Difficulty with Access

angry doc will have difficulty with internet access with this posting changeover, and posts may be infrequent and irregular.

We apologise for any inconvenience caused.

Perhaps a Discount might make you change your mind?

Today reported on the Health Ministry's latest 'priority' today.

The article is too long to reproduce in full here. I will just highlight certain passages here, but do read the full article to place them in their context.


"About 4,000 Singaporeans have signed an AMD. A third of which did so only after the high-profile case last year of Terri Schiavo, the American whose feeding tube was removed after being in a persistent vegetative state for 15 years.

The numbers worry Mr Khaw: "You know something is not quite right. You should be having hundreds of thousands of people signing on." "


"Although documents to apply for an AMD can be downloaded from the MOH website, Mr Khaw said yesterday that he has received feedback that it is not so easy to get it signed. Two doctors are needed as witnesses, for example.

He hopes to make the process simpler and easier, and also to enhance its public outreach, going as far as to suggest holding sessions in crowded shopping centres."


" "The legislation … may be rather limited. So, part of the discussion I'd like to see is whether it's necessary or desirable to open it up slightly," he said. "But, more importantly, for AMD to really bring about benefits to the person and to the family, you do need many more people to sign on."


angry doc does not get the last point. Unlike immunisation, there is no 'herd immunity' benefit to be had here and as long as a person signs an AMD, it affects ('benefits') him and his family. How many other people sign the AMD is irrelevant to him.

angry doc finds it curious that the Ministry assumes that people will want to sign the AMD in droves, if only they knew about it or if it was easier. Is it not equally probable that they know about it, but just choose not to sign one?

angry doc would like to ask his readers if they have signed an AMD, and why they decided to do so or not to do so.


"Associate Professor Lee Wei Ling, director of the National Neuroscience Institute, agrees that the AMD Act requires further fine-tuning and would like it to also apply before death is impending.

"It just doesn't go far enough now. A person should be allowed to stop life-saving procedures at an early stage. It should be up to each of us to decide what quality of life we're willing to tolerate. That's why it's called a living will in the United States," said Dr Lee, who has written to the press on the issue several times. She believes the best way to make the AMD a success is to make it an opt-out scheme, like the Human Organ Transplant Act. It will also be "politically unacceptable", she said.

"I doubt Singapore society is ready for the AMD. I don't think public awareness is enough to do it. I don't think it will get through without a lot of sweeteners.

"One possibility is that if you sign the AMD, you could reduce your hospital bill by 30 or 40 per cent. It's not just a sweetener. There's logic to it. The biggest cost of medical care is in the last days," said Dr Lee."


Long-time readers of the blog will know angry doc is (sort of) a fan of Prof Lee. Once again she displays an understanding of the Singaporean psyche.

angry doc agrees with Prof Lee that the AMD in its present form is just too 'two-dimensional'. You choose either to have it, and it gets activated when the doctors decide the circumstances are right, or you choose not to sign it and the doctors will (must?) do everything possible/reasonable to keep you alive.

A Living Will can be more detailed and sophisticated than an 'either-or' directive, but as the article points out, Singaporeans may not be ready for such a form of Living Will.

Besides, it will probably necessitate the involvement of lawyers...

You Will, Won't You?

Remember this letter?

Madam Tai must be glad to learn about this latest piece of news:


(excerpt, emphasis mine)

AMD one of MOH's priorities over next five years: Khaw

SINGAPORE: The Health Ministry will re-address the issue of the Advanced Medical Directive (AMD) as with an increasingly ageing population, the public has become more aware of its need.

Health Minister Khaw Boon Wan said on Sunday that the AMD would be one of the issues his Ministry would be looking into in the next five years.

He was giving reporters the heads-up on his focus areas ahead of the opening of the 11th Parliament on November 2.

Mr Khaw said his Ministry intends to have more outreach programmes to discuss the merits of an AMD.

Introduced in 1997, the AMD allows a patient to state in advance that he does not want to be sustained artificially should he become terminally ill or unconscious.

So far less than 4,000 Singaporeans have signed up for it.

The Health Ministry would like more Singaporeans to sign up.

To facilitate that, it will reach out to them and explain what the directive stands for.

