Angry Doctor

Friday, March 03, 2006

Hubris and Nemesis

I was thinking that the Hippocratic Oath was too one-sided, in that it demanded too much of doctors, but offered them little protection.

But perhaps I was wrong.

The Greeks were a smart bunch of people, and perhaps Hippocrates foresaw the state we would be in today all those centuries ago, and gave us this warning:

If I keep this oath faithfully, may I enjoy my life and practise my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot.

(Notice that the SMC Physician's Pledge does not contain an equivalent clause.)

Perhaps the colleagiality and blameless conduct demanded in the Oath were in themselves the best protection doctors could have against attacks on our profession.

Perhaps what our profession needs is not 'progress', but a regression to a more traditional ethos, when we saw colleagues as brothers instead of competitors, and patients as vulnerable people who needed our help, and not as clients or customers.

Perhaps angry doc is just too philosophical today, after learning that a senior colleague had willfully gone against a policy that compromised patient care, at the risk of his own career advancement.

Perhaps I should just lay off the sherry...



  • Regression?

    I have thought of this before.

    In the days of old, healing institutions were usually semi-religious. And there was no fee for the treatment. A simple "God bless you father" and a small donation would suffice.

    Perhaps we should go that route. Set up institutions or orders where doctors enter and do their work just like priests do.

    Of course medicine and religion should not mix. But how would you like a hospital to have doctors(like priests) serving the people. Relatives bring their sick loved ones to the hospital and the doctors take them in and treat them accordingly. If they survive good. If not they have tried their best. And all of this was free to the patient. Patients would have no recourse for complaints because the doctors have tried their best and have no financial or personal incentive to avoid treating the patients to the best of their ability.

    Doctors would have a fixed allowance, enough to survive but not enough to have luxurious lives. Their retirement would be taken care of (just like priests) and their families' needs taken care of.

    So nobody would accuse a doctor of being in it for the money.

    Sounds good?

    Of course there's a big problem. Who's going to fund it? Even if the docs accept this system, who would pay the pharmaceutical companies? Would donations be enough?

    I wonder why it used to work in the days of old and not now?

    The reasons are pretty clear to all isn't it?

    Which is why I think we need to change the bloody Hippocratic Oath because the health care systems have changed dramatically since Hippocrates' time. What applied then, clearly no longer applies today.

    By Blogger Dr Oz bloke, At March 04, 2006 4:00 am  

  • Imagine, if the people that you serve pay you a monthly compulsory 'donation' of 10% of their monthly income..your clinic's decor may probably tell you how affluent your patients are.

    NO matter whether they are rich or poor, you would be so busy treating them of whatever illness that they can think of and there will be plenty of requests for extra medicines (which you can say not without worrying about offending your patients)...whatever the model, I think fee for service is still best.

    By Anonymous Anonymous, At March 04, 2006 10:00 am  

  • I agree. Fee for service is the most equitable mode of controlling usage of medical resources. It is the best way to prevent fraudulent use of medical services.

    However it appears that there is a difference between how patients are treated based on their ability to pay. That is discriminatory and is the unwanted consequence of developing the "fee for service" system to another level.

    By Blogger Dr Oz bloke, At March 04, 2006 11:31 am  

  • Itemise medical bills to show the costs

    IN 'High prices of drugs in HDB heartland' (ST, Feb 21) and related letters, we note that the drug prescribed could clearly affect the size of a medical bill, especially when the health-care service rendered is at primary or community level.

    Our current health-care system has a 'service-first, pay-later' approach where the medical bills, which comprise consultation fee, investigation and medication costs, are revealed just before the patients leave the health-care facility.

    It is therefore prudent that they be told of their condition and diagnostic assessments and they have the opportunity to discuss the treatment options, including the estimated costs of medication, with their physicians.

    Patients should take ownership of their health and participate in the understanding and management of their condition.

    With this, they would be less surprised about their medical bills.

    Greater bill transparency is also needed. Medical bills should be broken down into individual components.

    Every service or item provided has a market price attached to it and itemised billing can clarify how the overall bill is arrived at to avoid ambiguity.

    In Singapore, there are usually generic alternatives available for branded medication.

    The Health Sciences Authority regulates and approves quality, safe and efficacious drugs, including generic versions.

