Confidence Goods 4

Singapore's healthcare system is once again in the limelight.

The Minister gives his views on the healthcare market in this speech, parts of which I have reproduced below (emphasis mine):


"In my view, the main problem behind healthcare woes is that we have unnecessarily mystified healthcare and some economists have further endorsed the myth by concluding that the market fails in healthcare. While the observation is not wrong, it has unfortunately given healthcare providers many excuses that their activities are unique and they are different from other economic sectors. This perception has given politicians and many interest groups justification to intervene, often for their own interests, and along the way, to further distort the healthcare market. It becomes a self-fulfilling prophesy. While the healthcare market can never become a fully perfect market (few economic sectors are perfect markets, by the way), the current level of market imperfection is not the natural order of things. The healthcare market fails because we collectively, unwittingly allow it to fail.

First, if patients do not know the choices available to them and the prices and quality of these services, how can we expect them to make informed choices and reward the efficient providers?

Second, if the bills are paid by a third-party with very little direct payment by the patients, why should patients bother to search for lower-cost solutions?

Third, if the providers themselves do not know or bother to know what their true costs are, and that of their competitors, how can we expect them to improve on their performance, to deliver better services at lower cost?

Fourth, if both providers and consumers do not regularly measure the clinical outcomes of their services, how can we know whether the services provided are optimal and desirable?

Finally, if prices are distorted by subsidies, how can we expect to achieve an optimal distribution of supply and demand, with minimum wastages and maximum productivity?"

"The world is searching for better answers to many of these systemic problems. As I see it, the more we can make the healthcare market behave like a normal market, the closer the world will be to having more efficient and effective healthcare systems."


angry doc wonders if he (and his blog) had done more to mystify healthcare in Singapore or to demystify it. Do let him know, gentle readers.

angry doc is however pretty convinced that healthcare is a unique 'activity' (and try as he might, he cannot think of another activity that is totally like healthcare - education comes close).

Reading between the lines, the Minister's idea of making the healthcare market more 'perfect' seems to be:

1. Make the providers make their prices and performances more 'transparent' so consumers can make educated decisions on whom to patronise, which will in turn effect competition between the providers.

2. Remove third-party payers and subsidy from the equation.

angry doc will not look at point 2, but with regards to point 1, he can already see a couple of reasons why it may not work in practice.

Medicine is a confidence good and while patients can (and should) know the prices of the services and goods, they will not always know the quality of the care they are receiving. To many hypertension patients, paying for and taking their daily medication must be like buying a lawn display that will keep tigers away from their house.

Because of that, providers and consumers do not always have the same desired outcomes in mind. To try to measure outcomes before we even agree on what outcomes we want is putting the cart before the horse.

But underlying the first four points the Minister has raised is perhaps the belief that there are answers in healthcare, and that we know those answers.

We believe we know what quality is, we believe we know what the cost-effective solutions are, and we believe we know what clinical outcomes are optimal and desirable; good old-fashioned medical paternalism which angry doc is proudly guilty of.

But importantly, we also know that what we think is best for our patients may not always be viewed as such by them, and vice versa.

Unless we are willing to agree with the patients (or consumers) that what they want is what is best for them, then making the market more 'normal' or 'perfect' probably isn't going to change the way things are.

As long as providers think they know best, they will continue to distort the market consumption to what they think is right.

Our task then, at least within the context of subsidised healthcare, is perhaps not so much how to make the healthcare market more 'perfect', but how to make the consumers align their expectations with ours, or how to incentivise them to do so.

Your task, however, is to answer yourself this question: do you want a doctor who gives you what you want, or a doctor who gives you what he thinks is best for you?

All-Cause Mortality

drug-pusher: The latest study shows that there is no difference in cardiovascular death rates between the group on our product and the control group, but there is a significant reduction in all-cause mortality in those patients on our product.

angry doc: I see... but the higher number of deaths in the control group were all due to injuries from falls sustained by patients while walking down the stairs in your research building!

drug-pusher: We are quite sure they didn't get a heart attack while falling down.

angry doc: ...

drug-pusher: Would you like some more free pens?

angry doc: So what else are you pushing today?