Mr Khaw said: "We think of it as a very taboo subject.....we do not want to talk about it. Because you don't talk about it, by the time the patients are dying or not able to express themselves, the burden is left to the family members. And it is tough for the family members who will say, 'let's do it this way' or 'let's do it that way'. So I would rather when we are in control of our faculty, make that kind of decision. Let's not pass the buck to the family members. That's my main message."


angry doc thinks everyone should contemplate his own mortality and make end-of-life preparations.

But he is nevertheless disturbed by the Ministry's latest 'priority'.

You see, the Advanced Medical Directive allows you to state that you do not want any extraordinary life-sustaining treatment to be used to prolong your life.

You can't sign one that says you want everything done, even when the doctors think you're a gone case.

Subsidy and other Preoccupations 2

Kim's blog is a delight to read, both because of her excellent writing style, and because of her collection of posters from yesteryears.

angry doc is so tickled by this one that he just had to steal it.

Says it all, doesn't it?

Subsidy and other Preoccupations

angry doc wonders why so many people who write to the ST Forum use the word 'shock' in their letters, like this writer here:


Switch to 'private patient' gets quick test

I WENT to the polyclinic recently to get a referral to see a specialist as I had symptoms resembling those of colon cancer, and asked that immediate attention be given to my case.

I was shocked to find out that my appointment would be two weeks later.

When I called up the National University Hospital's colorectal clinic to find out the reason, the nurse told me that the doctor's schedule was packed. After much pleading, the staff managed to schedule an appointment for me in a few days' time.

When I went down to see the specialist, he examined me briefly and recommended a colonoscopy. As a subsidised patient, he told me that the earliest he could perform the procedure was in November, about a month later.

Almost immediately, he went on to suggest that if I became his private patient, he could perform a scope and an ultrasound scan for me the next day.

I felt compelled to take the earlier option as I feared for my health. I was then made to sign a form to remain as a private patient for at least a year, paying the private rate throughout the year for any treatment.

After completing the colonoscopy and ultrasound scan, I had to return the following week to collect my ultrasound report. Surprisingly, I had to pay a further consultation fee just to be briefed on the report.

I have the following questions:

• Can a specialist reserve earlier time slots for private patients just because they pay more, leaving subsidised patients to wait in the queue?
  
• Why are private patients made to commit to paying private rates for one year without the option of going back to subsidised rates?
  
• Why did the specialist have to charge for the final consultation after the test when he was merely repeating what was in the printed report? If the patient is deemed to be normal after the test, shouldn't the precious consultation time of the specialist be used for another more-needy patient, subsidised or not?
  

I urge the authorities to allocate health-care resources based on need rather than on one's ability to pay.

James Chi Han-Hsuan


angry doc is glad that Mr Chi's tests were 'normal'.

The underlying question in Mr Chi's letter is about the rationing of healthcare - once you accept the fact that healthcare needs to be rationed, the question then is how it should be rationed. It's an old debate and angry doc is keen to read the reply from 'the authorities'.

angry doc's question for his readers today is not on the rationing of healthcare though, but one of conviction:

If you were morally opposed to the idea that money should buy a person priority when it comes to healthcare, will you, when faced with the *possibility* of a life-threatening illness like cancer, buy yourself priority?

(At the same time, angry doc wonders if he himself, when diagnosed with a cancer western medicine cannot cure, will try an unproven alternative medicine remedy. angry doc hopes he doesn't live long enough to die of cancer though.)

One Life Saved?

One of the problems with being a medical professional is that one tends to view seemingly 'obviously' good ideas with a more calculating eye.

Ideas like this one.


Are teachers trained in basic first aid?

IN SATURDAY'S Straits Times, it was reported that a Primary 6 pupil with a heart disease died in school the previous day.

What I found shocking was that a teacher called the father, who arrived minutes later and performed cardiopulmonary resuscitation (CPR) on the boy.

Why did the teacher not perform CPR first? When someone has a heart attack, every second counts.

Are our teachers not trained in CPR and basic first aid? And if not, why is this so?

First aid should be part of the curriculum for trainee teachers and teachers should be required to go for first-aid refresher courses. Training only the Physical Education teachers is not sufficient.

