Angry Doctor

Wednesday, May 31, 2006

Medicine And The 'Dilute-Down' Myth

This article on the International Herald Tribune was published in Today yesterday, with the title of "Business And The 'Trickle-Down' Myth".

It should come as no surprise to you that angry doc liked the pro-labour, anti-globalisation stance of the article. However, that is not the point of this post.

The point I want to make is about alternative medicine.

I was actually planning a post on homeopathy, after Blinkymummy asked me about this mode of therapy. I looked up several sites, dug up the
2005 Lancet article which discredited homeopathy, and the rebuttal from the National Centre of Homeopathy.

Enough material to make a point, I thought.

But the more I thought about it, the more I realised it didn't really matter how much background material I had, or what authority they came from.

The two sides cannot hope to convince each other or convert each other's adherents, because the very bases of their disciplines are not the same.

How can you have a productive debate when you cannot even agree on how a therapy is to be tested?

How can you discuss what is real, when you do not have the same interpretation of 'reality'?

I found it impossible to write an argument that will convince a reader what was 'right' or 'wrong'.

You see, how you decide which side is 'right' will depend on whose paradigm you buy into, and that in turn will probably be decided by what you have already decided about the two modes of therapy, which will in turn probably be determined by your personal experiences with these two modes of therapy.

In other words, one probably decides which way of looking at the world is valid based on subjective experiences, and the outcomes one hopes will realise.

Which pretty much describes angry doc reading the William Pfaff article, really.

He agrees with the author's description of the modern globalised economy, the effects it has on the workforce and populace of the 'home' country, the eventuality of the foreign labour force being dumped when they have out-lived their usefulness, and the prediction that this whole system is not sustainable.

All that is not based on having studied Economics at 'A' Levels or reading The Business Times daily, or on concepts and theories of economics like comparative advantage or 'the invisible hand', but his observations on the economic conditions of his patients, both locals and foreigners, and his limited travels around the region.

Now if you are a supporter of globalisation, you may think that the article is too simplistic and full of inaccuracies, and the author lacks an understanding of how the economy really works, and that angry doc is just choosing to see one side of the story and indulging in wishful thinking.

Some of you may agree with the author, like angry doc does.

Nevertheless, we all live in the same global economy. We all have physical bodies. We all live in the same reality.

We can't both be right now, can we?

Or are we both wrong?


Tuesday, May 30, 2006

angry doc is slow

I mentioned in the comments section of this previous post that:

"(the author) has not named specific companies or doctors involved in this 'controlled' market..."

Well, he hasn't.

But if you look at the first paragraph of his letter, you will see he expressed his 'appreciation' to two persons who had written to the ST Forum on the subject of cheap drugs earlier.

One of them is from the pharmaceutical industry, and the other one is a doctor.

Nice one there, Mr Chan...


Monday, May 29, 2006

Monkey See, Monkey Will

As expected, the letters to the ST Forum brought a few patients to my clinic, asking me to witness their Advanced Medical Directives (AMDs)...

Patient 1: Doctor, will you witness my Living Will for me?

angry doc: We'll see - what do you understand by the term Living Will?

Patient 1: Er... it's euthanasia, right?

angry doc: Sorry, wrong answer. Here's a brochure for your trouble. Better luck next time. Next!

Patient 2: Doctor, will you witness my Living Will for me?

angry doc: What do you know about the Living Will?

Patient 2: That if I sign it, when I am terminally ill and death is imminent, and I am unable to express my wishes, no extraordinary life-sustaining measures will be used to prolong my life.

angry doc: Model answer; but can you explain to me in layman terms what you just said?

Patient 2: Er... that when I am terminally ill and, er... and death is, er... imminent...

angry doc: Close, but no cigars. Next!

Patient 3: Doctor, will you witness my Living Will?

angry doc: That depends - what do you understand by the term Living Will?

Patient 3: That when I become a basket-case they will just pull the plug.

angry doc: Good. Sign here.


Saturday, May 27, 2006

Conspiracy Theory

Yes. Another ST Forum letter to make angry doc angry. And on a weekend too!