How NOT to argue for Alternative Medicine 5

angry doc grows weary, but he feels he cannot let this article on Today today go unchallenged...


The Solution lies with you
Richard Seah

THE kidney has become like a computer. When it stops functioning, it makes more sense to get a replacement than to keep servicing the old one.

And so we are now recommending that people suffering from advanced stage of kidney failure should opt for a transplant, instead of dialysis, as the treatment of choice.

It does make sense. A transplant is a one-off event. In the long-term, it costs less money than regular dialysis. It is also more productive than lying down doing nothing while receiving dialysis.

An organ transplant, however, is not without its risks — including those associated with major surgery, organ rejection and side effects of anti-rejection drugs. Several anti-rejection drugs can actually cause decreased kidney function.

So even if kidney transplant is preferable to dialysis, it is, at best, the lesser of two evils — still far from the ideal.

We need to look into the broader, longer-term issue of prevention. Or the problem of kidney failure will just get bigger. Already, Singapore has one of the highest rates of kidney failure in the world. Do we want to be No 1?

A quick check at the National Kidney Foundation (NKF) and Health Promotion Board websites did not turn up any advice on how kidney disease might be prevented.

The NKF mentions that it launched a "massive prevention programme" in 1997 but this consists primarily of health screening. Screening is detection, not prevention.

At best, screening can lead to early treatment to prevent the disease from worsening. True prevention means not having the disease arise in the first place.

Medically, it is known that kidney patients can slow down the worsening of the disease by limiting their intake of protein (meat), phosphorus (soft drinks, milk, dairy products and dried beans) and sodium (salt). It is also known that many types of chemical toxins and pharmaceutical drugs can cause kidney failure.

Does it not follow that normal, healthy people can slow down, or even avoid, the development of kidney disease by limiting their consumption of the same substances?

While our public health education programmes does recommend limiting salt intake, little is said about the rest. Our health education programmes also do not state clearly the link between meat, dairy, soft drinks, etc and kidney disease. Instead, these programmes tend to focus on the heart.

Traditional Chinese Medicine has plenty to say about how to care for the kidneys — because the kidneys (along with the adrenal glands and reproductive organs) are regarded as being responsible for a person's overall vitality.

And so there are plenty of herbs, tonic foods, exercises, massage techniques (such as foot reflexology) for keeping the kidneys in good shape.

These may not be scientific. But that is because the pharmaceutical and medical industries have little interest in studying things that lack the potential to generate huge profits.

Any research into traditional methods for preventing — and possibly reversing — kidney failure will therefore have to be initiated and funded by governments, universities and public organisations like the NKF.

Being in Singapore, with excellent medical and scientific facilities as well as access to traditional medical knowledge, places us in a prime position to conduct research of this nature. So will someone please take up the challenge?

For those who cannot afford to wait for scientific research that might never take place, try using a ginger compress: Dip a towel into some hot water with grated ginger mixed in, then squeeze it until it's nearly dry. Fold and place the compress over the kidneys on your upper back, and cover it with another dry towel to keep the heat in. Repeat for about 20 minutes until the area is red.

This treatment draws blood to the kidneys to heal it. It is a simple yet powerful treatment used by kidney patients I know.

If you can restore and retain your original kidneys, that would be the ideal. Kidneys are not computers. New ones are not necessarily better.


For the most part what Mr Seah wrote makes sense. Singapore does have a high incidence of renal failure that warrants our attention, and prevention is better than cure.

But unfortunately Mr Seah utilised the same old flawed arguments and fear to advocate the use of unproven therapy.

The fact is traditional Chinese medicine (TCM) is big business, and TCM remedies for renal diseases have been and are being studied, and there is evidence that some of them may slow down the progression of renal failure.

See for example this 'local' article, or do a pubmed search to see more. Hardly something that 'might never take place', don't you think?

Sometimes it's not about the bus

Thanks to one of his patients, angry doc learnt that a mobile clinic will be providing free health screening for the residents of certain neighbourhoods...


Patient: Doctor, the bus is coming to my estate next week - do you think I should go for the free screening?

angry doc: Well, we already know you have diabetes and hypertension, so you don't need to be screened.

Patient: But it's free!

angry doc: Screening is for people who don't know if they have the disease; you don't need to be screened.

