicine

It’s been a good call so far. You managed to eat dinner, shower, AND watch the news while you eat supper before going to bed, so you are actually not annoyed when your pager beeps at midnight.

It’s a nearby ward. You decide to walk there instead of calling back.

When you get there you find the night nurse performing CPR on an elderly patient. Your houseman is at the head end of the bed, trying to intubate him. He looks up when he realises you are here.

'I can’t intubate him,' he says, his face a mix of panic and embarrassment.

'Don’t intubate yet. Just bag.'

He drops the laryngoscope and starts to bag the patient. You adjust his grip on the mask.

'Stop CPR.'

You watch the monitor as you feel for a pulse. No pulse, no rhythm. Pupils fixed and dilated. Doll’s negative.

'Continue CPR. What’s the story?'


'It’s OK.'

You pick up the casefile and begin to flip through the thick notes. You spot your own handwriting and remember you saw this patient during your rotation in this ward last month. Why is he still here?

You find the entry you need.

Not for active.

You walk over to the nursing counter to page the Reg.

'What are you going to sign up as?' he asks.

'The morning team wrote to sign as pneumonia.'


You call the time of death. The nurses start to clean up the mess. The houseman stands at the counter, not quite sure what to do. Second posting, but the first was in orthopaedics. You realise he is still in his shirt and tie.

'Give me your pager. Go take a shower. Page me when you are done.'

He obeys and runs off.

You sit down to write the death cert.

'Staff nurse, have you called the family?'

'Ya. They say they will come with the IC in the morning.'

You decide to write the casenotes instead. You flip through the old entries and begin to remember this case.

Came in last month with pneumonia, multiple co-morbid factors. Recovered after a course of antibiotics, but family refused to take him back. Five sons, lived with the youngest one, but when he was declared fit for discharge the son said he needed a few more weeks to get a maid and renovate the toilet to install a ramp. The other sons each gave their excuse. Social worker, Case Manager brought in, no progress. Weeks went by, no maid, no more visits, no news.

You remember him because at one point he was so well he would help the nurses hand out the afternoon snacks to the other patients. Why would he need a ramp in the toilet? You wonder what happened between him and his sons.

Then a few days back he fell sick again with pneumonia. Son finally came down when patient was put on 'Dangerously Ill List'. Decided not for active management.

You write your notes and walk back to the bed to hand the nurses the file.

'Page me when the family brings the IC. Thanks.'

You watch the staff nurse and the assistant nurse do their thing with a quiet efficiency. You never did find out where the hospital morgue is located.

The patient’s eyes are already glazed over, his toothless mouth open as if uttering a silent cry. The dead look ever so dead. You smile when you remember that you used to wonder whether it was possible to tell the exact moment when a person’s soul left his body.

The houseman’s pager beeps. You walk back to the nursing counter to answer the page.

Friday, November 18, 2005

Recurring Nightmare 3

Please read Foreword first.

Recurring Nightmare – Neurosurgery

It’s close to knock-off time. You get a page from A&E.

Forty-plus man, sudden loss of consciousness at work, GCS 3 on arrival, they think it’s a stroke. You need to accompany the patient to the scan room.

It’s a massive bleed. Intraventricular. Mid-line shift.

You bring the films and patient back down to the A&E. You call your Reg. He tells you to start a drip to bring the brain pressure down, then discuss the prognosis with the family. If they want the op, he’s ours. If they don’t want the op, he’s neuro-med’s.

His wife has just arrived. You step out of the resus area to talk to her.

Late-thirties, slightly overweight, hair in a mess. She’s leaning forward slightly as you talk to her, eyes wide open, mouth slight agape.

You tell her her husband will most likely die. You tell her even if we drill a hole in his head to clear the blood clot compressing his brain he may still die, or end up a vegetable.

You don’t ask her about risk factors he might have had, you don’t quote her statistics and figures, because you know they don’t mean anything to her now.

She is silent for five seconds, and then she starts crying. A loud wail. The other people in the waiting area turn to stare, but she doesn’t see them.

She buries her face in her hands, but strangely you feel you can sense what she is thinking.

Why him? Why me?

What’s going to happen to our family? What am I going to tell the kids when they get home from school?

How are we going to pay the housing loan now? How are we going to pay for food? How am I going to put the children through school?

Her wails turn into sobs as she gathers her thoughts. She wipes her face with a sleeve and thanks you.

She thanks you.

You wonder why.

She does not ask to see her husband, but instead takes her handphone out to call someone, probably her sister.

You take the opportunity to return to the resus area.

Thursday, November 17, 2005

Recurring Nightmare 2

Please read Foreword first.

Recurring Nightmare – O&G

Your lunch is interrupted by a page from the A&E. Per vaginal bleeding, positive urine pregnancy test.

Young woman, found to be pregnant last week. First pregnancy. No scan so far. Sudden onset of pain this morning at work followed by PV bleeding which has since resolved. Her colleagues sent her here. Her husband is on his way.

You ask her to lie down and you do a scan. The uterus is empty. No adnexal mass or free fluid.

You call the OT Reg for the day. She says they can fit her in after the last case, say about 4 pm. Get a consent.

You pull a chair and sit down by the young woman's trolley. You tell her the baby is gone. She starts to cry.

You tell her up to 50% of pregnancies end in miscarriages. You tell her sometimes women wouldn’t even know they have had a miscarriage but just thought their menses were late.

You tell her it wasn’t her fault and there was nothing she could have done to prevent it from happening. You tell her that even though you didn’t KNOW that was the truth.