May 27, 2006
Some patients have no choice but to buy cheaper medicines across the Causeway

I appreciate the advice to be aware of the risks of taking counterfeit medicines from Jason Humphries, President of the Singapore Association of Pharmaceutical Industries, 'Beware, fake drugs can cause serious problems', and Dr Raymond Chua, Honorary Secretary of the Singapore Medical Association, 'Buy drugs only from well-known pharmacies' (ST Forum, May 20).

But I understand that those who seek cheaper medicines across the Causeway want to stretch their dollar.

There are three reasons why Singaporeans buy medicines from Malaysia or overseas. These patients have no choice in their own country.

Firstly, the prices of branded drugs are tightly controlled by the manufacturers or importers, with high profit margins, because patients are denied the free choice to purchase the equivalent or good generics from open competitive markets like in the US or Europe.

Doctors in Singapore only prescribe branded medicines to be safe and comfortable. The pharmacists here only follow rules and keep records to sell the prescribed drugs as stated by the doctors and charge you the same prices as instructed.

So does Mr Chan want doctors to NOT be safe and comfortable? Or does he want pharmacists to NOT prescribe the medications 'as prescribed' by doctors?

Secondly, the prices of branded medicines from your doctors and from the few privately owned pharmacies in Singapore are the same. It's a waste of time to ask for prescriptions from doctors. Eg, I pay $4 a tablet each day for Plavix, a 'new and better' blood thinning drug, after my bypass operation 12 years ago, as compared to $1.70 a tablet of Ticlid and 5 cents a piece of Cardiprin. Is Plavix so good that it can displace the time-proven Cardiprin?

Plavix is not Ticlid is not Cardiprin. The difference between them is not that of branded and generic. They are different drugs, and have subtly different indications. Some patients cannot take Cardiprin or Ticlid because of side effects or allergy or risk factors, some doctors prescribe Plavix because they are proven to be better for the patient's condition.

Health Minister Khaw Boon Wan has said that if the generics costing a fraction can do the job, why pay for the branded?

Because some drugs do not yet have a generic form. Unfortunately new drugs are covered by the same concept of Intellectual Property as movies and computer software, and to manufacture and sell them before their patent run out is to commit a sort of drug piracy.

Thirdly, due to controlled high margins of profits in branded medicines, both doctors and branded medicine suppliers would refrain from prescribing and importing good generics to protect their interests.

Now that's a bold accusation. Against doctors, that is. Not all doctors prescribe branded drugs, and not all doctors have 'interests' in prescribing branded drugs. As Oz Bloke has mentioned before the margins on generic drugs are actually higher than on some branded drugs, and of course they cost less to stock. A doctor who wants to make a quick buck may in fact stock cheap, popular generics, mark them up by a high margin but still keep the selling price 'affordable', and aim for high turn-over.

If indeed doctors and medicine suppliers controlled the import market, wouldn't we simply import cheap generics and not branded drugs at all, but sell the generics at the price of the branded drugs instead?

The multi-million-dollar pharmaceutical industry has virtually controlled the market for more than five decades. It is high time that shackles be liberated. We need prompt and effective action with mandatory recommended prescriptions for patients to purchase medicines of their choice - either branded or generic.

Shackles? That's a bit dramatic. And it's multi-billion-dollar industry, actually. Like I said some drugs are simply not yet available in generic form. And even if they are, not all generics are the same as the original drugs (especially those with a patented 'delivery system').

I urge the Government to pass legislation for separate consultation and dispensing so that patients can choose the cheapest source for their medicines.

Paul Chan Poh Hoi

I have nothing against separating consultation and dispensing, but as others have noted on this blog before this may not necessarily lead to lower costs for the patients.

If the problem is that the medicine importers control the import and the prices, how would preventing doctors from prescribing lower costs when the seller can still maintain a high price?

Are the prices of drugs high? Yes, for some drugs. But are they too high? Well, that depends on what criteria you judge it from. But I take issue with Mr Chan's potrayal of doctors as people involved in a conspiracy to keep drug costs high for their own interests.

God knows I never benefit directly from prescribing branded drugs...

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Thursday, May 25, 2006

"There is no such thing as alternative medicine"

As expected, Dr Crippen blogs about Prince Charles' campaign to promote alternative therapies in the NHS (May 24 entry).

One thing he wrote impresses me:

"There is no such thing as alternative medicine. There is only medicine."

