Well, you may be damned if you do it...

The issue patient-doctor confidentiality came up in the discussions over doctors revealing information regarding their patients in their replies to complaint letters in the ST Forum.

I had not planned on discussing the issue here as it was covered on Mr Wang's blog, but phelan's comment set me on a google search, which yielded this article.

Now the article covers specifically Disciplinary Proceedings by the Singapore Medical Council, and it can be (and was) argued that in such cases the complainant's consent for the pertinent facts of the case to be revealed is implied, since it would not be possible for a full and fair investigation to be conducted otherwise. In any case, the party privilege to the information will be small and on a 'need to know' basis.

As for whether a 'trial by media' on the ST Forum qualifies as an exception to the duty of patient-doctor confidentiality, I guess the jury is still out.

A rash of letters

I count a total on nine letters on the medical 'incidents' which we discussed over the past weeks in today's ST Forum.

Six of them touched on the issue of doctors refusing to see patients near to the closing time posted, and all of these argued on the subject of patient-doctor relationship and what the expectations of each side should be. Their arguments move from the specifics of the case to the general, and some are well-argued and others less so, but it is nonetheless interesting to see the view from both sides of the divide.

The letters I want to highlight today, however, are the ones relating to the use of 'Elidel'.

The complaint letter (emphasis mine), published 23 Feb, reads as follows:

Doctor prescribed unsuitable rash cream

I AM writing to highlight a very unpleasant experience I had with Thomson Paediatric Centre at Thomson Medical Centre.

On Feb 1, I brought my then four-month-old baby to see the pediatrician for a rash on his cheeks. The consultation with the doctor was over in about five minutes as he had to rush off elsewhere.

The doctor prescribed Elidel (pimecrolimus) cream 1% for the rash and told me to apply it twice daily on the affected area. Although this cream cost me $50, I did not mind as I thought it should be good for my son. But this was not the case.

Imagine my shock when I found out through the Internet that Elidel is not approved for use for children below two-years-old.

The possibility of carcinogenicity of Elidel aside, our Health Sciences Authority (HSA) and the US Food and Drug Administration concur in the recommendation against the use of Elidel for children younger than two-years-old.

In addition, both authorities recommend that Elidel should be used only if other creams have not worked.

It was my baby's first visit to the doctor concerning the rash on his face. Yet he was given a cream that is not meant for babies of his age. The doctor also did not caution me on the use of the cream.

I e-mailed Thomson Medical Centre my complaint on Feb 11. To date, it has not responded.

I am disturbed by the lack of consideration in prescribing Elidel for babies against the HSA's recommendations and the medical centre's slow response in this matter.

Are there any measures to ensure that such strong medication is not prescribed carelessly? I hope the relevant authorities can look into this matter to protect other babies and parents who may be none the wiser about this.

Ruth Tan Yueh Herng (Ms)

The reply is published today (again emphasis mine).

Safe to use rash cream on young infants

I APPRECIATE Ms Ruth Tan Yueh Herng's vexation over her child's skin condition in 'Doctor prescribed unsuitable rash cream' (ST, Feb 23). But her letter contains a few misperceptions.

First, this was not the first time Ms Tan had visited our clinic for her child's eczema. It was their third visit for the same condition.

A steroid cream prescribed in a previous visit was obviously ineffective. In fact, Ms Tan had mentioned that the rash was not responding to treatment elsewhere.

As the eczema was severe, a second line medication like Elidel 1% or Protopic 0.03% is in order. This was a considered prescription and not a careless one as mentioned.

The question is: Is Elidel safe in the dosage and duration prescribed? Elidel is an approved drug in Singapore, USA and other countries.

When the US Food and Drugs Administration approved the drug in 2001, the studies were based on children two years and older. Since then, there have been published studies showing that Elidel is safe for use as a topical skin medication in children three months and older.

As a result, the following countries have approved Elidel for use in children three months and older: Australia, Hong Kong, Indonesia, Malaysia, New Zealand, Pakistan, Philippines, and Thailand.

In Singapore, a multicentre trial involving the National Skin Centre, Changi General Hospital and National University Hospital has been initiated to establish the efficacy and safety of Elidel 1% cream in infants.

Perhaps this is why the Health Sciences Authority has not yet updated its recommendation for the use of Elidel 1% in young infants.

Both steroids and Elidel work by suppressing the immune system. Theoretically, both could cause cancer.

Indeed, oral and injectable steroids and Elidel have been implicated in studies to be carcinogens.

However, the topical forms of these drugs have been found to be very safe in large-scale use.

Topical steroids have been in use for decades while there are over seven million users of Elidel 1%. Studies have shown that such creams have minimal penetration beyond the skin and are not well absorbed into the body.