You don’t know if she believes you. You’re not even sure she is listening.

She’s probably thinking about what her husband will say. She’s probably thinking about what her mother-in-law will say.

She’s probably wondering whether she can get pregnant again. She’s probably wondering if she has become less of a woman now.

You tell her you need to do a 'procedure' for her to clear whatever 'products of conception' which may still be inside the womb to make sure the bleeding stops. You tell her it’s OK to wait for her husband to come before she signs the consent, but she decides to sign it now.

She wipes her tears dry with her sleeve, takes your pen and signs on the line, and then thanks you.

You give the excuse that you have to arrange her case with the OT and leave her with her thoughts.

Wednesday, November 16, 2005

Sometimes it's just about the bus

“I remember what it was like taking a bus 20 years ago. There was no air-con, the bus was rickety, and it wasn’t always there when you needed it. When it did arrive, you had to share the bus with lots of other people. The bus didn’t take you straight to where you wanted to; it took a winding route and stopped for other people too because the service didn’t serve you alone. At the end of the trip, however, you got where you wanted to go.

If you wanted to get anywhere fast, and in more comfort, you took a taxi. You could even tell the taxi-driver which route to take. Heck, you could even call for a cab to come to your door!

That was the way things were and you knew where you stood.

For the most part, the old non-air-coned buses were good enough for me. I was a student and had concession. The bus-driver wasn’t always friendly, but I was there for the bus.

But as I grew older and got more pocket-money I began to wish they would make the trip more comfortable.

One day we complained that it was always too hot in the buses. They said we would have to pay a little more but we thought it was a good idea. So they put air-con in some of the buses. The bus-drivers were still not always friendly, but then I was there for the bus. And the air-con.

Then they put air-con in ALL the buses, which was a little irritating because sometimes I just wanted to go two stops down and didn’t want to pay the extra for the air-con. But it was still cheaper than a taxi.

And then they decided to have a computer take your fare for you. It was supposed to be more cost-effective, but I had to pay more for the installation of the system. I wasn’t sure it was a good idea, because I was there just for the bus and I didn’t really care who took my fare. Plus the bus-drivers were still not friendly.

They liked the idea of computer taking our fare so much, they installed a contact-less system which cost even more, and the cost was again passed on to us. I was getting a little pissed, because I don’t remember asking for contact-less card. I was there just for the bus!

I looked for alternatives, but really taxis were still more expensive, and the only other bus company didn’t operate in my part of town.

That was when I decided to become a taxi-driver.”

Moral of the story: Remember - sometimes it’s just about the bus.

Recurring Nightmare 1

Please read Foreword first.

Recurring Nightmare – General Surgery

You stumble into your call-room at a little past 2 am, having finished the last e-case for the night. You tell yourself you will just lie down for a minute before you take your shower, even though you know there’s a good chance you will just fall asleep.

But you don’t get to sleep or take a shower, because no sooner had your head hit the pillow did your pager beep.

'Trauma standby. ETA 20 minutes.'

Alpha-numeric pager. The wonders of modern technology.

You groan and drag yourself out of bed to start walking halfway across the hospital to the A&E.

In the resus area the A&E MOs and Reg and you greet each other with a bored ‘eh’. Your Reg arrives a few minutes later, followed almost immediately by the patient.

Young man who lost control of his bike speeding down the highway. Barely conscious, blood from almost every orifice you can see. Same story.

You wonder who calls the ambulance in these cases.

The A&E Reg takes the head, your Reg takes the abdomen, you take the right arm, your usual place of honour.

Getting a plug in is almost never a problem. The fluids are running in before the machine has got a BP reading.

The BP is low. Your Reg decides to do a diagnostic peritoneal lavage. Your place a hand on the chest. The right ribcage feels like a bag of loose lego blocks. You decide to insert a chest tube before the Xray guy comes. You get some blood, but not enough to account for the low pressure.

You hear a sigh from your Reg.


You look at each other. You both know that means no sleep for the night.

Just then the alarm goes off. Flat-line. The patient’s gone into asystole. The team pounces onto the patient and start CPR in earnest.

Miraculously, after fifteen minutes, you get a rhythm and a pulse. You look at the A&E team, slightly embarrassed that your disappointment is showing. But they understand. There is no reproach in their eyes.

You go to the nursing counter to call the operating theatre and rifle through the patient’s belongings.

IC, Driver’s License, family photo.

You look at his handphone, which somehow survived the impact. Wallpaper of him and his girlfriend (or wife?). Last call made to 'mum'. You wonder if you should hit the 'call' button.

It takes nine rings before the OT staff picked up. They too were just settling down for some rest, it seems.

'OK, can send now.'

The OT is eerily quite and cold at 3 am in the morning. The anaesthesia Reg is even less talkative than his usual self. You wonder if it’s because he is sleepy, or if he blames you for keeping the patient alive long enough to make it here.

Inside the abdomen you find a liver laceration, but most of the bleeding is actually retroperitoneal and you can’t do much about. The Reg decides to close before the gut gets too cold.

You finish writing up the op notes and change into fresh scrubs. Almost six. Still a chance to get some winks.

You walk halfway across the hospital to your call-room. No sooner had your head hit the pillow did your pager beep again. It’s the ICU. You dial the number without getting up.

'Surgical MO is it? Can you come and sign your patient up?'

You groan and drag yourself out of bed.

At least the cafeteria is near the ICU. You so need some caffeine.