The so-called "western" medicine is in fact itself an 'integrated' and 'integrating' system. A lot of what was traditionally practiced in the west had been abandoned, and a lot from other traditional systems have been integrated.

The logic would have been plain enough: if it worked, we take it and/or keep it. If it didn't, we junked it.

Western medicine took what it considered was good, and integrated it into its own system with a unifying language.

I rather like the language we use in western medicine. Not the daily clinical one, but the one involved in the basic sciences. We talk about molecules, electrons, cells - same sort of language used in everyday science that helped make your TV, microwave oven, and launch men into space.

Electricians all over the world will talk in terms of voltages and currents, but when it comes to the matter of health, we speak in many different languages.

So do we cling to our different languages because they make us feel different and special, or are they truly integral to our treatment?

Afterall, if a certain therapy works, it should work no matter what you call it.

Certainly there are cultural differences and traditions involved in alternative therapies, but it seems to me that if practitioners of alternative medicine truly want more patients to benefit from their treatment, perhaps a better way to do so would be to let their traditions be interpreted in the language of science.

Diversity of languages is fine for literature and the arts, but if you have something worthwhile to share, wouldn't you want it to reach as wide an audience as possible?

Just as a form of therapy should not be rejected simply because it is 'alternative', the language surrounding a therapy shouldn't be insisted upon simply because it is 'traditional'.

Sure, it's just a paradigm thing and you can argue for western medicine to be styled in that of another tradition.

But this paradigm is one that built the computer you are reading this on.


Wednesday, May 24, 2006

Why can’t you be LESS like your father?

I expect Dr Crippen to be blogging on this topic soon, but in any case it was reported in Today today. I’ve included the link to the Times article and the letter in the text below.

Doctors counter-attack

They want UK govt to stop state funding for alternative therapies

LONDON — In a direct challenge to Prince Charles' vocal campaign for wider access to alternative medicine, a group of Britain's leading doctors has urged trusts under the National Health Service (NHS) to stop paying for alternative medicine and to use the money for conventional treatments.

In a letter, reproduced in London's Times newspaper yesterday, they expressed concern that the NHS was funding "unproven or disproved treatments", like homeopathy, acupuncture and reflexology promoted by the Prince, even as huge NHS deficits were forcing trusts to sack nurses and limit access to life-saving drugs.

The 13 scientists, who include top names in British medicine, have written to the chief executives of all acute and primary care trusts in Britain demanding that only evidence-based therapies are provided free to the public.

While "medical practice must remain open to new discoveries", it would "be highly irresponsible to embrace any medicine as though it were a matter of principle", the doctors said. "The public and the NHS are best served by using the available funds for treatments that are based on solid evidence," the letter added.

Prince Charles yesterday stepped up his crusade for increased funding to alternative treatments with a controversial speech to the World Health Organization assembly in Geneva, asking WHO to embrace alternative therapies in their fight against serious disease.

His views have incensed allopathic doctors, who claim that the therapies the Prince has been recommending have been shown to be ineffective in clinical trials or have never been properly tested.

The Prince's two major initiatives are: A government-funded patient guide that has been prepared by his Foundation for Integrated Medicine and the Smallwood report of last year that he had commissioned to make a case for increasing NHS fund allocations.

According to the letter, both the documents, have given misleading information about scientific support for therapies such as homeopathy. The letter described the alternative method "an implausible treatment for which over a dozen systematic reviews have failed to produce convincing evidence of effectiveness".

The letter's signatories include Sir James Black, who won the Nobel Prize for Medicine in 1988, and Sir Keith Peters, president of the Academy of Medical Science, which represents Britain's leading clinical researchers.

However, 93-year-old Jane Gilchrist, who uses homeopathic therapies, told BBC Radio that she had had "great benefit" from it. "It has been in the NHS since 1948. It's the best kept secret in Britain," she said. It was difficult to collect data because it was hard to prove the effectiveness of a therapy "based on people, not on symptoms", she added.

Complementary therapies also include reflexology, aromatherapy and a range of massage techniques such as reiki and shiatsu.

The scientists who penned the letter sound like a reasonable lot. They do not ask for alternative therapies to be banned altogether, but acknowledge that 'medical practice must remain open to new discoveries for which there is convincing evidence, including any branded as ‘alternative’'.