I understand Ms Tan's frustration when her email went unanswered. But she had chosen to email Thomson Medical Centre instead of our clinic.

We could have clarified the matter and saved her unnecessary worry. We would also have told her that I was called to attend to an emergency Caesarean section immediately after the consultation.

It was unfortunate but my patients who have further queries will wait for my return, which takes up to 15 minutes. If this had upset her, I apologise.

Dr Ang Poon Liat

I believe that despite what we read on the ST Forum (and what you read on this blog) most clinical encounters are mutually-satisfactory ones. By making an issue of a single unsatisfactory episode on a public forum, the complainant gives a one-sided and sometimes inaccurate picture of what a doctor and his practice is like. To defend himself against an unfair accusation, the doctor is put in the unenviable position of having to breach patient-confidentialty, and having to expose the complainant as ignorant or being a liar - again certainly not the sum of who that person is.

I wonder how many times incidents of this kind must happen before the ST Forum stops publishing unverified accounts from complainants without referring them first to the parties complained against. That would seem to me the more professional and responsible thing to do, even if it means fewer 'controversies' for us to blog about.

And the assault continues...

It seems like a bad month for GPs.

Here's the latest letter on the issue of clinics dispensing drugs and drug costs:


Liberalise distribution of prescriptive drugs

THE letter, 'High prices for common drugs in HDB heartland' (ST, Feb 21), by Madam Gan Siok Wah clearly shows the price of medicine in Singapore can be exorbitant.

A member of my family was charged more than $40 by a doctor just for a small rash, but the medicine proved totally ineffective. In all, the person spent over $100 with various doctors without success. Instead, the rash was later cured quickly and effectively with a $6 non- prescriptive ointment from a pharmacy which was recommended by the attendant pharmacist.

One way to counter high prices of medical care is to liberalise the distribution of prescriptive medicine via pharmacies. I have already petitioned the Government on this. Other countries that are more advanced medically have done this, so why not Singapore?

Furthermore, university-trained pharmacists are well-versed in the use of prescription medicine so why are they not allowed to dispense them via pharmacies? In the current situation, the pharmacist may need a prescription from the doctor just to use a prescriptive medicine on himself.

If medicine becomes too expensive, more people will prefer to sleep away their common illnesses - but for one thing. If one is working or studying, one's employer or school will accept only a doctor's medical certificate to excuse one's absence.

So even if one is treated by, say, a certified physician of traditional Chinese medicine (TCM), whose charges tend to be cheaper, an MC from him is useless. One must still pay a doctor to get a recognised MC. This adds unnecessarily to the cost of health care.

Why is TCM, which is part and parcel of our traditional Asian culture, not given the respect it deserves - especially when the physician has been certified by the authorities.

Besides, some people respond better to herbal medicine just as some do to Western medicine.

I therefore suggest that the Government liberalise the distribution of prescriptive Western medicine via pharmacies and give legal recognition to MCs issued by pharmacists and certified physicians.

I believe the cost of Western medicine has driven some people in other countries to buy them via legitimate outlets on the Internet, saving them a lot of money.

To give an indication, the demand for online medicine is so great that last year the Canadian government said it could not afford to jeopardise its national supply of medicine by selling it via online pharmacies.

Chia Hern Keng


I won't discuss the merits behind deregulating or liberalising drug prescription. I did try to read through the Medicines Act and the Poisons Act, but found them rather incomprehensible, and in any case not very enlightening - they tell you what the law is, but not why it is so.

Certainly more and more drugs are being deregulated and no longer require a doctor's prescription to be dispensed. I doubt the staunchest supporter of liberalisation will advocate deregulation of all drugs (including opiates and other potentially addictive drugs), so the argument will probably be one of which drugs to deregulate.

What interests me is Mr Chia's lines of argument (assuming the letter had not been edited beyond recognition of the author).

Mr Chia begins his letter by a personal anecdote: a family member was given expensive prescription drugs which did not cure his condition, and eventually a non-prescription drug did the trick.

Assuming that the condition resolved as a direct result of the non-prescription drug and of that drug only, I don't see how this episode argues for the deregulation of prescription drugs. Afterall, isn't that effective drug already 'non-prescription'? How would adding other ineffective drugs to the 'non-prescription' pool help anyone?

In effect Mr Chia is saying: a family member of mine had a condition that didn't get better with prescription drugs and only got better with a non-prescription drug, so the government should liberalise the distribution of prescription drugs. I don't think I quite follow that.

Or is his point: cheaper drugs are better than expensive drugs, so we should make all drugs cheaper by deregulating them?