    A health-care provider needs to know the choice of drugs available and what is approved for use locally.

    In the case of Klacid MR, there are about 20 alternative preparations containing the same active ingredient, clarithromycin.

    Klacid MR tablets (once-daily modified release preparation) may be substituted with twice-daily dosing preparations, which give the same therapeutic effect at a fraction of the cost.

    Pharmacists are drug experts and they can source and recommend cost-effective alternatives to a more expensive brand.

    This will reduce significantly the health-care bill on the medication component.

    Such cost savings become very evident for patients who are on long-term medication for their chronic diseases.

    An equivalent but more economical drug means patients save on drug costs everyday.

    The Pharmaceutical Society of Singapore is aware of the escalating health-care costs.

    We support and advocate the use of therapeutically equivalent medications, including generics, to ensure that patients continue to enjoy quality and affordable health-care services.

    Pharmacists will continue to work closely with other health-care providers to enhance the cost-effective use of health-care services, particularly safe and efficient use of medication, to benefit the public.

    Dr Camilla Wong
    Pharmaceutical Society of Singapore

    By Anonymous Anonymous, At March 04, 2006 12:33 pm  

  • It never seems to stop

    Outsourcing is the right way to cut costs

    IN THE letter 'Isn't it cheaper and better to have in-house radiologists?' by Dr Shoen Low Choon Seng (ST, March 3), he expressed concerns over the legal responsibility of radiologists and questioned the cost of the system.

    As a patient, I do not share his views. Let us look at the positive impact of outsourcing X-ray diagnosis to a third country that has a proven record in serving reputable clinics in the US and Europe.

    It does not matter if it is done in India or China as long as the results are swift and good and the services are value for money.

    I disagree with Dr Low when he questioned the rationale for spending $2.3 million on a system to send digital images to India for reporting. This infrastructure cost is necessary to ensure clarity of the images transmitted over a long distance. The sum is negligible when spread over three years and hundreds of thousands of images.

    The Ministry of Health has done the right thing to outsource it to reduce health-care costs and speed up diagnostic reports to save time for patients. If our 135 radiologists cannot cope with the workload and compete with overseas counterparts, should the patients be made to wait and suffer?

    I endorse the Health Ministry's philosophy to cut health-care costs without cutting corners by using state-of-the-art medical technology within Singapore or outside to benefit patients. There should be no boundary when seeking the most cost-effective methods.

    As to the legal responsibility of the radiologists in India, I presume their professional obligations would apply just as in Singapore.

    The teleradiology business in India has to compete for business with quality and price. Our doctors find the reports of Indian teleradiologists have more detail and scope. If the standard of proficiency does not meet our requirements, we should seek alternative sources.

    If Singapore wants to be a medical hub, we have to compete with the global markets where quality and value-for-money services are the norms.

    Our radiologists must face reality and compete head-on with those overseas. They have to prove that they can cope with the volume of reports and charge as cheaply as India. And they need to submit a detailed report quickly.

    If our medical fraternity cannot live up to the global market demand for high efficiency and low cost, it will have to accept that outsourcing more medical tasks is the only answer.

    Paul Chan Poh Hoi

    By Anonymous Anonymous, At March 04, 2006 12:34 pm  

  • I'm not against 'fee for service' (in fact the post wasn't even about fees, but since it's been brought up...); what I am against is the idea of 'any service for a fee'.

    We shouldn't pander in the name of service. Certain things should not be for sale.

    Hippocrates Oath invoke the gods, but I suspect the Greeks used the concept of gods to represent certain constants in human relationship, in this case the fact that if a profession stopped respecting itself, it will lose the respect of others.

    We prescribe treatment that do more harm than good for profit.

    We knowingly sell habit-forming and harmful drugs to addicts, or we keep silent about those whom we know to be doing so.

    We undermine each other on public forum and media when we feel our turf is being encroached on.

    Do you think providing more 'service' is the solution to the problem?

    We should start to take the thinking behind the Oath more seriously again, and know that the last sentence in the Oath is not an empty threat from gods no-longer worshipped, but a reminder of a perennial truth.