Patient: But it's free!

angry doc: If you go for the screening, you'll just be wasting time to find out something you already know.

Patient: It's OK, I'm retired and I have a lot of free time. Plus it's free!

angry doc: It may be free for you, but it still costs the organisers money to do the screening, so it's probably better if they spend the money on people who need the screening.

Patient: But it's free to me, right?

angry doc: Would you like to sign an AMD? It's free with this consult.

Nd2Fe14B

angry doc saw some really pretty bangles being advertised in Today today (page 50).

According to the website provided in the ad, these bangles don't just look good, they also:


"... incorporate(s) the health benefits of magnetic therapy in a fashionable accessory."


Wow.


"... made from neodymium, a high quality material, with iron and boron. The flux density (amount of magnetic field flux)... is about 5 - 10 times (~2000 gauss) more stronger [sic] than other normal bangles."

"When worn on the hand, it provides excellent health benefits for rheumatism users [sic] and at the same time relieves stress, pains and muscle aches, and improves blood circulation,"


That sounded so exciting angry doc just had to find out what neodymium is from Wikipedia (emphasis mine):


"A neodymium magnet or NIB magnet (also, but less specifically, called a rare-earth magnet) is a powerful magnet made of a combination of neodymium, iron, and boron — Nd2Fe14B. They have replaced marginally weaker and significantly more heat-resistant samarium-cobalt magnets in most applications, due mainly to their lower cost."


Hmm... The bangles do look good, but they are a bit expensive...

Oh well, angry doc will just have to see if he can obtain the same health effects by putting one hand over his hard-drive while he blogs.

Nightmare scenarios

angry doc had a bad dream last night. He dreamt that he was ordered to insert a chest tube but (for some reason he can't remember now) he never got around to doing it and as a result the patient died.

Not good.

What happens, he wonders, if he was ordered to pull the plug on a patient who had signed an AMD, but the patient dies before he could get around to doing it?

Thousands of years of practice... 2

angry doc was hoping to take a break from blogging this weekend, but Today had to publish an interview with a biomedical research scientist with an interest in fengshui...


(excerpt)

Q: Are Western science and fengshui truly incompatible?

A: I don't think there's any inconsistency between science and fengshui at all. It's just that fengshui acts on intangible energy and science can't explain or measure qi. It's wrong to say fengshui is unscientific as, to me, science is about formulated, systematic knowledge attained via empirical means — that is, experimentation, observations, so on. Fengshui knowledge has been attained through 5,000 years of observation and recording — 5,000 years of empirical evidence!


Cow dung.

angry doc doesn't have anything against scientists who choose to believe in fengshui in their 'private' capacity, but it's sad to see a biomedical research scientist who either cannot distinguish between science and non-science, or is trying to pass off non-science as science.

"A Mad Tea-Party"

'Have some wine,' the March Hare said in an encouraging tone.

Alice looked all round the table, but there was nothing on it but tea. 'I don't see any wine,' she remarked.

'There isn't any,' said the March Hare.

'Then it wasn't very civil of you to offer it,' said Alice angrily.

(with a mad-hat tip to Dr Crippen)

I Won't. Will You?

Alright, this tears it:


Don't leave it to family – you can decide how you go: Khaw
Tan Hui Leng

IT'S not often that you get to discuss death, especially with a Minister. But for Mr Khaw Boon Wan (picture), it's a natural ice-breaker.

"I am extremely aware of death. I think the worst thing is to be unaware, thinking that you are immortal. We are dying every moment. Even as I talk to you, I'm dying. Cells are dying.

"When you're very conscious and aware of death, you are also very conscious of time — the need not to waste time," said the Health Minister in an interview with Today.

There's a certain urgency with which the 53-year-old Mr Khaw, a Buddhist, approaches the whole topic of dying — set against Singapore's ageing population — before it comes under the spotlight in Parliament.

Especially tricky is the issue of the Advance Medical Directives (AMD), a legal document through which adults — while they are still in a position to decide rationally — can indicate that, in the event they are struck by a terminal illness, they would like to refuse extraordinary treatment.

On paper, it makes sense. But the fact that only 4,000 have opted to sign up for this since the Act was passed a decade ago shows that the concept needs to be conveyed more clearly.