I do agree with him regarding the need for MCs accounting for unnecessary healthcare costs. The reason for the need for MC is however usually social or legal, and if our employers and schools could trust employees and students to be honest about calling in sick, a lot of unnecessary time and money would have been saved by all sides.

(Some employers are even stricter with MCs, accepting only MCs from government hospitals and clinics, and some even requiring a patient/casualty to be seen at a polyclinic before he can be brought to the emergency department, but that's another topic altogether).

However, his argument for recognising MCs from TCM practitioner is a bit off the mark.

The point of a medical certificate is to certify a patients fitness (or unfitness) for school or work. Whether a healthcare system is part of our traditional Asian culture or not, and whether or not some people respond better to herbal medicine is not really relevant to the issue. MCs from 'Western' doctors are accepted not because they are a part of our Asian culture, nor because everyone respond better to 'Western' medicine rather than herbal medicine. In any case, I don't believe TCM has a tradition of issuing MCs.

Again, it is the social and legal considerations behind the non-acceptance of MCs from TCM practitioners rather than the efficacy of TCM as a means of healing or as a part our heritage that must be addressed.

The final paragraphs of his letter seem to argue for deregulation simply because people can circumvent regulation by buying drugs off the internet anyway. That is like arguing for deregulation of any other form of contraband simply because they are legal in their country of origin and because there are always ways people can smuggle them in. It would apply for alcohol, tobacco, pornography, subversive literature, uncensored movies, and endangered animals. Even if you consider smuggling of prescription drugs a victimless crime, I think this line of argument will not find favour with the authorities.

... comfort the afflicted...

This is what I meant.


Clinic did not overcharge patient

THERE are two issues in the letter by Mdm Gan Siok Wah in 'High prices for common drugs in HDB heartland' (ST, Feb 21).

First, the alleged overcharging. I would like to clarify that the $80 bill includes both the consultation fee and the medication prescribed to her daughter.

Her daughter was billed $22 for consultation fee for a visit at 9.20pm, when the Singapore Medical Association's recommendation to all clinics is $25 to $55 for consultation between 9pm and midnight.

With regard to the five tablets of Klacid MR 500mg costing $37, the price charged at our clinic adheres closely to the recommended retail price set by Abbott Laboratories (S) Pte Ltd. Mdm Gan is at liberty to confirm the price with them at customer.services.sg@ abbot.com.
Second, unnecessarily expensive medication.

As Mdm Gan has chosen to breach doctor-patient confidentiality by going public with her daughter's medical condition, I would like to highlight the fact that she omits to mention that her daughter had the symptoms for five days prior to the consultation in my clinic and that she had been treated elsewhere for similar complaints without improvement.

It is medically prudent to treat a patient with second line medication if the patient shows no improvement after treatment with first line medication. This was why her daughter was prescribed such medication by our clinic.

I stand by the fact that our clinic did not overcharge Mdm Gan. Nor was her daughter given any unnecessary treatment.

I would be most grateful if you can publish this to clarify the misconception that Mdm Gan's letter has created in the minds of the public.

Dr Low Jin Kheng
Clinic Manager
Street 11 Clinic


Had the editor referred the original letter to the clinic and sought their side of the story first, both sides would have been spared a lot of negative publicity. For the clinic, the damage is already done; but what recompense can the clinic seek from the author (who omitted vital facts of the case - so that we all thought her daughter was on the first day of a viral fever) or the press (which published the letter, knowing very well that such publicity would adversely affect the reputation of the clinic, but without first checking the facts)?

I like the tone of Dr Low's reply letter. It's a nice change from the usual apologetic replies aimed more at appeasement than stating the facts of the case - yes, I tend to believe in the clinic's account, not because of professional bias, but because they are unlikely to make those statements if they didn't have records that would stand up to examination in a court to back them up.

As I have said before, I don't mind complaint letters - they are an essential channel of feedback. But for the system to be efficient and not clogged by frivolous and unfounded complaints, the profession needs to stand up and tell it like it is/was even if it meant making people unhappy.

Will this change anything in the short term? Probably not. It remains cheap, convenient, and backlash-free to email a complaint off to a newspaper forum that does not verify your account. Few people who do not already know the author will know the author just from the name in the newspaper, but the name and address of the clinic/hospital are common knowledge to those in their vicinity. It's not a fair situation, but I think Dr Low has taken us a step closer to making it so.

Thank you, Dr Low.

... afflict the comfortable...

I envy the editor of the ST Forum.

You publish one-sided, sometime unsubstantiated complaints of 'aggrieved parties' without checking the facts behind their allegations, publish the replies to them, then sit back and watch the discussion develope, and when you are finally tired of the topic you issue a statement closing the topic, and then wait for the next hot topic to come up. All the while you do no (or little) writing yourself, and are relatively immune from the repercussions since you don't actually make any allegations yourself.