Goh Lee Jin


The logic seems sound and obvious:

1. Child had heart disease and died suddenly, so he must have had a heart attack.

2. CPR saves lives when it comes to heart attacks, so CPR should have saved his life.

3. The child died after CPR. But since CPR saves lives, it must be the delay in initiating CPR that prevented a life from being saved.

4. Since the teacher, who was on the scene, did not start CPR, the problem must be because teachers are not trained in performing CPR.

Conclusion?

Train all teachers in CPR and no child will die needlessly of a heart attack in schools.

Except it's not so simple.

The public has an unrealistic expectation of the efficacy of CPR, something which is often attributed to the common depiction of successful resuscitation on TV and in the movies.

Depending on the patient profile, the exact pathology, and the location of arrest, success rate of CPR will vary.

Specific to out-of-hospital arrests in the paediatric population, the overall survival-to-discharge rate can be as low as 2.6% or 8.6%, although a smaller study suggests that not only is CPR worth performing, it's worth performing for longer than 20 minutes. Presumably if they haven't had any reason to give up on you after 20 minutes, your chances are pretty good to begin with.

(Unfortunately for the 18 to 35 age group, which angry doc assumes many of his readers belong to, the evidence is not very encouraging either.)

All that is not to say that CPR doesn't work at all (it's better than nothing), but the public needs to have a more realistic idea of how often it is unsuccessful.


angry doc does not doubt that training all teachers in CPR will in the long run help save the lives of a few children (and of course it helps too when a teacher gets a heart attack), but he wonders how much it will cost.

Bear with angry doc's bad maths as he tries to count the costs...

There are some 26,382 teachers in Singapore (you can find the exact figure in the Education Statistics Digest on the Ministry's website).

The cost of a Basic Life Support Course locally is in the region of S$80 to 100. (Google 'BCLS Course fees')

Even if you take the higher estimate, it's still around 2.6 million, which is a small percentage of the total Education Budget.

But what is the cost involved per cardio-respiratory arrest? Well, how many cases of cardio-respiratory arrests in school-children occurring *in schools* have you heard of in the past year?

To be even more callous, what will be the cost per successful resuscitation?

How many of teachers, when an arrest does occur, will actually initiate CPR? One study showed that around 80% of the time bystanders may not initiate CPR, even when around half of them have been trained in it.

And what if we decided to equip all schools with automated external defibrillators (AED), which have been shown to double survival rates compared to CPR alone, and train all teachers in their use?

At the cost of S$2500 to S$4000 per AED for each of the 355 schools, and the cost of S$120 to S$200 in training, it will come up to around S$5 million.

Twice the survival rate at twice the cost, so no real bargain there.

But of course, we should never count the costs when it comes to saving children, should we?

Thousands of years of practice...

... can still be bullshit.

Or rather cow dung.

Whenever angry doc reads or hears an argument advocating a health practice based on its antiquity and popularity, he is reminded of the practice of applying cow dung onto the umbilical stumps of newborn babies.

You wouldn't think of doing something like that, but many people do exactly that.

(see here, here, and here)

They might argue that 'millions of women in Africa can't be wrong!', 'they've been doing it for generations - don't you think they would have stopped if it was not working?', 'cow dung is all-natural, how can it be bad?', and 'you western medicine people don't understand the virtues of cow dung'.

Are you convinced by any of those arguments?

Should you be?

It's a big problem. Or rather it was - progress has been made in reducing neonatal tetanus deaths.

The fact is, that just because a practice is old, traditional, is observed by millions of people and has a spiritual aspect to it does not mean that the practice is good, or indeed harmless.

So next time someone tries the same old flawed arguments on you, tell them: cow dung.

Have a good weekend.

How NOT to argue for Alternative Medicine 4

They say in China, nothing is true until it is officially denied by the government...

This little piece of news made it to our local Chinese daily yesterday (emphasis mine):


Idea of abolishing traditional Chinese medicine ridiculed

The Ministry of Health and the State Administration of Traditional Chinese Medicine (SATCM) have lambasted an on-line petition aimed at getting traditional Chinese medicine withdrawn from the country's healthcare system.

A source with the SATCM said, "The idea of abolishing traditional Chinese medicine is a denial of science."