Some are not comfortable with the fact that AMDs, which limit a person to just two options — saying either yes or no to such extraordinary treatment — are cast too narrowly.

Mr Khaw readily acknowledges this. "There are people who feel that definition of AMDs is too tight. I think because it was a major breakthrough in society attitudes 10 years ago, it had to be very narrow," he said.

"But I doubt if I could loosen it too much at this stage. I hope we can loosen it more, maybe in 10 years' time."

Still, he thinks that it is time for people to start talking about end-of-life issues again.

And they should talk with their family members about the eventualities.

Otherwise, this "huge burden" of making a choice might end up on the family's shoulders.

The issues or ageing and death need to be discussed; one cannot pretend that the problem does not exist, he said.

"It does. Day after day, if you walk into the intensive-care unit, you will find a couple such cases and see the distress, the anguish that both the patients and their families are going through," said Mr Khaw.

"If the interventions are effective, that's fine. If a patient is young, you go all out. But if you have multiple illnesses, have a patient of very advanced age, and it's terminal, then I think you have to accept that medical science has its limits."

The question is: What does a patient do after that?

If he found the definition of AMD too narrow, then it could be supplemented with other documents that can offer more choices — an option that Mr Khaw is open to.

One example is living wills, which detail the various modes of treatment you want or do not want in your last illness, covering the various scenarios that may arise.

Currently, the United Kingdom is exploring such forms of "complementary documentation", said Mr Khaw.

"The key point is, we want to know what your preference is, and then — within the limits of the law, morals, ethics — we try to accommodate you."

Mr Khaw was not convinced by a proposal by Associate Professor Lee Wei Ling, director of the National Neuroscience Institute, to give "sweeteners" — such as a deduction of hospital bills by 30 or 40 per cent — to those who opt for AMDs.

"My instinct is if you argue all this on dollar and cents, you lose the argument. Then you are saying, alright, you're rich, you can afford to live longer; if I'm poor I should be killed," he said.

"I think it will be caricatured into that kind of an argument which, first of all, is not the intention, and secondly is a destructive way of looking at this very important subject."

Also being reviewed: The need for two signatories in an AMD — a doctor and another person who will not benefit from the death of the person involved, he revealed.

But he made it clear that his ministry is not chasing after numbers, but merely raising the issue of death in the public consciousness.

For the record, Mr Khaw has walked the talk and made an AMD himself.

He said quietly: "I would like to spend my last days happy. The best way to die is to know when you want to die, how you want to die."


angry doc is confused. Very confused.

It seems like only last week when the Minister was reported to have said:"You know something is not quite right. You should be having hundreds of thousands of people signing on" and "... for AMD to really bring about benefits to the person and to the family, you do need many more people to sign on".

Now it seems that his position is that "ministry is not chasing after numbers, but merely raising the issue of death in the public consciousness".

He must have been misquoted then.

angry doc is also confused as to why the journalist would acknowledge that the AMD "limit[s] a person to just two options — saying either yes or no to such extraordinary treatment", yet conclude the article by quoting the Minister when he said "[t]he best way to die is to know when you want to die, how you want to die".

The AMD does not let you make those choices, and it's misleading to end the article on that note. In fact, the title of the article is also misleading.

(angry doc can think of a way to decide exactly the time and manner you wish to die, but even that is contingent on the train arriving at the station on time.)

angry doc also has no idea why an 'ageing population' is relevant to the discussion. As far as he is aware, people from previous 'non-ageing' populations have also died, and the average person has only one pair of parents to worry about, so whether the population is on the whole ageing or not has no relevance to the individual person or family.


angry doc wrote in a previous entry that he witnesses the signing of Advanced Medical Directive (AMD).

He would like to announce that with effect from today, he will cease to do so indefinitely.

angry doc is not against the idea of the AMD.

He still isn't.

But right now, he's not convinced that the media coverage is done in good faith and in the spirit of encouraging a public discussion on end-of-life issues. He is not sure that anyone should decide to sign an AMD at this time when misleading arguments for signing an AMD are being published in the mainstream media.

So he's taking the coward's way out and refusing to have anything to do with the AMD until the campaign fever subsides.

