Angry Doctor

Wednesday, February 15, 2006

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.



  • Talk and write and talk what for?

    Being a heavyweight, bring this matter up to the MOH and get changes made. Henry Lim may not be able to sway the MOH's thinking but Doc. Thiru if he is the heavyweight champ sure can ruffle a few feathers and make things happen via some concrete proaction instead of writing to the Straight Times. Your guess is as good as mine as to what our civil servants will reply.

    By Blogger uglybaldie, At February 15, 2006 11:02 pm  

  • There must be incentive for customers to upgrade to paying class instead of relying on tax money.

    One can't have both his cake and eat it. Thus, doctors should understand that without customers they are going to become out of jobs. They need to attract paying customers and thus there must be a difference between paying customers and subsidised customers.

    Can we afford to bankrupt our medical system.

    5th year medical student
    Medical administrator

    By Anonymous Anonymous, At February 16, 2006 12:23 am  

  • This will always be an unfair situation for doctors and health care professionals.

    I especially take issue when we hear the medical administrators talk.

    Firstly, how are the hospitals run? For profit? Not for profit? Charity? What do the administrators aim for in this aspect?

    Secondly how are the administrators' bonuses and performances determined? Based on financial performance of the health group?

    Thirdly, I do know that part of the calculation of doctor's bonuses is based on the group financial performance.

    So it all points towards a system designed to make healthy profits.

    Even you said it "They need to attract paying customers and thus there must be a difference between paying customers and subsidised customers."

    You see this is very much what the hospital administrators always emphasize. And rightfully so if you think of the hospital purely in business terms.

    Frankly. No problem. Let's do it. We should focus on the paying customers get many of them. The subsidized ones....aiyah anyhow lah, basic, cheap, fast, acceptable treatment can lah, don't waste so much time on them.

    But then on the ground, are doctors in public hospitals supposed to be like that? How would you feel if you were the subsidized patient?

    And guess what, when the subsidized patients write complain letters to these administrators, the reply would always be some fake address to their problems. I mean stand up and be counted lah. Write to the subsidized patients and say, you want good service please pay lah, because we the hospital "need to attract paying customers and thus there must be a difference between paying customers and subsidised customers"

    But you would never find the administrators writing such phrases in their replies. They are oh-so diplomatic and politically correct. Yet they impose their business-capitalist prinicples on the doctor in the way they practise in the public sector.

    So in the end it's always a dilemma for the doctors in public hospitals. What is the aim of the hospital? To make money (clearly what the admin wants) or to treat patients well even if they are subsidized and spending time with them doesn't generate money and in some cases loses money (clearly what the admin does not want, but only claims it wants when responding to complaints and public enquiries)

    By Blogger Dr Oz bloke, At February 16, 2006 10:30 am  

  • OZ,

    You're my Hero.

    Wah, you very eloquent leh.

    Say everything I wanted to say but don't know how to say.

    One sentence sums it all up:

    "What you pay is what you get."

    even in this island.

    So, the key is to make more money and be able to afford what you need in life. Don't depend on handouts because there are any. Well, at least the professional services we, the public really want.

    By Blogger uglybaldie, At February 16, 2006 11:02 am  

  • Uglybaldie,

    you must however note that although I understand the realities of the world, I did take the hippocratic oath.

    And personally I do feel that health care in principle should be approached from a socialist point of view.

    A sick man is a sick man regardless of what his financial status is. Sick people should be treated in the same way and to the same extent.

    If doctors were to treat them differently would be against our calling. But unfortunately this is an uphill struggle against the law of the jungle these days.

    Yet people would accuse doctors of being hypocrites. Frankly the control of health systems are no longer in the hands of doctors. As such it is unfair to blame doctors all the time for such atrocities.

    By Blogger Dr Oz bloke, At February 16, 2006 11:57 am  

  • "Yet people would accuse doctors of being hypocrites. Frankly the control of health systems are no longer in the hands of doctors. As such it is unfair to blame doctors all the time for such atrocities."

    Not true at all. Policy makers and most hospital administrators are doctors. Aren't they also bound by the Hippocratic Oath? If they do not agree with a policy and they feel strongly about it, just resign in protest. Doctors are definitely involved in the "scam" although the responsibility diminishes progressively as you go down the food chain.

    I won't really call what they (the docs responsible) do "atrocities" but it most certainly make the Hippocratic Oath an empty oath bereft of any meaning in today's world.

