Angry Doctor

Saturday, February 25, 2006

... 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
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.



  • The patient said in her letter:

    "I was astonished when I received the bill."

    This implied that the astonishment was indeed expressed to the clinic staff.

    "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."

    This was a further expression of astonishment at which point, the attending doctor should have called Md.Gan in to explain to her the necessity of prescribing Klacid and to allay her fears that she was being overcharged by inviting her at that point in time to contact the Pharma the next day if she was still unhappy about the cost of the second line medication.

    Had the Clinic done the COMMUNICATION right, this sorry episode would never have developed to the extent that we are witnessing now. Remember too that Mdm. Gan may have been a very distressed mother on that night, so some soothing words and assurances would have been in order.

    I wish to thank Mdm. Gan for highlighting the lack of communication that most doctors are guilty of. It's high time that if you flunk "communications" in your curriculum, it's out of the door for you. You would be better off clearing the dishes at a food court.

    By Blogger uglybaldie, At February 25, 2006 3:51 pm  

  • I don't think the prices of the medicines have been jacked up, but I have some questions here...

    1) Was it necessary to prescribe Klacid MR instead of the (much) cheaper generic versions (Klerimed) found in various hospital pharmacies?

    2) Also, was it necessary to prescribe Telfast-D (fexofenadine and pseudoephedrine) when there are much cheaper alternatives like the generic combination loratidine and pseudoephedrine tablets (priced $4 for 14 tablets) available over-the-counter at various hospital pharmacies?

    I agree with the point that if patients are concerned about price, they should ask their doctors for a prescription and then they would be able to 'shop' around for the best price available.


    By Anonymous Anonymous, At February 25, 2006 6:18 pm  

  • to Uglybaldie:

    why don't YOU become a doctor since you have so many complaints about them?
    change the world with your new and improved method of communication!
    stop whining

    By Anonymous Anonymous, At February 25, 2006 6:59 pm  

  • From experience, most complaint letters only tell one side of the story, with occasional embellishments or omissions to support their view. For some reason, the ST usually prints this one side first & wait for the response from the other side, by which time, the damage has already been done.
    Although she said that she had been astonished & surprised, who knows whether Mdm Gan expressed these feelings to the clinic staff or the doctor. We, the ignorant public, will never know, unless the local newspaper sends one of their newshounds to get the full story (which we all know will probably never happen). If the doctor had been informed, he could have spoken to Mdm Gan on the spot & this complaint letter may never have been written. But many Singaporeans are scared of losing face, or appearing cheap & do not like face to face encounters with doctors questioning their treatment(again, speaking from experience) & would rather grin & bear it, then turn around the next day & shoot a letter to the papers or to their MP or even a Minister! Talk about poor communication works both ways, uglybaldie :)

    By Blogger aliendoc, At February 26, 2006 12:07 am  

  • To wilted.cauliflower

    Do you really think that the generic medication is the SAME in terms of efficacy/potency and safety as compared to the patented/branded medicines?

    Even knowledgeable sales staff of generic medicines will tell you that their generic medicines are not the same/as efficacious/potent as their patented/branded counterparts.

    GOOD COMMUNICATION is a good way to prevent misunderstandings but there are other reasons as mentioned by aliendoc that give rise to complaints. Everyone could try to avoid it by improving our communication skills but at the end of the day, LUCK also plays a part too!

    By Anonymous Anonymous, At February 26, 2006 12:43 am  

  • Just out of curiosity.....

    Are there any lawyers out there who can give some advice? What would be situations where the doctor can sue the complainant for defamation?

    I mean we almost NEVER EVER read in the newspapers of letters of complaint against lawyers. They must be doing something right.

    Frankly the way I look at this particular case is this :

    If the purpose is to inform and educate the public about such a case and see what the other side of the story is, is there a necessity to NAME the clinic concerned in the very first instance? I mean by doing so, you are presuming guilty until proven innocent. Which seems defamatory to me. What the newspaper could do was to print the letter but leave the name of the clinic out first. Listen to the reply from the clinic and then make a decision in consultation with both parties if they agree to have the clinic named or anonymous at the end. Sometimes it's a simple misunderstanding, who knows Mdm Gan may have a personal feud with Dr Low and this is a personal attack?

    We see the politicians pull this card all the time. If someone makes allegations eg " overcharged and jacked up the price of common drugs" which are false, we learn that the politician MUST sue the other party to PROVE that the allegation is false and clear his name.

    So what about in cases like Mdm Gan and Street 11 clinic?

    By Blogger Dr Oz bloke, At February 26, 2006 4:14 am  

  • Perhaps Singapore doctors might want to pool funds together to hire lawyers to look into such "complaints/negative publicity/false allegation" letters in the Straits Times forum.