Zhang Gongyao, a professor with Central South University, recently launched an on-line petition calling for the removal of traditional Chinese medicine from the country's healthcare system. Some netizens signed their names in support.

However, many more people opposed the petition.

Yang Yonghua, a professor with the Hunan Academy of Traditional Chinese Medicine, said traditional Chinese medicine is undeniably a mainstream medical treatment method in China. He pointed out that 50 percent of patients suffering terminal stage cancer opt for traditional Chinese medicine treatments.

A Ministry of Health official said at a recent press conference that "traditional Chinese medicine is an essential component of China's medical care sector".

Referring to the petition, the SATCM source said people who denied the historical achievements, current function and scientific basis of traditional Chinese medicine were clearly ignorant of history.

"Thousands of years of practice demonstrate that people are fond of and deeply trust traditional Chinese medicine. The on-line petition to repudiate traditional Chinese medicine is a farce," the source said.

The SATCM source admitted that there were some cases of businessmen cheating customers in the name of traditional Chinese medicine. They might, for example, mix western medicine with traditional Chinese Medicine and earn money by exploiting people's trust in traditional Chinese medicine.

But shoddy practices such as these do not detract from the scientific value of traditional Chinese medicine, said the source.

Source: Xinhua


Interesting.

If the Chinese government hadn't issued an official comment, angry doc might never have known about this development, and gone and found Professor Zhang's original article and his follow-up piece.

A search on Google and Blogger will turn up many discussions on the topic. They are of course in Chinese, but the arguments will not be unfamiliar to most readers.

angry doc is ambivalent about the online petition - on the one hand it's a way of generating discussion, but on the other hand this is not a popularity contest.

Still, angry doc assumes that the Ministry for Trade and Industry is relieved to know the official stance of the Chinese Minstry of Health.

Dollars and Sense

The cost of outpatient consultation and investigations for urinary tract symptoms: S$200

The average inpatient bill (after subsidy for C class) for investigation and treatment of urinary tract infection: S$300

The chance to see a Singaporean point of view on healthcare costs: priceless

angry doc feels sorry for the person who has to reply to this letter:


Bills pile up with too many visits to hospital

ON SATURDAY, Oct 7, I took my son, who was experiencing excruciating pain near the kidney, to the A&E Department of Changi General Hospital where a urine test was conducted and blood was detected.

The doctor prescribed some antibiotics as he suspected either an infection or stone in the kidney and referred him to a specialist the following Wednesday. The bill: $65.50.

On Wednesday, when my son told the specialist he was no longer experiencing pain, he was told to go for another urine test and to return on Saturday for an X-ray to confirm his condition. The bill: $37.50.

On Saturday, the X-ray was taken (cost: $55.50) and I was told that my son would have to return on Oct 27 for the specialist to tell us the results, for which I would have to pay another $37.50.

I was told by the hospital that if my son had been admitted for, say, removal of kidney stones on his first visit, I would have been able to pay for the expenses with my Medisave funds.

It is my opinion that all expenses incurred in the exploratory stages, though done during different visits to the hospital, should be payable with Medisave funds when the tests finally result in a patient having to be admitted to hospital.

Also, why penalise the patient, when the scheduling for appointments and admission is done by the hospital?

The appointment on Oct 27 with the specialist is for the results of the X-ray to be made known to us. Why is there a need for the fourth visit and to wait 13 days when the results could be relayed to us via phone, e-mail or fax two to three days after the X-ray was done?

Why does one need to make so many visits?

If the urine test and X-ray could be done at the A&E, couldn't the final results be made known during the visit to the specialist?

Carol Lim Siew Imm (Ms)


angry doc is often amused by how the Medisave system shapes people's decisions on healthcare matters.

It seems that Ms Lim feels it's a better idea for her son to be admitted for investigation and treatment of his condition even though that will possibly double the size of the medical bill (95th percentile), since that money will come out of her Medisave funds rather than her own pocket.

Never mind the trouble that it would actually cause her family to have her son admitted, the cost of transport for the family to and from the hospital to visit him, or the bed and manpower her son would take up while he is being investigated (for what seems to be a condition which can be investigated and managed on an outpatient basis), possibly denying or delaying someone else who needed that bed more.