Recurring Nightmare - Foreword

Recurring Nightmare – Foreword

I had some misgivings about posting the next series of stories, but I decided I will do so afterall, with this foreword.

Doctors deal with human tragedies almost daily. After a while they all fall into one pattern or another; the details differ but the main plots are sadly similar.

But despite that (or is it because of that?), they all leave a mark on us.

Over the next few days I will share some of the stories which seem to repeat themselves. For those who are considering a career in medicine, and for medical students, these are situations you may have to deal with one day. The technical details may not be up to date, but hopefully the stories themselves will give you some food for thought.

I know the stories I am going to tell may bring back unhappy memories for readers who have had a friend or family who suffered from any of the conditions describe in the stories.

I want you to know I did not mean to offend.

If you think the stories will cause you distress, please do not read on.

Thank you.

Tuesday, November 15, 2005

"The Best Healthcare that Singaporeans Can Afford"

With the limelight on the issue of healthcare subsidy, I post the link to the Minister's speech on the MOH Budget; it's worth a read.

Here's the bit on Block Budget which I mentioned earlier:

Block Budget

Likewise, if hospitals have the wrong incentives, they may pursue wrong objectives. That is why I am refining our hospital subvention model to include some elements of block budgeting. As Mdm Halimah has pointed out, if hospitals are given piece-rate incentives, they would tend to pursue volume, leading to over-servicing and higher healthcare cost. And as Dr Michael Lim noted, night polyclinics are a reflection of this. I agree with him that it is not a meaningful deployment of limited resources.

But subventing hospitals at a fixed block is also not the panacea. Hospitals may pocket the block budget and do the minimum, pushing patients to one another to shift their costs, resulting in longer queues and under-treatment. In my younger days, public hospitals were in fact on block budget. MOH subsequently switched to piece-rates, not without good reasons.

I am not completely discarding piece-rates for block budget. I am going for both. Where outcomes are well-defined, it would make sense to continue with piece-rate subvention. We have identified 70 medical conditions which form the bulk of our patient-load in the hospitals. We should now go more deeply into the costing of these medical conditions and subvent hospitals based on their volumes for these 70 medical conditions.

As for the rest of the medical conditions, the subvention will come under a block budget. This will be a better way to align our interests. The clusters will then seek to co-ordinate care more effectively. They will "right-site" their patients by treating them at the most appropriate and lowest cost setting.

I must admit I don't understand much of the speech (the bits about Medisave and Medishield), but I am at least encouraged by the fact that he didn't come across as being dogmatic, and had addressed most of the topics we discuss on this blog. Except for the issue of 'heart'.

To me, the system makes it or breaks depending on the heart of the men and women executing it. No system, be it block budget or piece-rates, can ensure that the people in the system put patient before profit. What we need is for the system to recognise people with heart, and if not incentivise them, at least keep them safe from disillusionment.


"Managing the Angry Patient"

Came across this article from a Pharmacist Journal that is too long to reproduce fully.

Here's an exerpt:

Appropriate Expression of Anger

Now that you understand something more about anger, let’s discuss how to appropriately manage angry patients. Let’s also set a few ground rules. First, it must be understood that once you decide to practice pharmacy, you also make the decision to serve people. As such, you enter into a nonreciprocal relationship with your patients. Essentially, when patients become angry and yell at you, you and all others who work in this professional environment lose their right to yell back. You don’t lose your right to self-respect, just your right to yell back.

Second, for pharmacists to operate effectively as professionals, "the patient is always right" policy must be abolished. First of all, the patient is not always right. If the patient were always right, then every time Mr. Brown comes in and says he was shorted 5 tablets that cost the pharmacy $3 each, the pharmacist should give them to him even knowing that she double-counted them for accuracy. I have heard people in upper management who espouse "the patient is always right policy" say they want the pharmacist to use professional discretion in Mr. Brown’s case. But you can’t have it both ways. You either empower your pharmacists to make reasonable decisions or you give Mr. Brown his five tablets. "The patient is always right" is a policy that puts the pharmacist in "no man’s land" with irrational, abusive patients. It can be disempowering and humiliating.

We need to replace "the patient is always right" with "the patient deserves respect".This is worthy of some discussion. Even if patients behave in ways that are not generally acceptable, they deserve to be treated with respect. In other words, respect for people does not depend on accomplishments and is not diminished by bad behavior. As alluded to in an article by Reich, we owe people respect because disrespecting humans disrespects that which created us. We certainly don’t have to like people’s bad behavior or put up with it, but their bad behavior does not give us permission to be disrespectful. However, pharmacists do not deserve to be disrespected either. So, how can we respond to angry, abusive or disrespectful patients without being disrespectful in return? The process involves listening, empathy, respect for others, respect for self, ability to remain separate from others, and assertive communication.

Other People's Money 3

I nearly missed the reply from Touch Home Care:

Nov 15, 2005
Care for elderly: New fees allow more access to wider range of services

I refer to the letter
'Government should relook at the means test for medical subsidy' by Ms Wendy Teo (ST Online Forum Nov 9). We thank Ms Teo for bringing this matter to our attention.

The means test is commonly used by agencies for individuals who wish to apply for subsidies. The objective of the test is to ensure better allocation of resources in providing financial assistance to the people who need it most.

Although the means test has been used by the government to determine its subsidy level to our clients since 2002, TOUCH Home Care (THC) only started charging fees at the beginning of this year as it was able to sustain its free services in the past.

In Ms Teo's case, her mother had enjoyed free services, fully subsidised by THC, for the past three years. However our client base has doubled over the last few years.