I'd like a job like that.

Well, I don't have that job, but I nonetheless enjoy watching the ongoing saga, now continued in this letter 'published' on the online forum. The author covers many points, so I will interspace my take in the main text.


Doctors at fault? That's not always the case

CUSTOMER service is a two-way traffic. I refer to a clinic in Holland Road's vicinity which closes at midnight. Apparently, late patients were turned away and they complained.

Put yourself in the clinic assistants' shoes. If the patients come at the last minute and each patient takes 15-20 minutes from registration to dispensing and issuing receipts, the clinic's staff and doctor will go home very late every day. It is not as if patients suddenly became sick at midnight. More often, it's because Singaporeans like to put off doing things until the last minute.

Regardless of whether the patient had been procrastinating, or that she was there to see a doctor for a toothache when she should have gone to the dentist, I think it is not unreasonable to expect that if a clinic posts its opening hours as 'to midnight', one should still be served if one stepped in at 11:59pm. I could not find any legal regulation requiring a clinic to adhere to its opening hours, but would not be surprised if such a regulation exists.

The issue rather is the expectations of the clinic staff and the doctor. If you expected to leave the clinic on the stroke of midnight, perhaps it would be more realistic to close registration at 11:30pm and post the operating hours as such. Or if the employer expected the employees to stop registration only at midnight, then perhaps they should be paid for an extra half-an-hour thereafter?


One reader complained that her father was turned away at a clinic in Serangoon because its rules stipulate that only regular patients, and no new patients unless brought in by a regular, will be attended to on holidays.

From the clinic's view, opening the clinic on public holidays is a service to loyal patients of the doctor. They are loath to accept patients who see their competitor doctors but take advantage of their clinic's services only when their regular clinics are closed.

I remember the complaint letter vaguely, but do not recall reading a reply. In any case I think the law is pretty clear on doctors having to see urgent cases. But then again, to determine if it were urgent, you will need to see the patient first... so I guess, it's a no-win situation for doctors here.


Another reader complained she was charged $80 for simple flu medicine. The doctor had prescribed Klacid MR, which is very expensive.

The patient can always tell the clinic that he cannot afford such branded, expensive medicine. A face-saving way is to pay the consultation fee and ask for a prescription to buy the drugs at a pharmacy instead.

There are doctors who charge a premium for using branded, expensive drugs and not generics, so the mark-up and consultation fees go up stratospherically.

The message is: If you want good, strong medicine to cure you at one go without having to go back two or three times to the doctor, be prepared to pay for premium drugs.

The range of fees for simple flu medicines can be from $17 in a common HDB clinic to $80 in 'high-class' GP outfits. It always pays to ask first. It's like this: You can have your hair cut at $8 by the neighbourhood's Indian barber or pay $100 at a high brow hair saloon.

Lim Boon Hee


Leaving aside the question of whether 'good, strong medicine' that cure patients at one go without him or her having to go back to the doctor two or three times exist for all (or indeed a majority of ) conditions, I really like the hair-cut analogy.

I was thinking about the food analogy of a clinic being like a restaurant, but realised that the food analogy may not be apt because the chef directly adds value to the raw material that is the meat or vegetable, but a doctor does not necessarily add value directly to the drugs, which are manufactured elsewhere.

The hair salon analogy is more apt, because one would expect an upmarket salon to use more expensive shampoo and conditioner, for example.

Do more expensive shampoo and conditioner really make a difference? I don't know, but I suspect David Gan doesn't use any of the expensive stuff on himself...

Want it good, want it cheap

I started replying to Oz Bloke on the subject of this letter and decided I might as well just post a new entry altogether.


High prices for common drugs in HDB heartland

MY CHILD was sick, down with a bad cough, sore throat, runny nose and a slight fever on Feb 16. At 9pm, our family doctor had left so we went to another private clinic - 'Street 11 Clinic' at Block 139 Tampines Street 11.

After a brief consultation, she was given these medicines: cough syrup (one bottle, 'Dhasedyl, 90ml'); a packet of 'Danzen' (20 tablets, 5mg) for the throat; 'Telfast D' (10 tablets) for runny nose and antibiotics 'Klacid MR' (five 500mg tablets for throat and nose).

I was astonished when I received the bill. These medicines cost me $80. I am puzzled at the high cost because I believe that my daughter's symptoms were fairly common and she was treated by a locum.

I feel the clinic had either overcharged and jacked up the price of common drugs, or did it give me unnecessarily expensive drugs for a common illness?

I asked the receptionist for a breakdown of the cost of the various medicines. To my surprise, the staff informed me that the five antibiotic tablets alone cost $37.