    By Blogger angry doc, At March 04, 2006 7:47 pm  

  • I think the 'service' should be our professional services, not driven by profit or other temptations. I am one of those who think that subutex should be banned rather than leaving it around as a temptation for anybody to generate profit.

    and to gary ang's entry, i quote Camelia Wong's

    "Klacid MR tablets (once-daily modified release preparation) may be substituted with twice-daily dosing preparations, which give the same therapeutic effect at a fraction of the cost."

    Two implications :
    1) Generic medicines is actually not the same as original medicines even though they may show bioequivalence in in-vitro testing. Of all people, the pharmacists, whom she claimed are experts in medicines, should know that.

    2) If you were an MNC pharmaceutical company, would you invest in Singapore's Biomedical Hub if the Singapore government were to think that original medicines could be substituted by generic medicines because they are the same??

    By Anonymous Anonymous, At March 04, 2006 8:36 pm  

  • Thanks, Dr Lee.

    Yes, service should be that which I have been trained to do and which I believe is good for you.

    It should not include giving you an MC/excuse when I don't think it's indicated.

    It should not include giving you medicine which you don't need or will harm you if taken excessively.

    It should not include treatment/procedures/investigations which are unproven or not indicated, simply because you wanted it or because I have paid for the course/machine, or because my stock of that medicine is going to expire soon.

    By Blogger angry doc, At March 04, 2006 8:43 pm  

  • But angrydr,

    Those examples you gave are the very things that patients expect from us when they see us!

    They request for it. If they don't get it, we are called lousy doctors and they simply move to another (less respecting of our profession in your definition) doctor who would give them what they want.

    I see your point. Unfortunately, I don't see "idealism and philosophy" being among the tools and terms with which we can tackle this problem

    By Blogger Dr Oz bloke, At March 05, 2006 7:44 am  

  • Well, Oz, your decisions determine what kind of patients your practice accumulates. You can't directly control how other doctors practise, but at least you have control over how you do. You yourself have said that 'if I don't someone will anyway' is not a valid excuse.

    If you pander, you reinforce the patient's idea that doctors can be bought or coerced.

    If you are the third doctor who refuses to prescribe steroid cream to a patient with skin atrophy, maybe the patient will finally realise that repeated use is bad for him.

    If idealism is not the solution, then neither is pandering, in my view.

    By Blogger angry doc, At March 05, 2006 10:41 am  

  • I agree with your points angrydr.

    I wasn't actually saying that we should pander. I was highlighting the realities. Although the points you raised earlier were totally logical, rational and ethical, it was ironic that the public demanded the illogical, irrational and unethical.

    The problem for our profession at the end of the day is really a lack of unity among our members.

    It's not the patients. It's not the pharmacists. It's not the media. It's not the journalists. It's ourselves.

    Yes everything begins with me. As it is I am frustrated in Singapore, trying to practise good medicine but yet realising that for every one of me, there are probably 10 more GPs out there who will pander. And the patients choose to bank their money where they get their whims and fancies satisfied.

    And sad to say, I am not a doctor because I want to have fun doing my hobby. I can't afford to do that. It's my livelihood. And as it is I am terribly torn between doing the right thing and doing the "good" thing.

    One reason why I want to go to Australia is to experience first hand if having a system where docs do not dispense will solve this dilemma problem. Perhaps it does, perhaps it doesn't. But at least I get the experience.

    Locally, the only way really is to first have a strong leadership within our ranks, formulate strict guidelines and come down hard on errant members. Of course the leadership would need the support of the majority of doctors. And that means we need to have a consolidated show of unity.

    The problem with Singapore is that we have neither a leadership, nor any unity among our ranks. It's every doctor for himself/herself.

    So one doctor says no to steroid creams in the face of skin atrophy, and another says ok. And no one knows about the one who pandered and took the money. But the ones who said no tend to be the ones who get mentioned in the forums. Strange don't you think? Who really controls the doctors then? The SMC? The SMA? Or the laymen? I personally think the SMC and SMA pander to the whims and fancies of the public.

    So my conclusion is really that in Singapore the market decides how doctors practise. MOH has said before as well "Let the market regulate itself"

    Idealistic philosophies aside, that is the reality that we have to face up to.