To effectively meet the needs of our existing and future clients and to sustain our services, it has become necessary for us to charge fees. We hope to ensure the prudent and efficient use of resources while meeting the needs of the elderly under our care.

We fully empathise with Ms Teo's situation and wish to assure her that THC is committed to do its best to help the elderly enjoy greater independence and better quality of life at home.

We are constantly reviewing our policies to improve our services to those in need and we welcome feedback. For this reason, we have recently developed a new fee structure in which a client pays a flat rate instead of being charged on a per visit basis.

This new structure allows our elderly clients to have access to a wide variety of services, including occupational therapist support, counselling services, visits by doctors and nurses, at a flat rate.

The new fee structure is partially subsidised by THC as we are mindful of the financial challenges faced by families which do not pass the means test.

We are glad that Ms Teo has found our services useful. We invite Ms Teo to meet us for a discussion so that we can better understand her situation and explore alternative arrangements.

Kavin Seow
Programme Manager
TOUCH Home Care

Labels: ,


… in the paediatric ward

Medical Student 1: I think the kid’s got the typical chipmunk facies of thalassaemia.

Medical Student 2: I don’t think so. It’s just a family trait. Look at his brother – he looks the same.

Medical Student 1: Er… maybe that’s because thalassaemia is hereditary?

Monday, November 14, 2005

Angry patients vent online too

Came across this article:

As Angry Patients Vent Online,Doctors Sue to Silence Them

September 14, 2005

Doctors have long accepted that their patients share opinions about the care they have received, knowing that satisfied patients will refer others while those not so happy with their bedside manner might encourage prospective customers to seek treatment elsewhere. But when William Boothe, an ophthalmologist in Texas, saw that one disgruntled former patient was posting his complaints on the Internet, he launched an aggressive response. He sued for libel and other claims, and earlier this year a state judge ordered the material removed from the Web.

The case is one of a growing number of legal battles being waged over Internet postings about medical complaints. More patients are taking their opinions of their local doctors to the Internet, and a wider audience, and that has some medical providers on edge. Several Web sites have sprung up that encourage patients to post anonymous reviews of doctors and dentists, and some frustrated patients have created entire Web sites to criticize specific physicians.

"The potential problems are huge," said Matt Messina, a dentist in Fairview Park, Ohio, and a spokesman for the American Dental Association. "My reputation is my stock in trade … and we work years and years to build that reputation. To have that shattered potentially [by an Internet posting] is a concern."

Patient advocates, meanwhile, say patients have First Amendment rights to describe their experiences with physicians. "Blogs and personal Web sites are no different than talking over the back fence," said Charles Inlander, president of People's Medical Society, a patient advocacy group in Allentown, Pa. "Those who read it have to take it with whatever grain of salt you would take, just like a neighbor. It's too bad if doctors are insulted by this."

The 'Magic Laser Machine'

Dr. Boothe, who practices in the Dallas area, filed lawsuits in a state court in Collin County, Texas, in January against the disgruntled former patient, Dan Morikawa, and another man, Brent Hanson, who runs a Web site called

Dr. Boothe performed Lasik surgery, a form of laser-assisted vision correction, on Mr. Morikawa in September 2004, according to court papers. But Mr. Morikawa was unhappy with the results, and demanded his money back, citing a guarantee in one of Dr. Boothe's advertisements. Soon thereafter, Mr. Morikawa created various Web sites in which he criticized Dr. Boothe. One Web page said, "All these lives ruined by Dr. William Boothe, his magic laser machine, and wild irresponsible advertising claims."

According to Dr. Boothe's suits, Mr. Hanson republished allegations by Mr. Morikawa on Mr. Hanson, a 41-year-old software developer, says he was a victim of bad eye surgery by another doctor in the 1990s and uses to warn others about potential problems with the procedure.

Dr. Boothe and Mr. Morikawa reached a settlement, and a judge also issued a permanent injunction barring any more Internet postings. Mr. Morikawa's sites were shut down. A similar settlement was reached with Mr. Hanson, requiring him to delete certain material. Dr. Boothe was also required to remove messages about the matter he had posted in online forums.

Mr. Morikawa couldn't be reached. Mr. Hanson declined to comment on the case. Edward R. McNicholas, a lawyer for Dr. Boothe, said Dr. Boothe was unavailable.

First Amendment Fight

Other doctors have not been successful in their attempts to get negative information removed from the Internet.

In Palm Beach County, Fla., two dentists last November sued a patient who had created a Web site called, seeking to have the site shut down. But they withdrew their complaint last month, and the site remains online.

The patient, Elaine Prentice, criticized the dentists and others whom she said were responsible for shoddy dental work. She also posted information from a complaint she filed with the Florida Department of Health; the complaint had been rejected for lack of probable cause.

The two dentists who sued -- Leonard Tolley and Richard Kaplan -- said in their suit that the Web site was created "to publicly embarrass, humiliate or otherwise" harm their reputations. They claimed Ms. Prentice had violated Florida law by posting confidential information about a complaint to the health department, and asked to have that information removed.

Paul Alan Levy, a lawyer for Ms. Prentice, said the dentists withdrew their suit because it was "frivolous." Mr. Levy, who works for Public Citizen, a Washington consumer group, had argued Ms. Prentice had a right under the First Amendment to create the site.

Douglas M. McIntosh, a lawyer for the dentists, said they withdrew the case because "we felt there was enough of a cessation of the activity [the posting of information] that we could not burden the court any further."
Ms. Prentice, however, said "no information on my Web site has been altered or removed." The 41-year-old office manager for a construction company said her Web site is designed to serve as "an example to teach others."