I believe Health Minister Khaw Boon Wan had mentioned that affordable medicines be provided for patients at reasonable prices. Yet the clinic in our heartlands is charging drugs such as 'Klacid MR' at an exorbitant price. This is a worrying problem which I hope can be addressed to benefit the masses.

Gan Siok Wah (Mdm)


Not too bad as complaint letters go - the author sticks mainly to the point about drug costs, although she could not help casting doubt on the doctor's professionalism ('a locum'), or appealing to authority in her last paragraph.

I don't think it is my place to judge if the drugs were unnecessary (or unnecessarily expensive?) or 'jacked up' in price. Certainly it is a fair question.

What I am curious to know, however, is this: what do you think is the right price for your daughter's medical care when you were obviously worried enough by her illness that you took her to a private clinic at night instead of just giving her some OTC drugs and waiting till the next day (Feb 17 is not a Sunday) to go to a polyclinic?

Is $80 really unaffordable, or just an expense one would rather not incur?

(People complain about the cost of healthcare, yet for the vast majority of working adults and children, a year's healthcare expenditure would not exceed the cost of that year-end trip to Australia or Korea?)

While I agree with the idea of clinics not dispensing drugs, I think the patients too may need to consider a paradigm change and start to look at sick expenses as part of their necessary budget and not an unexpected loss.

The Reply

A bit of an anti-climax after the long wait, but here's the reply to the letters we looked at last week:


Team at outpatient clinic led by specialist

WE REFER to the letters 'Are subsidised patients treated by specialists?' by Mr Henry Lim (ST, Feb 11) and 'Doctor-patient link key to good health care' by Dr T. Thirumoorthy (ST, Feb 14).

We assure the writers that our priority is to provide appropriate and quality healthcare for all Singaporeans regardless of financial status. In fact, subsidised patients form the majority of our patients.

When a patient visits the polyclinics, the doctor will decide on the most effective course of treatment. When necessary, the patient will also be referred to a specialist in a hospital or national specialty centre.

Patients who are referred from polyclinics receive treatment at subsidised rates at specialist outpatient clinics regardless of which doctor they see.

Each patient at the specialist clinic comes under the care of a team of doctors led by a specialist. The attending doctor, whether a medical officer, registrar or consultant, would be an integral part of this team.

When a medical officer attends to a case, he does so under the specialist's supervision. As public healthcare institutions, we are a vital training ground for young doctors, who provide care to patients as part of a team of doctors.

Non-subsidised patients see the doctor of their choice and may be attended to in a different area, like the class of wards for inpatients. This arrangement has no bearing on the level of clinical care provided and all patients are assured optimal and appropriate care.

We have spoken to Mr Lim and have clarified that he has been receiving treatment at subsidised rates, regardless of which doctor he sees.

He raised the issue of access to specialists care at hospital specialist clinics for patients with chronic medical conditions. It is more important and effective that such patients get appropriate care in the appropriate setting.

Such patients are best treated and monitored at the primary care setting where possible, as this saves them time and the cost of specialist care that may not be required.

We have implemented various programmes where our specialists work closely with general practitioners and family doctors at polyclinics and in private practice. Together, they manage patients with chronic medical conditions such as asthma, diabetes and high blood pressure.

Some of these programmes are already showing results with patients reporting improvements in their conditions.

We thank both writers for their feedback and the opportunity to clarify these matters.

Dr Fidah Alsagoff
Director
Corporate Development SingHealth


I must say it's a very well-crafter letter. It states the official stand how things are supposed to work (in theory - I leave the conclusion to if that's how it works in practice to each reader's own experience), shows that the original letter-writer was in error (about the fees in this case), refers to 'results' in an unrelated area without quoting figures, and finally thanks both writers for their 'feedback' (thus assuming a moral high ground), and avoids addressing the basic question poased by both writers: does the current arrangement ensure that patients referred to specialist clinics get true specialist care?

This guy is good.

NICE

Oz Bloke's comments on a previous post led me to dig up this article evaluating the NICE head injury guidelines.

I reproduce the Result and Conclusion:


Result: 1130 patients with head injury were studied in four 1 month periods (two in each centre). At the teaching hospital, the CT head scan rate more than doubled (3% to 7%), the SXR declined (37% to 4%), while the admission rate more than halved (9% to 4%). This represented a saving of £3381 per 100 head injury patients: greater than predicted with no adverse events. At the District General Hospital, the CT head scan rate more than quadrupled (1.4% to 9%), the SXR dropped (19 to 0.57%), while the admission rate declined (7% to 5%). This represented a saving of £290 per 100 head injury patients: less than predicted.