    As it is I feel that the Straits Times does not have a ver mature approach to their reporting. They make many unilateral allegations about the medical profession but yet refuse to answer to them.
    I recall some time back several articles written by Salma Khalik who is the Straits Times health correspondent which made many allegations against Singapore doctors.

    One of the allegations was that doctors in Singapore prescribe potentially addictive drugs because of financial incentives to do so. She also said that the few who had been punished for it only represent the "tip of the iceberg". It was a very damaging allegation. SMA replied but there was no response from Salma Khalik or the Straits Times.

    See :

    There was another article which was CLEARLY defamatory and false where Salma Khalik falsely quoted the Director Of Medical Service MOH as saying that MOH was going to stop doctors from selling drugs. DMS wrote to all doctors to explain that he never said anything like that.

    SMA president Dr Lee Pheng Soon wrote to the Straits Times to refute her allegations in the articles "MOH to stop doctors from selling drugs" dated 1 Jan 2005 and "Doctors not swallowing the bitter pill" dated 9 Jan 2005.

    To date there has been no reply from Straits Times nor Salma Khalik.

    You can read more about that case here

    What are we doctors? Whipping boys?

    Does the Straits Times have some agenda against doctors?

    And Straits Times, please have some backbone to answer to our replies!

    By Blogger Dr Oz bloke, At February 26, 2006 4:39 am  

  • OZ,

    If you, as a doctor is not prepared to give medical advice in blogs, do you expect lawyers to do so?

    I suggest you quit whining and aspire to be the president of the SMA whereupon you may be able to put forward your ideas and gain popular support from the medical fraternity to fight for your rights. Anyway, isn't the SMA supposed to champion the rights of doctors?

    If you become the president, I will register an association to protect the rights of patients. I am thinking of calling it PPC (Patient Protection Co-operative). Other than protecting the interests of patients against incompetent, errant doctors our aim is also to buy medications in bulk and distribute them to poor patients who are chronically ill but chose not to go to government clinics or hospitals. On our board will be physicians, lawyers, philanthropists. Mostly lawyers.

    Hee Hee


    By Blogger uglybaldie, At February 26, 2006 9:24 am  

  • To Anonymous

    Become a doctor?

    No thanks, and here's why:

    1. Money making too slow. Count profits in cents and dollars instead of tens of thousands.

    2. No longer a revered and respected profession. Too many crooks spoil the soup.

    3. Too many complaints because the population is getting smarter and doctors are getting sillier.

    4. Too many doctors around. There's one eager beaver in every street corner.

    5. Too many incompetent peer colleagues and get myself mired in controversy.

    6. Too many regulations. This cannot do, that cannot do also.

    7. Too long working hours. I prefer to play golf and sing Karaoke.

    8. Job too monotonous. "Ah, open your mouth, Good. You have a sore throat, runny nose and fever"

    9. Too risky, can get sued easily.

    10. At the mercy of SYTs who will yell "molest" at the slightest provocation or if your charges are too much to stomache.

    Some more reasons but too lazy to think about it as today is Sunday and it's time for golf brother.

    Hee Hee.

    Have a good Sunday.

    By Blogger uglybaldie, At February 26, 2006 10:13 am  

  • Haha! I'd prefer to join your PPC uglybaldie!

    Safer to be allied with you guys!

    Anyway my point for whining is exactly the same as Mdm Gan.

    Miscommunication. LOL

    By Blogger Dr Oz bloke, At February 26, 2006 10:16 am  

  • One more important reason before I take to the club.

    Now, we have Dr. Google who will answer all your queries, competently, quietly, without tantrums and without charge.

    We now also have an avalanche of drug information at our finger tips so no need for the doc. to explain about drug chemistry, contraindications, side effects and assorted mumbo jumbo. And got to pay for the explanation some more.

    So who needs the GP sitting in his little shop peddling snake oil?

    But we do need the "butcher" and "plumber" now and then.

    By Blogger uglybaldie, At February 26, 2006 10:24 am  

  • Oz, you DON'T sue the only newpaper in town.

    Not even if you are a lawyer.

    Not even if you work for a 'medical' organisation.

    By Blogger angry doc, At February 26, 2006 11:41 am  

  • Personally, have seen this doctor a few times...

    generally he stocks branded medicine so the final bill is generally higher than most neighbourhood clinics. he doesn't usually give out generic medicine..even for Diclofenac supp also use Voltaren and not Voren.

    But I like his consultation process..very detailed..unlike some others , just cursory . This is especially impt when it comes to my child..

    Also he opens till are higher if seen after certain times.