Anonymous Critics

Meanwhile, several Web sites have emerged in the past year that feature anonymous reviews of doctors. These sites differ from official state medical-board Web sites that post background information about licensed medical practitioners, such as hospital disciplinary actions.

One of the new sites, called, for National Doctor Database, invites visitors to review thousands of doctors listed on its site, but so far has collected only about 600 reviews. The owner of the site is not identified and refused to give his or her name in an email exchange, saying in part that the site is wary about potential litigation.

Lawrence Hipshman, an Oregon psychiatrist who received a single, negative review on the site, said the posting was "obnoxious." The reviewer said he or she was treated "horribly" by Dr. Hipshman, rated the visit as "awful" and would "never" recommend the doctor to family or friends. A search on "Hipshman" in Google lists the site first.

"We don't know anything about who this person is, or if this person was actually a patient," said Dr. Hipshman, who is a professor at Oregon Health and Science University. He said he doesn't plan to contact the site's owner, but said he was concerned about the site's practices. "There shouldn't be any attempt to create a profile until there are maybe 100 reviews on a person," he added. (Aetna Inc., the large health insurer, requires a minimum of five reviews before posting patients' survey information in an online feature it calls DocFind.)

DR.Oogle Inc., based in San Francisco, runs a free Web site that features anonymous reviews on about 19,000 dentists. Submissions are filtered for obscenities but otherwise are not screened.

The site says it "receives complaints and legal threats from aggrieved dentists all the time." When legal threats are received, DR.Oogle says it removes that dentist's information; reviews have been removed for more than 100 dentists. One California dentist in June sued a woman in part for comments she posted about him on DR.Oogle. The case is pending in a San Diego court.

DR.Oogle recently received a subpoena for information about another user and intends to comply, said Sasha Hershfield, the company's chief executive. DR.Ooogle doesn't collect names or postal addresses but does store a user's Internet protocol address -- a unique number identifying a computer connected to the Web.

Another free site,, of Sunnyvale, Calif., includes ratings on about 11,000 doctors and lets physicians and others post rebuttals. "We've gotten a couple of threats of legal action, but nothing's come of it," said John Swapceinski, co-founder of the site. The site reviews each comment before posting it and warns users that "anything libelous will be deleted."

Trademark Tussle

Other patients have become embroiled in legal battles over trademarks when they have created complaint sites that use a medical group's name.

Bosley Inc., a large hair transplant provider, has sparred for years with Michael Kremer, a former patient who complained about a hair transplant performed by a Bosley physician. Mr. Kremer's malpractice suit against the company in 1994 was dismissed. But in 2000, he registered the Web site, which features criticism about the company.

The Beverly Hills, Calif., company, formerly known as Bosley Medical Institute Inc., sued Mr. Kremer for trademark infringement, among other claims. The U.S. Court of Appeals for the Ninth Circuit in April agreed with a lower court's ruling that Mr. Kremer's use of "Bosley Medical" didn't constitute trademark infringement because Mr. Kremer wasn't using for a commercial purpose. "Kremer is not Bosley's competitor; he is their critic," the court ruled. But the case is still pending because the appeals court said the lower court erred on several other rulings, and it has sent the case back for review.

How long before we have a similar situation here, I wonder.

Clues for the Clueless – Epilogue


That’s all I have for now.

Thanks for all the comments, both the ones criticising my position and those (few) agreeing. The 'correct' patient-doctor relationship is by no means immutable and in fact must change with time and social norms, and be individualised for each patient-doctor pairing.

The trend in the past few decades have been towards greater patient participation and autonomy. For this new paradigm to work, patients must play their part. It is vain to ask for more autonomy if the patient does not even understand or seek to understand the basic principles behind our practice, or continues to think in immature thought patterns.

And because it’s a two-way relationship, doctors must assert their views on what the proper patient-doctor relationship should be like.

A doctor’s right to minister to patients is not derived from the patients but from the professional body to which he belongs; he must practise according to standards set by that body and not just pander to patient demands.

A doctor’s right to minister to a patient is derived from the patient; the patient has a right to accept or refuse a treatment proposed by the doctor.

I guess that sums up my position.

Thank you for reading.

Sunday, November 13, 2005

Let him who is without vice...

... give the first advice.

Like I said, I've never quite been of that school of thought.

Especially when it comes to advice rather than stones.

And I believe that if you insisted on that principle when it comes to giving medical advice, many doctors will have awfully little to say to their patients.

Here are the numbers:

There are about 6500 doctors in Singapore. Let's say 5000 are male, and 1500 female.

Now given that 24.9% of men and 4.1% of women in Singapore smoke, that makes (assuming the ratio applies to doctors) about 1300 smoking doctors.

And 784 doctors who drink regularly or frequently.

And 2200 doctors who are overweight.

If they were the same doctors (i.e. the smoker is also a drinker and overweight), you have at least 2200 doctors who are disqualified from giving advice against these 'vices'.

If they were all different doctors (i.e. doctors only ever smoke, drink, or are overweight - an unlikely scenario), you end up with almost 4300 doctors who are 'into vices'!

In other words, if you assume that doctors are not more immune to vices than the average person, fully a third to two-thirds of us are disqualified from giving 'healthy lifestyle' advice.

So where does that leave us?

To milk the religious theme further, I would say it's a matter of whether you expect your doctor to be a saint who gave you the message through his viceless living, or an angel who is just here to give you the message. Whichever the case, at the end of the day you must remember it's really between you and God.