Conclusion: The implementation of the NICE guidelines led to a two to fivefold increase in the CT head scan rate depending on the cases and baseline departmental practice. However, the reduction in SXR and admission appears to more than offset these costs without compromising patient outcomes.


I once asked a senior why we did not practise the same protocol in our hospital. He told me that the savings in the study was due to the high inpatient costs in the countries studied; locally, in view of the lower ward charges compared to the cost of a CT scan, it was still more cost-effective to admit and observe the patients.

I'm not sure how true that was or is now, but I thought this was a good illustration of how economics affect clinical practices.

Ven-duh 2

A reader posted this comment under the Disclaimer thread. I decided to reproduce it in a separate post.


i read all the comments about pharma reps and they really are very lopsided from doc's point of views only.

i am a clinical biochemist but decided to work as a pharma rep for 2 years upon graduation. i must say despite all the challenges, rejection, verbal abuses, meeting sales targets, memorising of detailing stories, endless waiting at doc's clinic just so i could see the doc for 5 min, i really enjoyed my job. it broaden my outlook on life, made me more resilience and opened my eyes to see doctors and specialists as human beings just like all of us mortals. a few earned my respect as they are truly committed to the welfare of their patients. but a big number, sad to say, are just as driven for $$ and profits as the businessmen on the streets. how many really update themselves continuously by reading the latest published clinical journals? tho today i am still not in the mainstream healthcare system i still scan medscape and NEJM daily to keep abreast of the latest medical development and findings. we are not just out for the $$ and profits but we also genuinely care for the patients, just like you do.


Thanks for giving us a view from 'the other side'.

I make no apologies for lopsided views - in fact I routinely warn readers about taking all posts and comments on this blog with caution and discrimination.

My only issue is with the last sentence.

I do not question your care and concern for patients. The point I was trying to make was this: sometimes it's not the person, but the job description.

The job, at the end of the day, is about increasing sales.

Regardless of your good intentions, you need to ask yourself:

Have you ever tried to influence doctors to prescribe a product that was more expensive, but no more efficacious?

Have you ever given the doctor information that a rival company's drug has just been shown to be superior to that of your company in the latest head-to-head trial?

Did you ever decide to not give a doctor freebies, because you believed the evidence you presented was reason enough to convince the doctor?

Did you ever give a doctor freebies and literature, knowing that he would not read the literature anyway, but hoping that the freebies would convince him to prescribe your company's product?

How much real difference have you made in improving patient's lives, doing what you do?

We all work in an imperfect system, where the business of poeple's health are tied to profits and bottom-lines. Doctors are not exempted from having to take into account considerations other than medical ones, but at the end of the day, I believe we should all be able to feel that, on the balance, we are still helping people.

On a lighter note

Well, no reply to either of the letters mentioned in the previous entries yet, but this little excerpt from one of the letters on the ST Forum page commenting on the issue of teaching 'local' literature in schools:


About 40 years ago when Singapore was struggling for its economic life, a Member of Parliament who visited Tan Tock Seng Hospital was heard saying: 'Good, use local anaesthetic for we must support our pharmaceutical industry.'


I sure haven't heard that one before.

Logged for future reference 1

A couple of letters which appeared in the ST Forum this week seem to me to be worth noting, namely this one from a patient, and this one from Dr Thirumoorthy.

I reproduce them in full for future reference because I expect replies to be made over the next few days.


Are subsidised patients treated by specialists?

I WAS relieved to note that the committee on ageing has recommended, among other things, topping up Medisave accounts so that the aged need not worry too much about medical costs.

The ability to pay for medical expenses is only one aspect of ensuring good medical care for the aged. More important is quality and access to specialists for chronic medical conditions.

Most of the aged get medical care at the polyclinics, which may refer them to specialists.

This sounds good but as subsidised patients, do they actually see a specialist or just a medical officer at the specialist outpatient clinics (SOC) in the hospitals?

The truth is that most of them are seen by a medical officer and not a specialist.

The current practice is that polyclinic referrals to the SOC are made by a medical officer who decides whether specialist referral is necessary.

This results in a long waiting time at the specialist clinics.

To get a quick appointment with a specialist, one must be upgraded to be a private patient, who will be charged private rates for the consultation, tests and medicine.

I note that the hospitals provide different standards for subsidised and private patients.

The specialist clinic for private patients has well-appointed waiting areas and expensive decor, while the clinic for subsidised patients has plastic chairs in a cramped room.

As a subsidised patient, I was privileged to be treated by a very senior consultant during my regular visits until two years ago.

Since then, although my appointment was made under the consultant's name, I was attended to by a medical officer.

The reason, I was often told by the nurse, was that the consultant was busy. What's worse was that I was charged a consultant's fee.