    By Blogger Dr Oz bloke, At March 05, 2006 11:02 am  

  • Well, the SMC is supposed to protect patients, and the SMA is supposed to protect us, but they are not a 'GP business only' organisation and may not be able to focus all their attention on GP's plight (I imagine the radiologists are up in arms and the pathologists are getting worried too...), so maybe the College of Family Physicians shoudl come in, but I'm not sure if they have enough clout... and the ST... I don't know what they are supposed to do.

    Maybe eventually some 'body' will champion the rights of doctors effectively, but until then I will practise with a pinch of idealism in my reality.

    Thanks for sharing your situation on this blog - I am sure many patients will find your comment useful.

    By Blogger angry doc, At March 05, 2006 11:12 am  

  • I spoke to some older GPs who are members of the College of GPs and apparently, the political situation within our profession is very very sensitive. The College of GPs works on the principle that they do not influence government or MOH policy. They merely organize talks, and events, courses,CMEs etc. They are very serious about this and stay away from anything that can be interpreted as a stand or position. It's more like a "club".

    The College of GPs will say that the spokesman for doctors would be the SMA. But even the SMA stays away from being anything close to political or making statements of any position.

    I suspect that this has something to do with our political situation in Singapore. With the General Elections coming, I'm sure we are familiar with the intricacies of our system.

    So I really don't see anybody coming out to "Champion" our causes. It's unlikely to happen as long as our politics stays the same at the parliamentary level. Who knows, maybe MOH and the Minister of Health has previously made a warning to the SMA already?

    Well patients don't realize it, but there is a difference between a doctor doing what's correct and ethical for them as patients and satisfying their requests as customers. Sometimes the actions may be in total conflict with each other!

    I'm beginning to accept slowly that I must agree to do more of the "good" stuff rather than always sticking to the "right" stuff. You can say that I am selling my soul and my principles, but I think if I don't change, I'd either lose my sanity or lose all my business.

    Either way I lose. After all what's there to gain for me by only doing the right thing when most patients accept and want the "good" things?

    By Blogger Dr Oz bloke, At March 05, 2006 11:52 am  

  • "Generic medicines is actually not the same as original medicines even though they may show bioequivalence in in-vitro testing. Of all people, the pharmacists, whom she claimed are experts in medicines, should know that."

    Actually only HSA would have the accurate information for anyone to evaluate this. Generics can be just as good as the original. MSD has their own line of generic for simvastatin I think and they are using it for tender. Of course many generic use raw material of lower grade compared to the origin. If comparing klacid MR and generic then klacid MR is a better formulation and the price difference for me is justified. I don't know about doctors pricing but some sells generic at a price pretty close to the original. :)

    Angry doc

    The reality is many doctors are running a business. They cannot continue to serve their patients if they do not make certain decisions that seems grey to you. Maybe if you've placed yourself in a the private practice environment then you can fully appreciate the challenges encountered by private practice. Of course there are certain things that are clearly wrong but sometimes they have to move along the grey.

    By Anonymous Anonymous, At March 05, 2006 12:14 pm  

  • I have posted a message to patients all over the world on my blog.

    By Blogger Dr Oz bloke, At March 05, 2006 12:20 pm  

  • "Of course there are certain things that are clearly wrong but sometimes they have to move along the grey."

    Agreed. However I just want to ask. What is grey? Who decides what is grey and "not clearly wrong"?

    What about telling patients old outdated information that is more pleasant to their ears. Eg telling them that their BP is normal for their age of 60?

    Is that wrong? Or is that grey? Who decides?

    Ideally, as doctors we should be doing out best never to consciously be practising grey medicine.

    By Blogger Dr Oz bloke, At March 05, 2006 12:30 pm  

  • Actually, once all medical records are electronic and available from a central access database, it will become possible for someone to say what is 'right' or 'wrong' (not that they will be right about being 'right' or 'wrong', but they will be able to see your records and say whether the doctor has done 'right' or 'wrong').

    Once the means to do so becomes available, I suspect the Ministry (which wants to 'Exploit IT Maximally') will find someone to monitor and decide for us what 'right' and 'wrong' are.

    'Wrong' doctors will find it harder to hide (unless they falsify their records), but 'Grey' doctors who 'allow' patients to have suboptimally-controlled BP or HbA1c because they do not want polypharmacy or insulin will be penalised.