There is an accompanying article which describes the various types of alternative therapy and whether they have been proven to work. In this article the author suggests that the reason why alternative therapy is popular with patients is because their practitioners have more time to establish rapport with them, something which the overworked 'modern doctors' cannot do.

But instead of allocating more funds to train more doctors so patients will get more time with their doctors, the Prince wants funds diverted from them.

I guess that's the problem when medicine is publicly-funded and politicised - the temptation to choose cheaper, unproven therapy to please the populace over more expensive, proven, but more impersonal therapy is always there.

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Monday, May 22, 2006

"One Patient, One Physician"

Interesting news from the Ministry of Health.

18 Family Physician Clinics at polyclinics will be up and running by July

By Hasnita A Majid, Channel NewsAsia

SINGAPORE: By July, all 18 Family Physician Clinics that treat chronic illnesses will be up and running at polyclinics and the Health Ministry hopes that this will transform how the polyclinics operate.

Firstly by building up the doctor-patient relationship and secondly, through the appointment system to cut down on queues at the polyclinics.

Under the Family Physician Clinic, patients see the same doctors for their treatment in line with the Health Ministry's aim of having "One Patient, One Physician" concept.

"Every visit you'll get to see the same senior doctor, and once you build up a better rapport, the patient and the doctor and the whole team can actually work together to help the patient," said Dr Ruth Lim, Director of Sengkang Polyclinic.

This also means better compliance rate and the ability to empower patients with the necessary skills to manage their condition. As part of patient empowerment, those on the disease management programme at the Family Physician Clinics will be encouraged to get one of these Self-Care Toolkit - a kind of a health booklet where patients can jot down their blood pressure or sugar levels to chart their progress every step of the treatment.

Health Minister Khaw Boon Wan hopes these Clinics will help transform how polyclinics dispense their services in the long run.

Currently there are already 12 of these clinics up and running throughout the island.

"If you do things well and do things right, then 90% of patients ought to be by appointment, so why the need for all these long queues and unpredictability?" said Mr Khaw.

Earlier, he said there's much room for improvement in polyclinic care.

"I'm not proud of our polyclinics, honestly. You queue up one hour and suddenly you get that clinic open to you. You may be a repeat patient, but the next time you come, you see a completely different doctor, so it completely undermines this doctor-patient relationship which is so crucial," said Mr Khaw.

Besides polyclinics, general practitioners are also expected to help in the management of chronic illnesses as they form 80% of primary care.

The Singapore General Hospital has set up a new department, known as the Department of Family Medicine and Continuing Care, where doctors under the department will see patients for a few visits before referring them back to their GPs after a treatment has been mapped out.

"This is the way that we think we can improve the care so that as the patient move out of the hospital, to their primary care in the community, there is no break in the care and that means they can get the same level of care with the same family doctor, probably at a lower costs because there's no specialist fees and at the same time there's convenience," said Lee Kheng Hock, Head of Department of Family Medicine & Continuing Care, SGH.

The Ministry has said that it will allow Medisave withdrawal for outpatient treatment of chronic diseases.

angry doc does not have a Family Doctor, but he does have a 'Family Plumber'.

He was our family's plumber from since angry doc was a kid, and now, several address-changes later, he can still be counted on to help when angry doc's amateur attempts at rectifying any plumbing or electrical faults at home fail.

Typically, a detailed history of the presenting problem is taken over the phone, following which advice on remedial measures would be given, and an appointment for a 'house-call' would be made.

He never misses an appointment, can always be counted on to have all the requisite tools ready, and almost invariably has all the replacement parts required available.

I like to chat with him as he does his stuff. He would give a running commentary on what he was doing, explaining to me how things worked, where I went wrong in my attempts to fix the fault, and how I should repair the fault if the same thing happened again.

He is a craftsman and it's a joy to watch him work. It is clear that in the course of his work he combines extensive background knowledge with years of experience, and not a small amount of ingenuity when some improvisation is called for.

And when the time comes for him to leave, I not only get a feeling that a problem is solved, but that I would be better prepared to handle a similar problem should it occur again.

I am not sure if his charges are considered high by 'market rate', but I feel they are reasonable. In any case I do not have to ask for his help more than two or three times a year, and he makes enough to put his three children through university. None of his children are following in his foot-steps though, and sometimes I wonder whom I should turn to for help when he eventually retires.