I'm no saint, but I have been called the Angel of Death.

Saturday, November 12, 2005

Health Promotion Board reverses anti-cancer, anti-heart disease strategy

Health Promotion Board - An organisation that makes you believe that if you lead a healthy lifestyle, you stand a good chance of finally dropping dead suddenly without pain, suffering and big hospital bills.

- The Hobbit's Nonsensical Glossary of Healthcare Sector Terms

Bonus Bogus Story

Singapore -

The Health Promotion Board (HPB) announced today that it will cease all programmes related to the prevention of cancers and cardiovascular diseases such as heart attacks and strokes.

Mr Wee Ah Rong, spokesman for HPB, announced this at a press conference today.

"HPB has always based its health promotion strategies on the principal causes of death in Singapore, with the understanding that the biggest problems should be the ones we are tackling. However, the task force set up to study our overall strategy this year made the observation that if we were to reduce significantly the incidence of death from cancers and cardiovascular diseases, and pneumonia which is usually caused by debilitation from the diseases above, the current 5th leading cause of death, being 'accidents, poisoning and violence', would quickly become the number one cause of death in Singapore." Mr Wee explained.

"After consultation with the Health Minister, we concluded it would be unacceptable for a modern nation like Singapore to have violent death as the leading cause of death – we would be the laughing stock of the region and indeed the international community."

HPB will now instead divert its resources to making sure that Singapore continues to maintain the current status quo.

"As a First World nation, our citizens deserve to die from First World diseases, and HPB will spare no efforts to make that happen." Said Mr Wee.


Friday, November 11, 2005

Do as I say, not as I do

A comment on one of the posts asked if doctors should lead by example when it comes to the matter of maintaining a healthy lifestyle.

I am not actually a big fan of the 'lead by example' or 'practise what you preach' school. It’s not that I don’t think you should not lead by example or not practise what you preach, but I don’t think someone should be deterred from a right course of action simply because the person advocating it is not living it himself.

If a smoker advised you not to start smoking, would you ignore him and start smoking just because he is not practising what he preaches? Conversely, if a smoker asked you to start smoking, would you do so just because he is leading by example?

I believe that any advice should be judged on its own merit, and not by the person giving it.

As for the matter of giving healthy lifestyle advice, I think some 'healthy' doctors do inspire and some 'unhealthy' doctors nonetheless do manage to convince patients to adopt healthy habits. However, I suspect most of the time the more likely scenarios are:

Scenario One

Fat Doctor: Mr Tan, you need to reduce your weight. You must watch your diet and exercise more often, OK?

Patient says: OK, doctor. I try my best.

Patient thinks: What the heck? You yourself so fat ask me to lose weight… you lose some weight first then we talk lah! Hmm... now which burger joint should I go to for lunch?

Scenario Two

Fit Doctor: Mr Tan, you need to reduce your weight. You must watch your diet and exercise more often, OK?

Patient says: Easy for you to say, doctor! You work in an air-con room all day and make so much money, sure free to go California Gym to work out and buy expensive organic food lah. We all have to work long hours to make ends meet, eat cheaply at hawker center where the food is all unhealthy, and at the end of the day we are too tired to exercise!

Patient thinks: Hmm... now which cha kuay tiao stall should I go to for lunch?

In both cases, the thought pattern is immature and not helpful. The doctor's state of health has nothing to do with whether the patient ought to keep a healthy lifestyle, and to use that as an excuse to not keep yourself healthy is stupid.

I think until the system is willing to hold patients accountable for their own diseases, things will not get better. But given the fact that healthy lifestyle is not 100% disease-proof, and the impracticality of monitoring everyone's lifestyle habits, I can't see that happening in the short term.

Better, Faster, Cheaper

All the comments on the healthcare costs and subsidies reminded me of this documentary I saw a while ago on how the (then) new NASA chief promised 'Better, Faster, Cheaper' space missions. But then they found out that you can't have all three.

To a very large extent this is also true of a healthcare system, which when it comes to the subsidised healthcare system consists of three parties: the patients, the doctors, and the Health Ministry.

Patients expect the best healthcare delivered timely and with good service, but baulk at the cost, or else at the waiting times if they go the subsidised route.

Doctors want less work, more pay (yes, admit it!), and higher standards for themselves (in terms of the job satisfaction, quality of delivered care, upgrading of skills and knowledge, and living up to the ethical code), but find it hard to achieve all three when in the system.

The Ministry must strike a balance between three components: patient/voter satisfaction, health of the nation (as it affects productivity), and budget.

At least the Ministry seems to have decided what it wants its
priorities to be.
(If you look at the priority list, you realise that the Ministry is concerned with costs and wants to 'spend within our means'. Patient expectations are expected to be 'moderated'. There is nothing there that says they should be seen fast or about service with a smile. :) )

At the end of the day, you have three parties, each with its own priorities and agenda, competing for limited resources. It seems that one party's gain must come at another's loss.

Is that a bad thing?

It may surprise you that angry doc doesn't think so. All three parties are stake-holders and are accountable to each other. All three parties should argue for their position and negotiate for the best terms. A system dominated by only one of the parties will mean the others lose their voice.

My hope is that we as a society can argue and argue with the understanding that it's about us sharing limited resources within the same system, and hopefully we all come to a status that is sustainable and satisfactory to all three parties involve.

My rantings on this blog is sometimes just me arguing for what I think doctors' position should be. I am not advocating that my view should be the only one. In fact, I think it will be a dark day for mankind if it was...