To me, good quality medical care and equal treatment at hospitals are more important than just having the money to pay for medical services required by elderly folk.

Henry Lim


I'll reproduce Dr Thirumoorthy's letter in the next entry.

Logged for future reference 2

Here is Dr Thirumoorthy's letter:


Doctor-patient link key to good health care

I REFER to the letter 'Are subsidised patients treated by specialists?' by Mr Henry Lim (ST, Feb 11).

Mr Lim said ability to pay medical expenses is only one aspect of ensuring good medical care. Almost all who seek medical care expect a good clinical outcome. A major determinant of this is a strong doctor-patient relationship. When hospitals create a situation in which a subsidised patient sees a different doctor on each outpatient visit, continuity of care and the potential to develop a strong doctor-patient relationship are jeopardised. This affects quality of medical care.

In the ethics of health-care resource allocation, emphasis is on both benefits and needs. The patient with a more complicated medical problem needs a more experienced and skilled doctor. When hospitals incentivise the more experienced and skilled doctor to care for private or full-paying patients, the subsidised patient in need is inevitably deprived.

The Singapore Medical Council ethical code expects doctors to be advocates for patient care and well being. In addition, they are expected to provide access to and treat patients without prejudice of financial status.

When hospitals create conditions in which doctors find it difficult to practise medicine in the true spirit of medical ethics and professionalism, the medical profession, patients and society will slide down the perilous slope to loss of trust in the health-care system.

The solution lies in hospitals' organisational culture and ethics aligning with medical and health-care professionals being patient-centred in both policy and practice.

Dr T. Thirumoorthy


He takes the discussion a little away from Mr Lim's point, but brings up a point that many do not discuss openly.

Dr Thiru is sort of a heavy-weight in the local medical circle, so I'm very interested to see the replies to his letter.

Added: I forgot to add my usual caveat about the letters porbably having been edited; this seems to be the case for Dr Thiru's letter, in which the argument seems to have been truncated. I wonder what suggestions he had for helping the institution's organisation culture align with medical professionals' ethics.

No "two-tier" please, we're Canadian

I had the chance to have a better read through the article I took the statistics for my previous post from over the weekend.

This bit in particular caught my interest:

"In Canada, where the single-tier health care system is mandated by law, increasing numbers who are frustrated by the growing waiting lists for surgery simply cross the border to the United States to buy more responsive, private health care." (emphasis mine)

Interesting.

A search on google brought me to this site, which looks official enough but doesn't actually tell you who owns it, so do look up other sites to check the facts.

Anyway, the site tells us that:


"Under the health care system, individual citizens are provided preventative care and medical treatments from primary care physicians as well as access to hospitals, dental surgery and additional medical services. With a few exceptions, all citizens qualify for health coverage regardless of medical history, personal income, or standard of living."


However...


"While the health care system in Canada covers basic services, including primary care physicians and hospitals, there are many services that are not covered. These include things like dental services, optometrists, and prescription medications."


Sounds fair enough - it's free, covers the basics, but no frills. Yet the twist in the tale is this:


"Under federal law, private clinics are not legally allowed to provide services covered by the Canada Health Act. Regardless of this legal issue, many do offer such services.

The advantage of private clinics is that they typically offer services with reduced wait times compared to the public health care system. For example, obtaining an MRI scan in a hospital could require a waiting period of months, whereas it could be obtained much faster in a private clinic.

Private clinics are a subject of controversy, as some feel that their existence unbalances the health care system and favors treatments to those with higher incomes."


So I guess if you had a non-urgent condition which was covered under the Canadian Health Act, you most probably have to wait a long time before you can get it treated.

And if it was not covered by the Canadian Health Act, you most likely have to pay a premium to get it treated.

I guess that's a Catch-22 situation right there.

Free at the Point of Delivery 2

But what cost at the point of taxation?

A letter to Today on Wednesday, written in response to another one regarding healthcare spending, has this suggestion:


"We could perhaps work towards increasing personal taxes to cover Government healthcare cost and make healthcare free for every citizen."


That got me thinking: what would it cost to provide free healthcare for all citizens?

It was a few days before I could find this article (which we might discuss perhaps another time) with the statistics I was looking for. Again, I remind all that I failed statistics in med school, so take the bits that follow with a pinch of salt…

Now figure 3 gives you the total national health expenditure, and breakdown into Government and Private expenditure.

The figure for the year 2000 is about S$4.7 billion, with the Private expenditure amounting to about S$3.5 billion.

Now the Government part is already being paid for by the taxes we now pay, so if we want to provide free healthcare, we need to raise another S$3.5 billion or so per year (assuming we don’t want to disturb the rest of the Budget).