Every family should have a Family Plumber like him.


Thursday, May 18, 2006

Smoke gets in your eyes

Encouraging news from the Health Promotion Board (HPB):

Smokers heed graphic warnings on cigarette packs: HPB
By S Ramesh, Channel NewsAsia

SINGAPORE : Graphic warnings introduced on cigarette packaging since August 2004 seem to have had an effect on smokers, according to a survey by the Health Promotion Board.

Nearly half (47 percent) said they smoked less frequently after seeing the health warnings, while 57 percent said they became more concerned about the health effects of smoking.

The survey covered some 1,300 smokers and non-smokers from the ages of 18 and 69.

It was conducted between November and December 2004, a few months after the health warnings were introduced on cigarette packaging.

The survey also showed that the labels were effective in reinforcing health messages among smokers. Seventy-one percent said they knew more about the health effects of smoking as a result of the warnings, while a quarter said they were motivated by the warnings to quit smoking.

The warnings also helped kick-start the quitting process among smokers -- 28 percent said they smoked fewer cigarettes; 14 percent said they made it a point to avoid smoking in front of children; 12 percent said they avoided smoking in front of pregnant women; and 8 percent said they smoked less at home.

Among non-smokers, 46 percent said they had advised smokers to quit smoking after seeing the health warning labels; 17 percent of them were wives who had advised their husbands to quit smoking.

The Health Promotion Board said it was looking at introducing a new set of graphic health warnings by the end of the year.

(You can also see the text of the Press Release from HPB here.)

angry doc is all for public health measures to reduce smoking, but this report has brought a few questions to my mind.

I wonder why, if the survey was done almost 18 months ago, that they waited so long to release the findings.

The sample size of 1300 is not really very big, considering that Singapore has a population of 4 million, and 24.9% of men and 4.1% of women are smokers. The report does not state percentage of smokers in the 1300 persons interviewed, so it's hard to see how representative the survey is.

Also, being a survey, the study relied on responses from those interviewed rather than objective parameters - and in angry doc's experience every smoker he has had the privilege to know smokes 'very little', or has been 'cutting down', or 'has stopped smoking' (usually just prior to admission to the hospital or arrival at the clinic).

The report and the press release do not actually tell you how many smokers had managed to successfully quit smoking as a result of the graphic health warnings. Granted the survey may have been a once-off questionnaire, but as we all know quitting is a (long) process, and an indication of a desire to quit smoking may sometimes be just that - a desire. A follow-up survey would have provided more information.

More importantly, when conducting a health study, one should really keep the objective in mind. In this case, the real question should not be how people feel about the graphic warnings, but whether they do achieve their purpose of cutting down smoking-related illnesses through cutting down smoking.

Now since the ill-effects of smoking may not manifest themselves for many years, a good surrogate and a more accurate way to assess the effects would be simply to look at whether cigarette sales per capita has dropped since the introduction of the graphic warnings. Certainly there may be other factors influencing smoking patterns (such as the rise in price of cigarettes and the banning of smoking in certain public areas), but at the end of the day it's the end results we are interested in, isn't it?

( I am willing to bet, however, that the sales of cigarette cases have increased since the introduction of graphic warnings on cigarette packets.)

Still, I suppose the public likes to see a survey with lots of numbers and percentages.

More than pictures of diseased organs anyway.


Wednesday, May 17, 2006

Living Will, Living Won't 2

As expected Mr Reginald's letter brought two letters to the ST forum today. One was from (presumably) a lay-person, and another one by a doctor, which I reproduce here:

IT IS time the medical profession showed clear support for the Advance Medical Directive (AMD). Many doctors are still uncertain as to what to do because of their religious beliefs, and tend to shy away from being witnesses.

The authorities, like the Singapore Medical Association and the Singapore Medical Council, should make it clear that it is not against medical ethics or religious beliefs to act as a witness for patients signing up for the AMD. It is not euthanasia.

Doctors have a professional duty to help patients who want to sign up. It is the patient's choice.

Doctors should be neutral and professional in the practice of medicine.

Dr George Wong Seow Choon

Unfortunately, doctors are not gods, and the SMC and SMA do not and cannot decide what is or is not against religious belief.