    By Blogger uglybaldie, At February 16, 2006 12:34 pm  

  • "As such it is unfair to blame doctors all the time for such atrocities."

    If you read it carefully I said it was unfair to blame doctors ALL the time. But it is PERFECTLY FAIR to blame doctors in some instances.

    Yes doctors are in admin. But frankly these guys are more administrators and businessmen than clinical doctors. A professor once told me this : " I have seen many young doctors go into admin with lofty ideals. They want to change things for the better for patients and their clinical colleagues. They go into admin, have a couple of dinners a few golf games and then it hits them that if they don't play the game according to the rules of the administrators, they would never win. In fact they would get ejected from the game again and again and their careers would never progress. So they turn to the dark side eventually"

    I remembered that very well. And I think it is absolutely true. Look at a certain eye surgeon cum Minister as a possible high profile example of this.

    What I am trying to say with all this is that in the public sector there are many good doctors in the clinics and wards who are trying their best to live up to the hippocratic oath. However the administrators who decide their pay and livelihoods, workign conditions, how they practise etc are really the one with all the power. The humble doctors on the ground can only try so hard. But ironically they are on the frontline and are usually the ones who are abused verbally and accused of things that the admin are really responsible for.

    By Blogger Dr Oz bloke, At February 16, 2006 12:48 pm  

  • "Turning to the dark side"

    "Selling their souls to the devil"

    Jeez, I thought these sentiments were more for the less honourable professions! For example, lawyers, stockbrokers and bookies.

    I've all along suspected that the medical profession isn't as hallowed as the public thought it to be.

    Now, we have the confirmation coming from the horse's mouth.

    By Blogger uglybaldie, At February 16, 2006 1:10 pm  

  • I disagree that medical administrators have turned to the dark side simply because we work in the real world and not in an ideal world where we can treat everyone equally.

    Healthcare in Singapore is not cheap and thus many have no choice but to become subsidised patients. Yet they do not understand that they pay for only a fraction of actual costs and yet behave like a true paying customer.

    The medical administrators are just helping to keep the clusters profitable (a long and uphill battle against doctors who insist treating everyone equally).
    Doctors must realise that they are in the service industry and add little to the economy.

    Thus we should treat partial paying customers well but full paying customers even better. This is the spirit of medicine in an era where costs have gone out of hand


    By Anonymous Anonymous, At February 16, 2006 3:49 pm  

  • Dear "Medical Administrator" 3.49pm comments...

    * Given your comments, then it seems like the administrators have been pretty Inefficient in managing your resources (medical professionals), and meeting your customers' (the patients) needs and demands.

    * When it comes to "quality service" to your Full paying "customers", the quality is also Half-Baked. How to compete with the pte hospitals and your Regional competitors?

    No wonder not making profits, lah.

    Angry Dr, Hope you don't fallz off your chair with a "Medical Administrator" holding the view that "Doctors must realise that they are in the service industry and add little to the economy."

    ... this makes uglybaldie's comments (when he's trying to play devil's advocate) sound so mild now... poor doctors...

    By Anonymous Anonymous, At February 16, 2006 6:02 pm  

  • No worries, pretzel. :)

    The real problem is of course very complex and I enjoy looking at the points of view of all the stake-holders.

    Still, I wonder upon whose shoulders will fall the unwelcomed tasks of replying to Mr Lim's and Dr Thiru's letters.

    Poor guy is probably running around the MRO trying to find out which 'Henry Lim' it was who wrote that letter!

    By Blogger angry doc, At February 16, 2006 7:21 pm  

  • Dear ang yee,gary

    "Thus we should treat partial paying customers well but full paying customers even better. This is the spirit of medicine in an era where costs have gone out of hand"

    That is exactly what you would expect medical admin people to say. Basically fibbing to a certain extent.

    Anyway I do understand that these issues of cost are very real. However one must understand that as clinical doctors dealing with patients, we are not trained nor well versed in the cost management policies of the hospital. However, because clinical staff are on the frontline, they will be asked questions pertaining to that area on a regular basis. Many times the doctors are in a dilemma when faced with such questions.

    For one the doctors don't really know the exact details of the correct answer. Most times when they try to come up with an answer, and screw it up, the admin people will say why didn't they call them.

    Secondly, if the doctors reply with health economic answers, the relatives and patients will view the doctor is a different light. Perhaps accuse the doctor of being a hypocrite, "what about your hippocratic oath?", money-minded doctors etc.