Ironically, while she wanted admission for management of the problem, she is happy to receive the results of the investigations for that problem 'via phone, e-mail or fax'.

No need to see a doctor to discuss the implications of the findings or further management options and plan.

Anything to avoid having to pay out of pocket, it seems.

Perhaps there really *are* some things money can't buy...


Added: The reply to Ms Lim's letter is reproduced below.


Why patients have to return for review of special X-ray

I REFER to the letter by Ms Carol Lim Siew Imm, 'Bills pile up with too many visits to hospital' (ST, Oct 18).

It is necessary for patients to come back for a review of their specialised X-ray examination results. This is to ensure confidentiality as well as to provide professional consultation on the medical condition.

A normal result does not exclude other causes of the problem. Hence it is necessary in this case for a review by the specialist to discuss the other possible causes of the problem and decide on the management plan.

Our staff has spoken to Ms Lim to explain the situation. She wanted to know why the Intravenous Urography (IVU) could not have been done on the day her son saw the urologist, and why it takes 13 days to churn out the report from the time the IVU was done until the follow-up date.

The IVU could not be done immediately because the patient's bowels had to be cleared for the examination. Once the radiographer has done the procedure, the films would be reported by the radiologist.

In addition, we would need to find the earliest available slot for the patient to see the doctor for the review of the results.

If Ms Lim needs further clarification, she could contact Ms Grace Segran of Corporate Affairs on 6850-2734.

We thank Ms Lim for bringing this matter to our attention.

T. K. Udairam
Chief Executive Officer
Changi General Hospital

Hazy Thinking

view from window of angry doc's consultation room

angry doc apologises for the lack of posts over the past few days. The fact is the haze is just sapping the energy out of him as he has to take a lot of time correcting the misconception of all his patients who, like the patient quoted in in this news article, are blaming every medical condition they have on the haze:

(quote)

"I haven't had cough and flu for the past two years. So I believe it is due to the haze. The cough is pretty bad so I came here to see the doctor,"

Unless the virus has flown all the way from Indonesia with the smoke, angry doc thinks it's a little unfair to pin it all on the haze. More importantly, the seasonal winds have always been blowing from other lands, whether or not they carry smoke particles that allow you to actually visualise the process, so there is no reason to believe that the infection has actually anything to do with the fires and the haze.

But it illustrates how the human mind often mistakes temporal sequence with causality. angry doc will not be surprised if a patient who blames a viral infection on the haze subsequently buys himself an air-purifier and later, when the viral illness has run its natural course, attributes his recovery to the machine.

Of course it is also likely that the patient just has a reaction to the irritants in the haze, and does not actually have 'the flu', but respiratory illnesses are not the only ones that are being pinned on the haze; angry doc suspects the ophthalmologists must be seeing an increase in the number of referrals for cataracts this month.

All that is understandable, of course.

What puzzles angry doc, however, is the advice to stay indoors.

Unless a house is under positive pressure from an air source that has been passed through a (good) filtered ventilation system, angry doc fails to understand why the smoke particles that have traveled all the way across the seas would be so obliging as to stop at the threshold of your door or your window sill (sill - I've always wanted to use that word!).

After all, wouldn't Brownian Motion ensure that the smoke particles are as evenly distributed in the air inside as they are in the air outside a house?

Perhaps people *think* that it is less hazy indoors simple because the average room is not big enough for the effects of the smoke particles on visibility to be obvious? In other words, maybe people think it's less hazy indoors only because it *looks* less hazy?

angry doc: Career Counselor

A kind reader has provided angry doc with a topic to blog about today.


"qns.

what are the prospects for life sci grads in the healthcare sector?

would one be able to work as a MT/phlembotomist(eg)after training on the job or would they require further certifications in that area before they can apply for it.

it's already been noted that there's an oversupply of life sci grads and apart from alternative careers in teaching and medical/pharm sales not much has been said if there are jobs suitable for a bio grad within the healthcare industry.

-future test tube washer"


angry doc must confess he didn't have the answer - he was pretty sure that if he ever got struck off the register he would do something else totally unrelated to the medical field, so he never bothered to find out.

Thanks to Google, however, he now knows there are lots of exciting career opportunities for Life Sciences graduates in the medical field, at least in the two healthcare clusters.