    By Blogger angry doc, At March 05, 2006 12:57 pm  

  • Do you guys actually formally "take" the Hippocratic Oath. We do not in the UK and I don't think we ever have done?


    PS and OT (sorry) I just love this idea of legislation to force families to look after their own elderly relatives. I can see it must be a minefield. Please, please do a definitive post on it.

    By Anonymous Anonymous, At March 06, 2006 12:20 am  

    Is medicine just another business?

    Letter from
    Dr Huang Shoou Chyuan

    Medicine is a noble profession and the public has high expectations of
    those who have chosen this path. And rightly so, as those who have gone
    before us include legendary men and women like Hippocrates, Louis Pasteur
    and Marie Curie.

    In Singapore, our torchbearers included giants like professors Gordon
    Arthur Ransome, Seah Cheng Siang, N Balachandran and Chao Tze Cheng - all
    of whom belonged to an earlier and nobler era. It is incumbent on us to
    pass their legacy to junior colleagues.

    The practice of medicine is at the crossroads.

    Unlike before, when specialists in private practice could only be referred
    to as a "specialist in private practice" in the local press, and one
    risked being dragged before the disciplinary committee of the Singapore
    Medical Council for "unprofessional conduct" if any doctor's photograph
    got printed in the newspaper, the pendulum has now swung to the other

    Many now strut around like centrefold media superstars in the most
    unlikely magazines. I suppose for some doctors, "any publicity is better
    than no publicity" so long as some financial benefits are to be had.

    Contrast these with other role models like Drs Tan Lai Yong (training
    village doctors in Yunnan, China) and Andrew Ng (serving in Niger, Africa)
    who, without publicity or fanfare, use their professional skills to lessen
    human suffering.

    The tragedy with the mantra "medicine is now just another business", is
    that some among us are actually beginning to believe that it is true.

    How can we blame them when our watchdog authorities appear to stay silent
    even when there are doctors who unashamedly proclaim in the media that
    they would pander to the patients' requests for procedures even if these
    were professionally unwarranted?

    Most of us recognise that globalisation is irreversible and that we have
    to learn to grapple with both the "good and bad" that it entails.

    The challenge facing us is how the medical profession is going to harness
    the tools that modernity affords us, and by self-regulating moderately,
    ensure that the "outliers" in our profession do not tarnish the good
    reputation that our forbears built painstakingly.

    Only in this manner can we keep true to our noble roots, and ensure that
    the public continues to have deep trust in the integrity of our

    Fortunately, I can vouch that most doctors I know (both GPs and
    specialists alike), are dignified and remain true to their vocation.

    Medicine helps to bring home the bacon, but it is more than just a
    business for them.

    The writer is a specialist in

    private practice.

    By Anonymous Anonymous, At March 06, 2006 10:16 am  

  • The administrator is firmly in charge. Beware Radiologists.
    Learn Interventional Radiology b4 it is too late.

    Teleradiology cheaper, faster and of good standard

    IN THE letter, 'Isn't it cheaper and better to have in-house radiologists?' (ST, March 3), Dr Shoen Low Choon Seng asked if it would be cheaper to station a radiologist at Ang Mo Kio (AMK) Polyclinic, rather than outsource reading of X-rays to Bangalore, India, via teleradiology. It would not be cheaper. With 700 X-rays per month, his proposed arrangement would cost AMK more than $30 per X-ray just to cover the radiologist's salary. This is much more than AMK pays India.

    As a trainee radiologist, Dr Low should know teleradiology has a proven track record and has brought sustained benefits to many patients in hospitals in the United States. It is not merely cost savings, but more important, faster turnaround time and often even better quality reports. Our brief experience so far has already demonstrated these benefits.

    Dr Low raised the issue of legal liability. This is important in any outsourcing arrangement. It was fully and satisfactorily addressed in the US, even within the strong culture of medical litigation there. The key is to ensure that the appointed provider is appropriately accredited.

    In this case, an assessment was carried out thoroughly. The Ministry of Health appointed the College of Radiologists as the accreditation body to determine the provider's suitability. The college conducted a site visit in Bangalore to assess the facilities and processes, and found them to be good. The college also noted that the provider was accredited by the Joint Commission on Accreditation of Health Care Organisations, the largest accrediting body on health care in the US. The college further tested the provider's proficiency and was satisfied with its standards.