    It's a no-win situation for the ground clinical staff.

    I'll give you an example. When patients go to the public hospital A&E, they pay a flat rate eg $75 for EVERYTHING. That is inclusive of all consult, investigations (blood tests, X-rays, CT scans etc), procedures (eg sutures, wound dressing, plaster casts etc) and medicication. So even if you did 100 tests, you still pay $75.

    Now some patients know about this rule and exploit it with many requests. Some honestly don't know and requests for certain tests agreeing to pay extra for it anyway. But hospital policy (decided by the admin guys) is that certain tests are allowed to be ordered from the A&E and certain tests are not allowed to be ordered from the A&E. There is no in between whether patients are willing to pay for it or not.

    One illustration is fasting blood cholesterol tests. That is NOT allowed to be ordered from the A&E period. I have experienced patients requesting, "By the way, can you also do a blood cholesterol screen for me?" And I tell them no we don't do that test. And they say how can? Hospital so big no test for cholesterol? I say you go GP clinic or polyclinic have but A&E cannot. They sometimes say "I willing to pay for it lah. Not say I got no money. Don't have to look down on us like that"

    At that point I would wish there was a public relations officer of quite high rank to explain to these people the economics of it all. And then I can spend my time to see more patients in the already packed waiting area. Instead I get stuck with these guys and I try my best to explain.

    All this while, where are the people who actually do totally understand the policies and in fact make them? Maybe in some meeting. Maybe at some computer terminal writing another proposal for another policy. Maybe escorting the Minister or VIP or a tour of the hospital. Well one thing is for sure, they are never there when you need them.

    So my challenge to the admin people is this. You make the policies, you explain them to the patients and relatives. Don't leave the poor clinical doctors who know nuts about economics to explain your economic policies for you. Get off those cushion seats in your offices upstairs and come down to the ground and talk to the people on the street.

    Don't hide away upstairs and only come out in the form of well thought of, diplomatic, fibbing letters in forums of the media.

    By Blogger Dr Oz bloke, At February 17, 2006 9:54 am  

  • Oz,

    Thanks for the spirited defence of the docs. at the frontline of the war zone. Now I know who to blast just in case I suddenly became a pauper and have the need to go and get back some of my hard earned money via GST taxes at the fish market they call the Hospital A and E.

    Er. doc. are you sure that $75 bucks also cover all the tests and not only just for consultation? If really true ah, I sure would like to hookwink the A and E newbie into giving me all the freebie tests at no charge by feigning the symptoms which cannot be clinically detected.

    This is a loophole that cannot go unexploited.

    By Blogger uglybaldie, At February 17, 2006 10:22 am  

  • I am very certain that it is a flat fee for everything.

    Of course there are certain tests which if ordered from the A&E would not be run. Only very basic emergency tests are usually allowed to be ordered from the A&E.

    I'll tell you another fact. If you get a CT scan (eg CT head for head injury) at the A&E, you will be told that you will have to be admitted regardless of the result. That means even if you have no bleeding within the skull and all is normal you will need to stay in hospital. Why?

    Because of charging problems. If you go home, you only pay $75. And we all know the CT scan costs much more than that. So to circumvent the problem, the patient stays in-patient and the CT scan costs can be charged. Now I am not sure as to whether this is a recommendation from the admin people or not. But it is practised.

    I do know that the admin people usually make it seem so straightfoward and simple how a doctor decides if a patient needs a CT scan or not. Truth is, sometimes patients have lucid intervals and then later deteriorate. It is not simple. In most centres in the western world a CT scan is a basic test for head injury.

    So you want to exploit the system? Well very hard lah. Because the people who do the tests are not based at A&E. For example to get a CT scan, you have to call the radiologist (who is usually sleeping at night or doing something else) and is not keen to have extra work for no extra money. So they will ask a lot of questions, ask why must it be urgent etc etc etc. For blood tests, the lab will call up the doc and say "sorry this test is not standard order from A&E, you want to ask your consultant for approval?"

    As for medicines, they also usually don't give out months supplies of medications.

    Trust me the admin people have got it all worked out very well to stop YOU the consumer from exploiting them. But they aren't there to explain this to you. So when you hear the poor old clinical doctor trying to cook up some cock and bull reason why he can't do X or Y test, remember he does not hold an MBA.

    By Blogger Dr Oz bloke, At February 17, 2006 11:04 am  

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