You can google up Singhealth and NHG and check out their offers - there are in fact many positions posted just this month!

Some of the jobs which might be suitable are:

Transplant Counsellor (SH) - requires 'Degree in Science, Life Science or arts or Diploma in Nursing'

Medical Technologist (SH) - requires 'Bachelor of Science or equivalent/ Diploma in Biomedical Science or equivalent'

Epidemiologist (NHG) - requires 'Preferably a medical-related basic degree (MBBS or MD or BSc Nursing) but non-medical candidates may also apply. At least MSc qualification. The postgraduate degree should be in Public Health or Epidemiology.'

Research Assistant (Infection Control) (NHG) - requires 'Degree in Paramedical or Health Science discipline or foreign MBBS'

Executive - Tissue Repository (NHG) - 'Candidate must possess a degree with at least 1 year of working experience, preferably in a healthcare setting'

Medical Technologist (Molecular) (NHG) - requires 'Mininum Bachelor of Science majoring in molecular biology'


The list goes on and on, but you get the idea. Many of them require some IT know-how, 'team player'-ness, and that elusive 'prior experience' (imagine if they required that before you could become a doctor...), but there *are* jobs out there. You might even consider applying for and working in a Diploma position first so you can get the requisite working experience in a hospital or healthcare setting first and apply for a degree position when you have a better idea of how work conditions are like (except the other diploma-holders wouldn't like you very much for competing with them...).

And I haven't even searched under the private sector yet. Don't expect me to do that for you too - you *are* a university student, afterall...

Good for what ails you!

Sometimes angry doc thinks the western medicine establishment is really stupid in the way we do things.

We study individual diseases, study the effects of individual drugs on the diseases, and then we have each drug submitted for approval by the FDA for each indication.

All that takes years and millions of dollars, which is really a waste of resources when you realise that there is already one single thing that can (according to this ad in Today today - see right upper corner of page 39) 'improve high-blood pressure, allergy, migraine, etc'.

Wow.

As far as angry doc knows, western medicine has no cure for 'etc' yet!

And here we are plodding along one drug, one disease at a time, when "Dr Hydrogen" can 'improve' all these illnesses all at once!

So how does "Dr Hydrogen" do it? According to their website (see ad for website address):


Dr. Hydrogen reacts with water in this way:

Mg + 2H2O
Mg2+ + 2e- + 2H2O
Mg2+ + 2e- + H2+ + O2-
MgOH2 + H2
Mg2+ + 2OH-


It's good old Magnesium Hydroxide!

Who would have thought that the cure to so many illnesses was available in your average secondary school chemistry lab? angry doc should have stopped at 'O' levels Chemistry instead of going on to medical school.

What else is it good for? Well, according to the website, 'Gastric ulcer, Cerebral infurction [sic], Rheumatism, Wrinkle, Skin problems, Atopic dermatitis and Constipation'.

And why shouldn't it be good for gastric ulcers? Milk of Magnesia *is* an antacid!

angry doc managed to dig up the first page of the study paper mentioned on the website, but it doesn't seem to mention anything about how:


The effectiveness of Dr. Hydrogen against these conditions were verified:

slows down cancer
the antioxidation properties slow down ageing
improves skin allergy
relieves stress in the stomach
promotes regular urination
good for dieting


Well, two litres of water a day should 'promote regular urination'.

But who needs study papers when you have a whole page full of testimonials from anonymous users in Japan who have benefitted from this wonderful product?

Perhaps the Public Utilities Board needs to consider putting "Dr Hydrogen" into our water-tanks; sure would save the Ministry of Health a lot of money treating all those pesky diseases.

"The Science of Acupuncture"

This excellent article on the topic of scientific studies and clinical trials on acupuncture appeared in the ST today. It is very readable, compared to say this paper which was mentioned in the article.

angry doc wonders if his readers actually read or understand the journal articles he links to; he himself confesses that he cannot understand something like:

But never mind that. What was interesting to angry doc was the author's observation on the difficulties of conducting a randomised, placebo-controlled, double-blind trial on acupuncture in China:


Part of the problem in China is choosing the patients to be studied. After all, patients come to hospitals that practice traditional Chinese medicine because they already believe in acupuncture and are likely to be using it to treat another illness. Getting such patients to accept being put into a control group where no acupuncture is applied is almost impossible. This difficulty makes random studies of the effects of acupuncture treatment on stroke patients particularly difficult in a traditional Chinese medicine hospital.