Added: A related letter on the topic published also in today's Today.

You can live with dignity...

"Our bodies break down, sometimes when we're ninety, sometimes before we're even born, but it always happens and there's never any dignity in it. I don't care if you can walk, see, wipe your own ass. It's always ugly. Always. You can live with dignity, we can't die with it." - House


I swear, the next person who uses the phrase 'dying with dignity' in a discussion on the Advanced Medical Directive (AMD) is going to get an earful from me.

Seriously.

Just what exactly is so undignified about dying with 'tubes' running in and out of your body?

How does having an endotracheal tube down your throat or an intravenous access or an intra-arterial line make your exit from this world less glamourous?

Or, how is choking on your own secretions and gasping for air *without* any tubes inserted into your body a 'dignified' way to go?

'Dignity' is in itself a social construct. We, as a society and as individuals, choose what to call 'dignified' and what to call 'undignified'. The fact is there is nothing inherently undignified in receiving life-support measures and treatment. People receive it all the time - from preterm babies, young people who suffered trauma, old people with serious infections, to people who are dying.

Dozens of SARS patients received extraordinary life-sustaining measures during the outbreak. Nobody called them 'undignified'. They were called 'heroes', as were the people who put them on these measures and treatment.

So what exactly is so different about dying from SARS as opposed to dying from cancer or heart failure that makes it acceptable for one group of patients to receive such treatment till the time their bodies fail despite all efforts, and 'undignified' for another group?

angry doc suspects that this 'dying with dignity' talk comes from a fundamental fear of our own mortality and a desire to have some sense of control over the manner and timing of our death.

Unfortunately an AMD doesn't really give you those choices.

You can't choose how or when you want to die by just signing an AMD.

You are allowed to state in advance that you do not want extraordinary life-sustaining treatment when your death is imminent, but don't pretend that you have a real choice over how you got there to begin with, or when it's going to happen. Chances are, if you need your AMD to be activated, you are not going to be looking your best or in a very sound state of mind. In other words, you are still going to look pretty undignified.

angry doc has no problems with people who decide that they do want an AMD signed, for whatever reasons they might have, but anyone who wants me to witness their AMD so they can 'die with dignity' is going to get some tough questioning.

The problem with not questioning the oft-quoted statement that signing an AMD means 'dying with dignity' is that people will let themselves believe that they have thought the whole issue through when all they have done is to parrot someone else's assumptions.

By all means sign the AMD if you want to reduce your final hospitalisation bill, sign the AMD if you want to spare your family from taking the decision on whether to initiate or continue extraordinary life-sustaining treatment, sign the AMD if it makes you feel better about your own mortality.

But don't pretend that signing one will guarantee that you will die with dignity, or that people who do not sign one will die without dignity.

There are no stupid questions... 2

Unusually swift response to Mdm Haslinda's letter from the Obstetrical and Gynaecological Society of Singapore:


Saving lives
Have a Pap smear done at least every three years

Letter from Dr Chia Yin Nin Member
and A/Prof Tay Eng Hseon President
Obstetrical and Gynaecological Society of Singapore

The Obstetrical and Gynaecological Society of Singapore (OGSS) thanks Haslinda Shamsudin ("How often should Pap smear be done?", Nov 4) for her support for the cervical cancer awareness campaign.

The Pap test, like any medical test, has its limitation. It has a false negative test rate of as high as 30 per cent. The latter is overcome by regular repeated testing. However, the frequency must be balanced against the cost of testing.

Based on studies, Pap smear screening prevents about 84, 91 and 93 per cent of cervical cancers when performed at five-yearly, three-yearly and yearly intervals respectively. That is, the cost of screening would triple, from three-yearly to yearly screening, to gain an additional advantage of 2 per cent increased benefit.

Therefore, the best balance reported between cost effectiveness and life years saved from cervical cancer is a screening interval of between three and five years.

More importantly, the effectiveness of a national Pap smear screening program to prevent cervical cancer hinges on the percentage of population coverage more so than the interval of screening.

In Singapore and elsewhere, the majority of cervical cancers occur in women who have never been screened or have not been screened within the last five years; additional cases occur in women who do not receive appropriate follow-up after an abnormal Pap.