So do continue to post your comments when you feel like; hopefully together we will make a difference.

Added: Dr Oz Bloke's comment reminded me that there is another arm in the subsidised healthcare system: the Primary Care Partnership Scheme.

Thursday, November 10, 2005

Clues for the Clueless – Chapter 8

Chapter 8 – Other people’s money

You would imagine that healthcare is a simple relationship between two parties – the patient and the doctor.

This is still the case if you see a general practitioner or a private specialist: you agree on a care plan that is mutually satisfactory, at a price that is acceptable to both parties.

A simple transaction. You pay, you get.

But when it comes to seeing a doctor at a government polyclinic or a specialist at a subsidised clinic or in a subsidised ward, you actually take more than you give.

Subsidy means you don’t pay the full cost, which in turn means someone else, in this case the taxpayers, pay.

That means with every visit or admission, the institution makes a loss.

Other people are paying for you.

Yes, I know you pay taxes too, but if the amount you pay exceeds the cost of your triple bypass, you wouldn’t be staying in a subsidised ward now, would you?

So to demand the most expensive drugs or short waiting time or more personalised care at a subsidised clinic or ward is like going to a soup kitchen and demanding a steak and a table for two with candles and a violinist.

Subsidy is the same reason why the government spends money on health promotion; if you are willing to pay your own medical bills in full no one would care if you ate unhealthy food, smoked, or didn’t exercise. Your body, your money, your choice.

Problem is many people mess their own bodies up and expect the rest of us to pick up the tab, and unfortunately that’s a state of affairs we have to tolerate until someone with enough moral courage puts a stop to it.

Until then, the next time you step into a subsidised clinic or ward, try to remember that you are a recipient of tax dollars, and not 'a paying customer'.

Thank you.

Other People’s Money 2

This letter is from the ST Online Forum yesterday, but I thought I would comment on it relation to today’s ‘Clues for the Clueless’.

Nov 9, 2005

Govt should relook at the means test for medical subsidy

My mom suffered three strokes and was bedridden since 2002. Ever since her discharge from the hospital, Touch Home Care (THC) has been taking care of her. It started with free service provided by THC.

Beginning this year, I had to pay for each visit ie. $29 for a nurse and $88 for a doctor. When the nurse comes, she checks my mom's blood pressure, cholesterol and conduct other tests.

When the doctor comes, it is a routine check on my mom's heartbeat etc and he writes a prescription for her medication. The nurse and doctor rotate to come once every month. So on average I have to fork out $58.50 per visit per month.

But starting next year, I have to pay a monthly premium of $148 regardless of the number of visits. This is because THC has implemented a new fee structure and I failed the means test. So I am not entitled to any form of subsidy, which comes directly from the government.

Why I failed the means test? It's because my family head-count consists of only two members ie. my mom and I. I am the only child in the family.

I am earning over $2,000 a month. I hired a maid to look after my mom full-time. Therefore I am not entitled to any subsidy. Subsidy provision is only for those who pass the means test with $750 and below per head. In this case, my means test is $1,000 per head.

It does not take into consideration my hiring a full-time maid to look after my mom. This costs me $300 (salary) + $200 (levy). It does not take into consideration that my mom has to wear adult diapers, which cost $100 a month.

It does not take into consideration that my mom's medication costs $35 a month. It does not take into consideration the daily expenses incurred ie. three meals a day for my mom and the maid, about $10 a day or $300 a month.

How about my own personal expenses? I have to work, eat and pay for transportation, insurance, etc. Or maybe I should not work, just so that I can pass the means test to enjoy the subsidy from the government.
Sure, I can look after my mom without the maid. But without any income, who's going to pay for my mom's diapers, medicines, food, etc? Can the government provide these necessities as well?

On one hand, our government encourages its citizens to work even beyond retirement age. Our government also encourages us to stay with our parents to help look after them in their old age.

Does this include sending our aged parents to an old folks home when they are no longer of help to the family and considered 'useless' when they are helpless? Is this the only solution?

Can we as their children provide some form of filial piety at home instead of sending them to a lonely and cold home? Even if we choose to send them to a home, it doesn't come cheap. Again, depending on the means test, we may have to pay between $1,500 and $2,500 a month.

So what is this means test all about? To turn away people who may really need the government's aid? Is this a fair measure? Maybe the government should weigh the means test on a case-by-case basis. Or maybe the government is inflexible about handing out subsidies?

I guess my family is not the only one affected by the new fee structure implemented by THC. But then, other families may not voice their woes like I do.

Ever since I received the 'service agreement' letter from THC, I have been calling many 'home medical service providers' for help. Most of them were helpful in answering my queries but they were of no assistance.

That's because my mom's case is under THC, and THC is the only community provider in the precinct which my family resides. Given no choice, I have to continue with THC, which I feel is unjustifiable.

It's not because of the money problem, but I feel 'cornered'. If I do not continue with THC, my mom would not be able to get her medicines unless I 'force' her to go to a (polyclinic). In this case, I have to pay for the ambulance service to fetch my mom there and back.

Or maybe my mom should just forget about taking any medicine if she thinks it is becoming too troublesome, which she might just do. But being filial, being the only child, I have to continue providing my mom the best when she is alive and it's not fair for her to suffer.

Probably that's why there is this saying that goes: 'You can die here but cannot fall sick.' Dying is so easy and it is a one-off payment, whereas when one falls ill, the amount to spend is without limit.

I sincerely hope the government will relook at the means test. Is this really the fairest way to measure one's wealth? I wonder.