More fundamentally, however, Chinese doctors who use traditional medicine argue that outcome measures of acupuncture as a treatment for stroke should be different from conventional measures used in Western trials, because the theory of acupuncture is different. But no one has yet specified what the appropriate outcome measures for acupuncture should be.


The first paragraph makes perfect sense, but angry doc has difficulty wrapping his brain around the argument in the second paragraph. He blames it on Monday.

Who needs diabetes medicines?

Prompted by a comment in the previous post, angry doc googled up the DREAM study.

It'll occupy angry doc for the weekend, but so far one line has stood out and made him laugh:

'One patient in the rosiglitazone (Avandia) group and three in the placebo group stopped (withdrew from the trial) because of hypoglycaemia (low blood sugar level).'

With a placebo like that, who needs real medicines?

Health risks come from being hit by car, not jaywalking, says study

Being hit by a car, not jaywalking, increases risk of developing critical injuries and early death

Being hit by a car puts people at risk of developing critical injuries and dying early, but jaywalking without being hit by a car does not. A study published today in the open access journal Highway reveals that individuals being hit by a car are three times more at risk of developing critical injuries and dying young than individuals who have not been hit by a car. Jaywalking individuals who do have not been hit by a car, by contrast, have the same risk of dying or of becoming critically injured as non-jaywalking patients who have not been hit by a car. These results are surprising, as jaywalking is linked to being hit by a car. The authors of the study conclude that the relationship between jaywalking, being hit by a car and critical injuries is complex and that jaywalking, per se, does not predict poor outcomes.

Minnie Driver and colleagues from Rhode Island University Hospital collaborated with colleagues from Volvo University School of Medicine to analyse data from 15,408 subjects aged 44 to 66, coming from four different US communities, who had originally been studied between 1986 and 1989. The authors analysed the subjects' road-crossing habits, incidence of being hit by a car and the subjects' history of critical injuries and mortality within 3 years.

Driver et al.'s results show that, in the absence of being hit by a car, jaywalking individuals do not have an increased risk of suffering from critical injuries, and of dying from critical injuries, than non-jaywalking individuals. By contrast, patients hit by a car are three times more likely to become critically injured and they are three times more likely to die from critical injuries, or from any cause, than patients who have not been hit by a car, regardless of their road-crossing habits. Driver et al. conclude that being hit by a car is a strong independent predictor of critical injuries and subsequent death, or death from any cause.


OK, in case you are wondering, this is a Bonus Bogus Story, adapted off this news release on this study, which is reported in The Straits Times today (off the Los Angeles Time) with the title 'Health risks come from diabetes, not obesity, says study'.

Yippee! Now we can all feel less guilty about being obesed - afterall, scientists say you don't actually die from obesity!

Well, except that the study doesn't really say that.

It's true that people don't die from obesity.

They suffer (and die) from complications resulting from obesity.

And that includes diabetes.

In fact, the study mentioned that '[a]t baseline, participants with a BMI of at least 30 were more likely than those in lower BMI categories to have DM (22.4% versus 7.9%, p <0.01).'

So obesity is not going to kill you, but it will put you at a higher risk for diabetes, and *that* is going to kill you.

angry doc is not against obesed people (he is against obesity), or the idea that obesed people can feel good about themselves, but he is worried that people who have all-along crossed the road at designated crossing areas will start jaywalking after reading such news articles...

Contemplating Mortality

Is this vlogging gone too far, or just honesty?

How much is that doctor in the window?

OK, we may not be quite there yet, but it does seem like we've just taken another step closer?

AVA introduces Pet Shop Grading Scheme to up standards of pet shops

SINGAPORE : Pet shops in Singapore will soon be graded.

The scheme is similar to how the National Environment Agency (NEA) grades hawker centres.

This is part of Agri-Food and Veterinary Authority's (AVA) plans to improve the standards of pet shops in Singapore.

Shops that sell cats and dogs are the first to be affected by the Pet Shop Grading Scheme.