The OGSS recommends all sexually active women, aged between 20 and 69, to attend regular Pap smear screenings at no more than three years in between screenings.


A very informative reply, and it explains why '[p]olytechnic [sic] doctors... advise their patients that it is sufficient to have it done once in three years'.

But it doesn't answer the question as to why '[g]ynaecologists in private practice and at government hospitals... advise that such screenings be done annually' though, does it?

Or would that be a stupid question?

There are no stupid questions...

This letter to Today gives angry doc the topic for this weekend's musing.


How often should pap smear be done?

Letter from Haslinda Shamsudin

I am pleased to read that the Obstetrical and Gynaecological Society of Singapore is launching a cervical awareness campaign ("Pap smears = prevention", Nov 2).

Many women are hesitant to go for pap smear screenings for fear of the pain. I was one of them. Having had pap smear screenings for many years now, I would say it merely involves a short period of discomfort during the procedure.

I would like to raise a point about conflicting advice given to women. Polytechnic [sic] doctors who perform pap smear screenings would advise their patients that it is sufficient to have it done once in three years.

Gynaecologists in private practice and at government hospitals would however, advise that such screenings be done annually. Perhaps the Obstetrical and Gynaecological Society of Singapore could clear the air.


Many patients have the misconception that in medicine, there is always (or at least often) a 'right answer'.

But most of the time, there isn't.

Instead, there are (usually) several 'right answers'.

And of course, there are probably many 'wrong answers' too, and a 'right answer' today may become the 'wrong answer' of tomorrow with the publication of a 'landmark study'.

Depending on which study or studies they base their protocol on, different centres will have different recommendations for frequency of Pap smear screening.

But angry doc suspects that Mdm Haslinda isn't really asking about the 'right' frequency for Pap smear screening though.

Or maybe he's seeing un-asked questions where there are none?

"Blow Out"

An interesting story that perhaps all doctors in Singapore could do well to follow.


No specialist would see injured child in hospital

ON OCT 18, my five-year-old daughter fell at home and hurt her eye. I brought her to Mount Alvernia Hospital. She was seen promptly by the doctor and the x-rays showed a fracture. The doctor wanted a specialist's opinion.

As my daughter is insured under my husband's company medical insurance with Aviva, the specialist had to come from the panel of doctors appointed by Aviva. There were six ophthalmologists on the list. The hospital called all of them but none could come to treat my daughter.

The doctors were uncontactable with no phone number or answering service, and those who were contacted said they had other appointments. One or two of them declined to treat my daughter. Another doctor said no because he did not treat patients at Mount Alvernia Hospital. The hospital then called its own specialists. They were not on Aviva's panel and this had ramifications on the claim process. But because we had waited a long time, I agreed to it.

But Mount Alvernia's doctor was on leave and his colleague declined because he said he did not treat pediatric eye cases.

Finally, in frustration I took my daughter to KK Women's and Children's Hospital where she was treated.

My questions are:

Can doctors choose their patients? How ethical or professional is this? Clearly, if a doctor is called after office hours to attend to a case, this is likely to be an emergency. Yet none of the six or seven doctors contacted would go to the hospital.

Why should people pay to be insured under a medical insurance scheme which does not guarantee prompt treatment by its panel of doctors?

How are doctors selected to be on the panel for insurance companies? Do they screen the doctors before appointing them? Surely a condition of such appointment must be their willingness to treat patients at any hospital.

Mount Alvernia Hospital must also look at its specialists. If a patient cannot get treatment in a private hospital, why would they go there?

But I want to commend Mount Alvernia Hospital for its excellent, caring and sympathetic nurses at the A&E department. They tried their best and made many phone calls to get help. While the nurses provided good service, the specialists fell far short. For Singapore to be the region's medical hub, the doctors have to do much better than this. I hope Aviva, Mount Alvernia Hospital, the Health Ministry or the Singapore Medical Association can comment on this.

Patricia Chong-Koh Hee Ching (Mrs)


Now angry doc has no idea how to manage (what sounds like) an orbital fracture in a five-year old child (yes, there is no 'orbit bone', so technically no such thing as an 'orbital fracture'...), but he imagines it might be akin to putting a miniature Humpty Dumpty back together again. Not that all fractures of the walls of the orbit need to be treated surgically, or that it would automatically be a life- or vision-threatening condition though.