Wendy Teo Whee Chin (Miss)

Ms Teo’s situation is as she said by no means unique, and I hope she gets the help she needs.

Means Testing is by no means perfect, and letters like hers highlight the deficiencies should be taken seriously by the policy-makers. The letter must also have made many readers aware of this entity called 'Means Testing'. Being aware of it is the first step towards understanding it and having an opinion on whether it should exist, and if so in what form.

However, I take issue with the tone of her letter in the form that it appeared. (The editors are sometimes over-enthusiastic in their duties.)

She gives no word of thanks for all the time when she and her mother had received the care free of charge, and in fact dismisses the doctors’ and nurses’ visits as 'routine', which she only accepted because she wanted the medication. The polyclinic, which also provides subsidised healthcare, is a place so unpalatable to her that her mother has to be ‘forced’ to go to.

Ms Teo does not ask why THC is the only service available in her precinct. The answer is
THC is part of a not-for-profit voluntary welfare organisation. With every visit they make, they LOSE MONEY! Believe me, if they were making money, there would be more than one service vying for her customs. The money that funds such community services comes from somewhere, and in this case it’s donations and grants. One should be thankful for receiving even if it doesn’t cover all one needs.

It's one thing to criticise and question policies (in fact I think we all should), but another to dismiss the efforts of voluntary welfare organisations and the men and women who work in them, some of who could actually command a higher salary elsewhere but choose to do this work instead.

Charity is not an entitlement.

(angry doc is not affiliated with Touch Community Services)

Labels: ,

Wednesday, November 09, 2005

Clues for the Clueless – Chapter 7

Chapter 7 – It's NOT going to get better

Some illnesses resolve by themselves. We usually leave them alone and you get better.

Some don’t. Some worsen. That is when we advise treatment. If you don’t follow our advice, chances are you are not going to get better.

If you are not going to adopt healthy lifestyle habits, your health is not going to get better.

If you don’t avoid those food or material we told you are causing your problem, if you continue with those activities which we told you are causing or worsening your problem, it’s not going to get better.

If you don’t want to escalate your therapy or drug treatment regimen when you need to, your problem is not going to get better. 'Wait and see' until the next appointment is not a logical plan if there is not going to be any change in the way you handle yourself or the treatment you receive. OK, maybe it will get worse.

'Miraculous' cures do occur, but they are rare enough to be called 'miracles'. If you are unlucky enough to get the illness you have got to begin with, what makes you think you are lucky enough to be one of those miracles?

Either accept the consequences of your action/inaction, or do something about it. Simply hoping that it will get better usually isn't good enough (prayer has not been scientifically proven to be helpful for all medical conditions).

Yes, I know all about being 'in denial' and 'in the precontemplation stage', but I prefer to call a spade a spade and call it 'stupidity'. Afterall, if you know you have a disease, you fear the consequences of your disease, and you are offered a remedy for the disease which is not worse than the consequences and which you can afford, I really don't know what else to call it.

But then, Vioxx

I've used that phrase a few times on this blog when I wanted to caution against enthusiasm for a new drug because of the hype.

This letter on the ST Forum today discusses another 'new wonder drug'.

New drugs must be used with caution

WE THANK Ms Chua Mui Hoong ('Costly, but put wonder drugs within reach'; ST, Oct 29) for sharing her insights on her battle with early-stage breast cancer. We are happy that she is satisfied with the treatment she received.

We would like to clarify Ms Chua's concerns on the use of Herceptin in Singapore.

Herceptin was licensed in Singapore in 1999 as an anticancer drug and has been available for use by our doctors since then for the treatment of patients who have advanced-stage breast cancer that has spread to other parts of the body and in which the cancer has an excess of Human Epidermal Growth Factor Receptor 2 (HER-2).

Recently, in experimental trials, this drug has shown effectiveness in patients with early-stage HER-2 positive breast cancer.

Data from the trials showed that Herceptin could improve the survival rate at four years by five percentage points (from 86 per cent to 91 per cent).

The figure for patients alive and disease-free is more promising.

But the benefits of Herceptin must be weighed against the estimated risk of heart failure. Based on data from the same clinical trials, up to 4 per cent of patients treated with the drug developed severe heart failure and another 14 per cent were noted to have a drop in heart function.

International regulators such as the United States Food and Drug Administration and the European Medicines Agency have not licensed the use of Herceptin for early-stage breast-cancer patients as they need to make an independent assessment of the trial data.

New drugs must be used with caution. The experience with Vioxx should be a lesson for all to heed. There was enthusiastic anecdotal endorsement of Vioxx by many patients. However, because of complications related to the drug, Vioxx was withdrawn from the market.

Therefore, before we endorse the widespread use of any new drug, as a routine practice we must evaluate all the information carefully and be cognizant of the clinical limitations and possible long-term effects of the drug.

Otherwise, we could inadvertently be putting our patients at risk.

Karen Tan (Ms)
Corporate Communications
Ministry of Health

The press sometimes sensationalise so-called 'new' drugs which promise to revolutionise treatment of one disease or another, when in reality that drug had been in use for several years overseas. The public, unaware of the approved indications, would then pester their doctors for this 'new' product, which may or may not be useful for them. Why the press or the patients would imagine that the doctors will not prescribe these drugs to their patients if it were indicated or cost-effective is beyond me.

I think the Vioxx case is a victory on the part of the consumers against a pharmaceutical industry that has come to put a quick buck above the safety of their customers, but here's another view from an excellent blog.