They account for about 160 pet shops out of the 460 in Singapore.

The scheme, which is to be rolled out later this year, is part of the government's overall plan to enhance the professionalism of the industry.

This was announced at the AVA's Responsible Pet Ownership Roadshow on Saturday.

"We have always been looking at ways to lift the standard. We do have some spate of events recently about pet abuse, so I think it is good that the community is becoming more aware and the response has been encouraging," says Grace Fu, Minister of State for National Development.

"It's good to know that Singaporeans do care about pets' welfare and I think we should all work towards increasing animal welfare standards in Singapore," she adds.

AVA hopes the move will motivate pet shop owners to maintain a high level of animal care.

Says Dr Leow Su Hwa, head of Animal Welfare Education at AVA: "It's going to be based on three factors. First, we will see how the pet shop maintains and keeps these animals, whether they're looked after properly. Second, we want to see how they maintain the premises, that is, if it's clean and the cages are of the right sizes so that there are sufficient space for the animals.

"Third, we want to see how they do their client education. So it's not just a question of selling the pet but they should give relevant and proper information about how to take care of the pets."

Many pet shop owners welcome the move but some have raised concerns that the grading may affect their business.

"If a customer comes into my shop and see a Grade C or D, they will walk out of my shop before they even ask any questions. My shop is an eight-year-old store. If I need to get a Grade A, I have to improve on the hygiene and the smell, but it will cost us a bomb to renovate the whole store," says George Tan, who runs Joy Doggy.

Animal welfare societies say it's a step in the right direction but pet lovers have mixed reactions.

"(Grade) A is the best of course. It's more trustful, and if I have any queries, I believe they'll know the answers," says one member of the public.

"The grading doesn't make a difference because I would have done my homework prior to coming to the pet shop, and also through friends' recommendations. So when I come to the look at the dogs, I would get a sense of how the shop owner is treating the dogs, and the environment that they're being put in," says a pet lover.

AVA says its animal welfare inspectors will conduct routine checks on pet shops at least once a year.

Those that have a poor grade and do not show any signs of improvement may be suspended from business or have their licences withdrawn. - CNA /ls

OK, the day for an open grading scheme for GP clinics may never come, but angry doc is nevertheless intrigued by the topic.

A grading scheme has meaning to a consumer/patient only if he understands how the grading is arrived at, and whether the criteria used in the grading are the same ones he would use to grade that service/clinic. Customers who understand that will choose the service he personally grades highly, and disregard the official grade.

That's why some 'C' grade hawker stalls seem to pull in the crowd - if it tastes good and you don't get a stomach upset from it, you'll probably return. And if you didn't like the food, an 'A' grading wouldn't make a difference to you.

Still, those who do not know the above and choose to put their trust in an official grading system, especially those with no prior experience of patronising the service, will be influenced by the grades.

The grading for pet shops involves a new dimension - that of professional knowledge. It makes the grading perhaps more helpful as professional knowledge is to most laymen 'confidence goods' - you don't know if it's good advice before you apply them, and sometimes not even then or after. It also approximates the GP-patient situation.

Likewise, the criterion on care provided for the pets also approximates subjective clinical outcomes (like blood pressure and HbA1c levels) which can be monitored.

One dimension that is not assessed is that of service-provider-client relationship, or the patient-doctor relationship. It is perhaps impossible to assess meaningfully, and it is an aspect angry doc is ambivalent about.

The patient-doctor relationship is an important one in determining how functional a therapeutic alliance is. Ok, that was just a quacky way of saying that patients tend to trust and follow the advice of doctors who seem to understand and care for them. It is helpful, but without good knowledge on the part of doctor which translate to good clinical outcome indices, an emphasis on a good patient-doctor relationship will turn the practice into quackery. A patient can be poorly-cared for but happy with his doctor, simply because he doesn't know any better.

Yet if we leave this criterion out, we risk ignoring the fact that for some patients, their aim in seeing a doctor is not simply to hit those clinical outcome results for the doctor, or that some patients simply cannot hit those targets. Grading a doctor or practice on target figures will put a strain between the patient and doctor when they do not have the same therapeutic outcome in mind.

Will the day come? And when it does, will you be influenced by the grading system?