    The National Healthcare Group, which runs AMK Polyclinic, is legally accountable to its patients for the quality of its radiological services, including X-ray reports that are outsourced. Indeed, doctors are not new to cross-border consultation. Occasionally, doctors send tissue samples overseas for reading by foreign pathologists. Doctors who do so remain accountable to their patients here.

    The delivery of health care will continue to be further globalised as a result of technology and the Internet. This opens up many opportunities. We should be alive to such opportunities, so we can bring such benefits to our patients, as pointed out by Mr Paul Chan Poh Hoi in his letter, 'Outsourcing is the right way to cut costs' (ST, March 4).

    Teleradiology and any kind of outsourcing need not necessarily take place across borders. Our public hospitals and polyclinics will readily outsource reading of X-rays to local radiologists, when they can offer a similar or higher quality service as Bangalore at lower cost. Such competition will be good for our patients.

    Karen Tan (Ms)
    Corporate Communications
    Ministry of Health

    By Anonymous Anonymous, At March 06, 2006 10:19 am  

  • So is medicine a business or not?

    Last I checked, most clinics are registered as businesses for tax purposes....

    I think it's high time we stop denying it.

    There are several stages of grief. Perhaps some doctors are stuck in different stages.

    Tell the managed health care organizations, the insurance companies that medicine is not a business and see what reply you get.

    By Blogger Dr Oz bloke, At March 06, 2006 10:22 am  

  • Well it looks like Dr Shoen is going to have a meeting with his head of department today......

    Anyway I'm not sure whether this is true, but I heard that manhy trainee positions are going to foreigners now. Apparently they are better trained. For eg a young MO from Malaysia can do a gastrectomy, hemicolectomy and even neurosurgical drainage of intracranial hemorrhage!

    Is it true that all trainee positions for O&G this year went to Malaysians?

    I think Singaporeans are no longer wanted in Singapore.

    By Blogger Dr Oz bloke, At March 06, 2006 10:27 am  

  • John,

    (Actually, I feel a little presumptuous calling you by your first name...)

    We don't actually take the Hippocratic Oath, but a local, modernised version of it called the Singapore Medical Council (SMC) Physician's Pledge. The text is in an earlier post I made, linked in this post.

    As for the parent maintenance issue... well, I haven't got a story related to the topic, but I'll cobble something together just for you!

    By Blogger angry doc, At March 06, 2006 5:16 pm  

  • all docs are trying to cheat money la... tok so much... tok to a bloody doc for few minutes must pay $25 when no work is done... or give some panadol must charge $50... pls la... i oso can be doctor liao

    By Anonymous Anonymous, At March 06, 2006 10:47 pm  

  • Outsourcing is indeed the way to cut health costs, although we might pay in other ways.

    The writing is on the wall for diagnostic radiologists. I wouldn't encourage any young doctor to go into this field if they intend to practise in Singapore. In any case, with the 'simpler' X-rays outsourced to India, how are we going to teach the trainees? Over time, we will lose expertise in this medical specialty and if you wish to discuss a case with a radiologist, one might well have to use VoIP..

    I am thankful that I did not choose radiology for a specialty. Young doctors should consider specializations where it is harder to outsource, such as surgery, O&G and internal medicine. Better still, do cosmetic surgery and inject botox for a living!

    Young radiologists should go into therapeutic radiology without delay, although with everyone going into the field they will expect to see their earnings slashed. Unfortunately, many radiologists only have M.Med and not qualifications of the Royal Colleges. It will be difficult for them to emigrate as a result.

    One possibility senior radiologists might consider is to set up a rival radiology clinic in China. Train the locals and offer the service at a lower cost than Bangalore. They will have to be based overseas but with the lower cost of living there, they can still enjoy a reasonable quality of life.

    Forget the Hippocratic Oath, you are respected only as much as you are needed to bring in earnings.

    By Anonymous Anonymous, At March 07, 2006 4:06 am  

  • Well, I do not actually imagine it is likely to have effect.
    this 1 | this here | you may 9 also 4 | good 4 | you may 3 do not forget link | do not forget 4

    By Anonymous Anonymous, At December 30, 2012 10:51 pm  

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