The Singapore Medical Council Ethical Guidelines states that a doctor 'shall be prepared to treat patients in an emergency or humanitarian basis unless circumstances prevent him from doing so'. I guess the key here is whether a child who was already in a hospital, had been assessed by the emergency department doctor, and is awaiting a second opinion or definitive treatment constitutes an emergency situation.

Certainly the doctors must have had their reasons for not wanting to take on the case, and we shall probably learn of them when a reply is posted.

angry doc just finds it ironic that despite insurance coverage and a 'private' paying status, no specialist could be found to take the patient's case and she had to seek treatment at a 'public' (restructured) hospital.

Perhaps 'market forces' isn't as powerful as we thought it is?

Rational Rationing?

The reply to Mr Chi's letter is published today.


Patient gets priority when the case is urgent

I REFER to Mr James Chi's letter 'Switch to 'private patient' gets quick test' (ST, Oct 26).

We have contacted Mr Chi to thank him for his feedback. I understand his concern and assure him and your readers that the National University Hospital is committed to providing appropriate medical care and services to all our patients regardless of their payment status.

Patients who are assessed to need urgent medical treatment will always be given priority and no patient will be denied care and treatment due to their inability to pay.

Mr Chi was referred from the polyclinic on Oct 12 with a general referral (i.e. non-urgent and with no specialist named). He was given the earliest available consultation appointment on Oct 31. Although all appointment slots were filled, an exception was made to accede to Mr Chi's request for an earlier appointment when our staff sensed his anxiety.

He was seen on Oct 16 at our colorectal clinic and assessed by the team specialist. His condition was assessed as non-critical and there was no indication for an urgent or early colonoscopy. Thus the earliest available appointment for the colonoscopy in mid-November was suggested.

Referrals from the polyclinics to our specialist clinics are managed by a team of doctors instead of named specialists. Patients enjoy a good level of care which is heavily subsidised by the Government.

Thus the demand is high and waiting time for appointments or procedures is usually longer.

On the other hand, patients who choose to be under the care of a specific specialist are charged at higher rates. Depending on the individual specialist's schedule and the demand for his service, there may be more flexibility and shorter waiting time for appointments and procedures.

As Mr Chi expressed his preference for an earlier colonoscopy appointment, he was given the option to have the procedure performed by the specialist on a non-subsidised basis. In Mr Chi's case, the specialist was prepared to perform the procedure before he left for an overseas conference the following day.

For continuity of care under the same specialist, a non-subsidised patient retains his payment status when he returns for subsequent consultations. However, patients in genuine financial difficulties have various avenues for assistance, including downgrading of payment status if they qualify.

I apologise that these points were not adequately explained to Mr Chi by our staff. We have reviewed his feedback and will improve the counselling process at our specialist clinics.

Following the colonoscopy, a consultation with the specialist was necessary for the doctor to review Mr Chi's condition, explain the colonoscopy findings and answer any queries.

We would like to assist Mr Chi if he has any other concerns. He can contact Ms Deborah Ee, Senior Manager, Quality Improvement Unit, on 6772-2296.

Chua Song Khim
Chief Executive Officer
National University Hospital


It seems now there are three ways to determine priority in receiving medical care: according to the severity of illness, the patient's paying status, and the patient's anxiety level.

I don't suppose anyone has problem with the idea that the sickest patient gets seen first.

Some of us may be uncomfortable with the idea that paying more gets you priority.

How many of us feel that a patient's anxiety level should be a factor when it comes to priority?

Given two patients with the same condition assessed to be non-urgent, should the one who expresses more anxiety get priority?

Given five patients, all of whom have the same condition assessed to be non-urgent, should the one who expresses the least or no anxiety be put at the back of the queue?

Should the squeakiest wheel get the oil first?

A patient's perception of his medical condition is not always commensurate with its actual severity; that's why triage is a medical-personnel-directed process, not a patient-directed one.

Or maybe 'anxiety' is a new parameter in the latest triage protocols, and angry doc needs to go on a course to learn how to 'sense' anxiety?