Angry Doctor

Wednesday, January 25, 2006

W.W.H.D.

Here’s one they will never ask during the Final M.B.B.S. MCQ paper.


"You are a colorectal surgeon in a restructured hospital.

Two weeks ago an old man was admitted to your team for bowel obstruction.

He was initially seen by his GP, who correctly judged that the case was urgent and the patient had to be seen at the A&E. He referred the patient to a Government Polyclinic, in the mistaken belief that if the patient was referred by a GP he would not be entitled to government subsidy. The patient was seen at the polyclinic and given a referral to the A&E, where the doctor decided to admit the patient.

At the Admission Service, the patient’s family decided to opt for B1 Class for the patient, hoping to let the patient have better service during his stay, not realising that all subsequent follow-up will be at non-subsidised rates.

The patient underwent surgery that same night. The diagnosis was an obstructive cancer. The patient will need follow-up at your clinic (as a paying-class patient) and also expensive chemotherapy. The full cost of his treatment now becomes clear. The family hope that you can help them reduce the medical costs by downgrading them to subsidised-class."

What should you do?

A. Nothing
Continue seeing the patient as a paying-class patient – you're a doctor, not an accountant. Besides, they should have known better when they chose a paying class for the patient.

B. The correct thing
Refer them to the hospital Medical Social Worker for Means Testing since you can't make a decision on the downgrading. The MSW will then assess the family's income and make a recommendation, a process which may take weeks, during which the patient will undergo further investigations and treatment at non-subsidised rates.

C. Exploit the loophole in the system
Discharge the patient from your clinic and ask them to go back to the polyclinic for a referral to the subsidised clinic on the day that you will be there so you can continue to see the patient. There may be some time lag between due to the long waiting list, but at least the family will save some money. Well, a lot of money.

D. Abuse the system
Discharge the patient from your clinic and make the patient to go to the A&E faking severe abdominal pain, so that he will be admitted to the ward (this time as a subsidised patient) where he can have his treatment continued.


What would Hippocrates do? What would you do?

14 Comments:

  • Hmmm...curly one, AngryDoc.

    Me, I'd discuss the options with the patient and go with B or C. But the prioirty would always have to be ensuring that optimal treatment was always being given, so it would depend a bit on the specifics of what was subsequently required, and of course the decision would ultimately rest with the patient.

    By Blogger Dr Dork, At January 25, 2006 7:17 pm  

  • i suppose i'll have to go with B or C as well... the conscience won't let me do nothing, nor will it let me frankly abuse the A&E and our poor embatterred ER colleagues.

    and, of course, the patient and relatives will have to understand the risks of any delay in follow-up and treatment that may result.

    By Anonymous distinguished mediocrity, At January 25, 2006 11:06 pm  

  • The contention seems to be between B and C. But realistically, I'd present the options of A and B to the patient, discussing the pros and cons, alluded to by your post/previous commenters.

    If cost-savings were deemed prime, I'd choose B, because you need to look after your own ass. Plus maybe try your utmost to speed up the process of B as far as is possible. Patients nowadays, you never know when they'd turn around and hit you hard; and what if the patient doesn't re-enter himself into the healthcare system and something less than favourable happens? On paper, your "discharge" will look far worse than it is supposed to be.

    By Anonymous igakunogakusei, At January 26, 2006 12:30 am  

  • I thought that C-class patients do not get to choose their doctors?

    If that's what they want, then they have to decide if they want to self-discharge from your clinic and be put on the usual waiting list to see any surgeon, just like everyone else.

    If they want to choose you to be their physician or jump queue, then they should pay for that priviledge - or wait to be means tested.

    By Blogger tscd, At January 26, 2006 2:40 am  

  • I'll sue the hospital administration for not alerting me that opting for B1 class will not entitle my grandpa to subsidies.

    I'll kick myself for not knowing para 1 above in the first place.

    I'll be a more knowledgeable person to get round all the loopholes available in the medical subsidy circus.

    By Blogger uglybaldie, At January 26, 2006 8:57 am  

  • I personally could choose to do a few things.

    1) I could explain the situtation to the patient and then say I am not an accountant and I don't formulate hospital charging policies. If they continue to make noise about the high cost I would write them a memo to bring to patient services to lodge an appeal or consult (basically tai chi the problem to the administrators after all this IS THEIR JOB!)

    "Dear Sir/Madam in charge,

    The above mentioned was admitted 2 weeks ago to our department for bowel obstruction.

    At the Admission Service, the patient’s family decided to opt for B1 Class for the patient, and was not counseled by the admission services staff that all subsequent follow-up will be at non-subsidised rates.

    The patient underwent surgery that same night. The diagnosis was an obstructive cancer. The patient will need follow-up at our clinic (as a paying-class patient) and also expensive chemotherapy.

    The full cost of his treatment now becomes clear. The family hope that you can help them reduce the medical costs by downgrading them to subsidised-class if possible.

    Kindly assist this family to overcome their financial difficulties.

    Thank you,

    Dr Oz"

    Additionally I would tell the family to go to www.angrydr.blogspot.com to see the other possible options they could choose.

    And of course if all else fails, go to the Meet-the-MP sessions and talk to their MP about this.

    And if it fails to call 68222268 for the Mediacorp Newshotline and tell them your story.

    By Blogger Dr Oz bloke, At January 26, 2006 10:44 am  

  • Hmm... except for the fact that the question asked you would do as the docor, Oz Bloke wins the best idea award for suggesting going to the press.

    He also wins the worst idea award for going to his MP, especially if the MP will later regret saving him 'because it cost the hospital more $300,000'.

    By Blogger angry doc, At January 26, 2006 11:46 am  

  • In any case, this problem should be handled by the powers that be who decide on charges and ward classes etc.

    I personally feel there is no need to have ward classes in Singapore. A simple B2+1 class across the board would suffice.

    Such issues I usually let the admin people deal with because if you try to handle it yourself and some crap happens, they will ask you "Why didn't you just refer the case to us?"

    Don't be a hero if you are not asked to be one.

    By Blogger Dr Oz bloke, At January 26, 2006 11:59 am  

  • igakunogakusei, I must say that for someone who is not 'in the system' yet, you display a remarkable awareness of the situation.

    Respect.

    By Blogger angry doc, At January 26, 2006 7:11 pm  

  • Dear God

    I thought we had problems in the UK! I don't know where to start on that one. Is there a thumbnail sketch anywhere of how the medical system, and access to, works (or does not work) in your part or the world?

    John

    By Blogger Dr John Crippen, At January 27, 2006 4:52 pm  

  • More bad news for us in today's entry, John...

    I tried looking through the Ministry of Health website (link on main page of this blog) but not much detail can be found there.

    Most of the information we pick up 'on the job'.

    It seems that in this day and age doctors need to help patients navigate the maze that is subsidised healthcare. I am sure they didn't teach me how to do that in medical school...

    The Medisave system is now under reform (I think) and Means Testing is still work-in-progress.

    I'll keep you informed. :)

    By Blogger angry doc, At January 27, 2006 5:26 pm  

  • I think this hypothetical final MB question is really one that should be included in the medical curriculum. One of the short-comings of the system that I went through was that it didn't prepare me for the other side of medicine: the social and human aspect of it.

    I'm not sure how the system works now but the discharge & re-admit route sounds good.

    By Blogger andrew, At January 28, 2006 12:54 pm  

  • Thanks for the compliment, angry doc!

    By Anonymous igakunogakusei, At July 14, 2007 11:12 pm  

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    By Anonymous Hugh, At July 18, 2012 7:12 am  

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