With a population of about 3.5 million (counting citizens only), that works out to about S$1000 per capita per year. And that’s over and above what you already pay in taxes.

So for a family of four with one working adult and two children, that’s S$4000 per year. If this working adult makes just enough to not have to pay income tax (S$1800 per month?), that’s 18.5% of his income each year.

Another way of looking at it is as a monthly rate of S$83 per person. Doesn’t sound like much, but to spend that amount of money on healthcare, you will have to do one of the following:

1. See a doctor at the polyclinic once a week
2. See a private GP once a fortnight
3. Visit the A&E once a month
4. Have a hernia operation once a quarter
5. Have your appendix taken out every six months
6. Have your gallbladder taken out every year
7. Go for a heart bypass every 2 years
8. Have a baby once every 3 years
9. Be on long-term medication that cost you S$2.75 per day.

If you are already doing one or more of the above now, then you would probably want to lobby for free healthcare.

If you are not, then you probably wouldn’t. But if you WERE paying S$1000 a year, wouldn’t you be doing all of the above?

I used to think that people would not consume more healthcare than they need to, but I soon realised how wrong I was after starting work.

Why take a cab to the GP when you can get an ambulance and be seen at the A&E for free?

Why NOT have an X-ray for that ache in your leg after running the 2.4km yesterday, since it is free? Better yet, gimme an MRI!

I am sure you can think of other things to add to the list.

Net result? The total healthcare expenditure will soon exceed S$4.7 billion, and your per capita taxation will soon be more than S$1000.

So let’s all be careful what we wish for…

Ven-duh

I have nothing against drug reps as people.

They are educated (most if not all have a degree, sometimes two), intelligent (they sound like they know what they are actually talking about), and smart (they can teach doctors how to use that new laser machine, or how to insert the new implant), and as mentioned in the comments to the previous post, most have the personality and appearance to do sales. I try to deal with them honestly and professionally, and occasionally they respond in kind.

They don't have the easiest job, and they don't deal with the easiest bunch of people to deal with. (It's bad enough to have to push a new, expensive drug that is only marginally better than its predecessor or closest competitor, but wait till you are the guy assigned to push the company's brand of paracetamol or children's vitamin syrup...)

I'm not out to make things difficult for them, but I think we should all be aware of the consequences of our actions.

What a drug rep does (if he or she is doing the job correctly) is to influence doctors to prescribe a medication over other brands (not necessarily type), for reasons other than purely medical ones. The means by which they do this have already been discussed, and we can assume that they succeed because they are still in employment.

There is a cost behind this, consisting of the salary of the drug reps, their commission (if any?), the costs of all the free gifts and lunches, plus all the advertising material and literature.

Ultimately, the cost is passed on to the patients, or in cases of subsidised patients, taxpayers too.

I'm aware that as people working in the 'healthcare sector', we all to a degree live off people's misfortunes and fears. But at the end of the day, I would like to feel that what I am doing is about supplying a need, and not creating a want.

Big Pharma 1, angry doc 0

Got into my clinic room this morning to find an A4 sized 'literature' with picture of 16 (yes, sixteen! male, female, young and old) happy people on the front page, a stack of pamphlets, a couple of free pens (look nice, but experience tells me the ink will run out too soon), and a nice coffee mug with the name of the drug advertised and the logo of the company prominently displayed on my table.

The drug rep had sneaked into my room when I was not there and deposited the bribes without my consent!

So what should I do with all this stuff now? Chuck them in the bin? Donate them to the Salvation Army? Bring them to Cash Converter? Slip them onto the desk of another consultation room and let the other guy handle the problem?

What would Hippocrates do?

Experiencing technical difficulties...

I seem to have problems logging on to blogger (and reading other blogs too, for that matter) and at least one comment had been rendered 'invisible', while another spam comment cannot be deleted.

Hopefully they can get this glitch sorted out soon.

Added: Hmm, now it seems my previous post had been deleted. I think I'll stop making new entries until this mystery is solved...

Added 2: It's still somewhere, just not where you can see it...

Say 'No' to free lunches

Transparency International released its Global Corruption Report for 2006, with the focus being on corruption in healthcare systems.

Singapore is not referred to in the report, but I think the section on the role of the medical profession in fighting corruption in the pharmaceutical sector is worth reading.

I used to take free stuff from pharmaceutical companies without a second thought, but now I know there really isn't such a thing as a free lunch. The stuff is not free - we're just not paying for it with our money. Now I don't take even a pen from them, let alone a free meal or cruise.

Maybe it's time you said "No Free Lunch" to them too?

Dr Crippen did.

What a Dork!

angry doc welcomes Dr Dork to the blog.