    By Anonymous Anonymous, At February 26, 2006 2:13 pm  

  • Thanks angrydr and uglybaldie for reminding me. Reality check.

    Cetainly don't want to end up like TT Durai!

    So I guess the newspapers can say whatever they want, anytime. anyplace.

    I forgot that they were the 140th ranked "Free Press" of the world.

    So lan lan lah. We just have to suck up to the ST to be in their good books then.

    If you can't beat em, join em! :D

    By Blogger Dr Oz bloke, At February 26, 2006 7:21 pm  

  • "angry doc said...
    Oz, you DON'T sue the only newpaper in town.
    Not even if you are a lawyer.
    Not even if you work for a 'medical' organisation. "

    I wonder even if the PAP can sue the only newspaper in town???

    By Anonymous Anonymous, At February 27, 2006 2:03 pm  

  • Does the PAP need to sue the papers??? hehe

    BTW I tot Klacid MR would be a good choice with the once a day dosing to improve patient compliance.

    Well some generics are inferior to the original so I think docs who dispenses proprietry drugs are actually quite noble. It will affect their reputation as a lot of patient will view them as expensive but they are actually providing quality drugs for the patients.

    However antibiotics generics should be quite ok, because I think most need to submit a bioequivalence testing before the product is approved. Whether they manufacture the data is another story :)Different generics also use different grade of raw material. Not all generics are good choice for reducing cost.

    By Anonymous Anonymous, At February 27, 2006 2:56 pm  

  • Will reducing healthcosts lead to reducing doctor's income?
    There is nothing to fear if doctor can continue to add value by providing laser therapy, mesotherapy, chemical peel etc. But those who rely on traditional means of providing patient care, be very afraid

    Feb 27, 2006
    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

    By Anonymous Anonymous, At February 27, 2006 3:15 pm  

  • nah that day would not come because logistically it is not possible.

    By Anonymous Anonymous, At February 27, 2006 3:32 pm  

  • uglybaldie said (@ 3.51pm):

    It's high time that if you flunk "communications" in your curriculum, it's out of the door for you. You would be better off clearing the dishes at a food court.

    The above statement is particularly offensive as it puts down people who work menial jobs. It is attitude like this that hinders the advancement of civilization. Everyone has a part to play in society, everyone has a place in the sun.

    By Anonymous Anonymous, At February 28, 2006 9:36 am  

  • Dear Gary,

    I am personally all for Singapore going the way of Australia and USA where doctors provide only consultation and do not dispense. Why do you think I have made arrangements to go to Oz to work?

    I think we should do it. But I can understand why MOH will not do it. Mostly because it will cause the cost of seeing a doctor to go up as well as make things inconvenient for patients.

    As it is most GPs DO NOT charge the recommended consultation fees. Many charge way below the recommended minimum of $18. I know most patients would say "What 'consult'? The doctor never even talked to me!"

    That's true! Which is why I welcome the move. Let doctors do what we are supposed to do. Give consultation, counsel, educate, inform. And be paid for it. The culture in Singapore is that they don't want to pay for consults but will only pay for medicine. It's like th consult is a value-added service of a drug selling doctor. That's terrible. Which is why you then see doctors who don't talk to patients but dish out drugs.

    Anyway I doubt Singapore would ever go the way of the west because people here have been spoiled already. The irony is that they don't realise or appreciate the convenience they enjoy. Ask any foregin visitor from the West and he will tell you that seeing a doctor in Singapore is simple, easy, fast, cheap and convenient. $80? That's chicken feed.

    A Singaporean once complained to me that when he went to San Francisco and went to see a GP for fever and sore throat he had to make an appointment, paid US$200 and only got a script for Tylenol (Panadol) and Lozenges which cost US$30. One of his big gripes was....NO ANTIBIOTICS!

    I guess it's a totally different culture here in Singapore. When in Rome you do what the Romans do.

    By Blogger Dr Oz bloke, At February 28, 2006 10:42 am  

  • Singaporeans don't know what they are asking for. Healthcare cost will not drop if doctors do not dispense medication as will rise. It is well known that many GPs undercut their consultation fees and break even by earning from the medication. If they only prescribe, consultation fees will rise and the cost of medication will not drop as the pharmacies will have to employ full-time pharmacists. If you are sick at 11pm, even if you get a prescription, do you know where is the nearest 24-hour pharmacy with a duty pharmacist who is licensed to dispense?

    Be careful what you ask for, might just get it.

    By Anonymous Anonymous, At March 07, 2006 4:35 am  

  • I read Dr LowJK's account of how little support he received from SMA and Abbott.

    Very tragic.

    By Anonymous Anonymous, At March 07, 2006 4:39 pm  

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