While one can argue that practically everything a doctor does in relation to his patient can be called a duty, the law makes it sufficiently clear that in certain cases (such as in abortion and the AMD) a doctor may choose to not engage in such acts or duties. Specifically for the AMD, the law states that:

10. —(1) A medical practitioner or any person who acts under the instructions of a medical practitioner, who for any reason objects to acting on a directive shall register his objection in the prescribed form to this effect and register it with the Registrar and such objection may be revoked by notifying the Registrar in the prescribed form.

(emphasis mine)

Of course the law is not always 'right', but in this case I think it is pretty fair. The doctor is allowed to exercise an option based on his personal beliefs, without imposing it onto his patient. Let's face it, a patient is not going to die if his doctor does not want to witness his AMD (irony intended), and he can always find another doctor who will witness it. Perhaps what is needed here is merely a list of doctors who will witness AMDs.

angry doc is not a religious person, but does not perform abortions (and thanks to a certain somebody no longer inserts IUCDs too), yet witnesses AMDs. The decisions are based on my views on the nature and value of life. I don't believe the SMC or the SMA should be allowed to override them. Certainly not for mere convenience to patients.

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Monday, May 15, 2006

Living Will, Living Won't

Interesting letter in the ST Forum today on the subject of Advanced Medical Directive (AMD):

May 15, 2006
Doc won't witness medical directive

MY WIFE and I, aged 73 and 80 respectively, read in The Sunday Times that one can make a legal directive stating that if one is terminally ill and in a coma with no hope of recovery, no life sustaining treatment should be given ('When death strikes'; ST, April 16).

So my wife, who is a stroke victim, and I went to the nearest doctor, each with a prepared advance medical directive, with our daughter who was to be a witness, with a request for the doctor to be the second witness. It was stated in the article that two witnesses are required, one of whom must be a registered medical practitioner.

Imagine my surprise when the doctor declined to be a witness, saying it is not clear she is empowered to do that. She also said that as we had no medical records at her clinic, she could not witness our signatures. In my wife's case, she suggested she go to Tan Tock Seng Hospital where she was admitted for her stroke and ask a hospital doctor to be her witness as her records are there. She suggested I go to Ang Mo Kio Polyclinic as I was treated there for asthma.

From my observations, I believe ours was the first such request this doctor has had, as the advance medical directive is new, and I suspect she decided to play safe and not get involved.

There must be many elderly poor who want to make an advance medical directive, but are either unaware that such a scheme is available or don't know how to do it.

Can the authorities kindly enlighten us what one has to do to get an advance medical directive validated?

Trevor Reginald

Mr Reginald's letter contains a couple of inaccuracies:

1. The AMD is not something new, but has been around for 10 years.

2. The doctor is the first witness, and his daughter, being someone who may stand to gain from his death, cannot be a witness.

Of course he cannot be faulted for the misconceptions; in fact this proves his point about the general ignorance about the existence of such a law. You can find out more about the AMD (or 'Living Will') from the MOH website.

I won't be surprised if the doctor had, as Mr Reginald suspected, never witnessed an AMD previously. I don't think I have witnessed more than two or three AMDs in the ten years that the law has been passed. In any case, a doctor can actually refuse to witness an AMD if he registers his objection with the Registrar, or if he does not believe that the patient fulfills the criteria for an AMD.

If I were the doctor, I too would have been reluctant to witness an AMD for someone who had just read about it in the newspaper and decided to go to the nearest clinic to have one signed. A doctor has the duty to make sure that the patient understands the nature and consequences of an AMD, and also that he or she is not under any compulsion to sign one - hardly something you can be certain of for someone you see for the first time.

I have actually been thinking about the topic over the weekend because I have just witnessed an AMD for a patient last week. I am not his family doctor (like many Singaporeans he did not have a 'family doctor'), but he had seen me a few times previously for his chronic medical condition, and at the age of 73, had decided that he would plan for his eventual death. He did not want to burden his family in the event that he would require "extraordinary life-sustaining treatment" when death is imminent. He understood the nature and consequences of the AMD, and had thought the matter over.

But there was a slight problem - he had not discussed the matter with his family. I told him his family would most likely feel hurt that he had not discussed the issue with them, but he was determined to keep the AMD from his family. One does not require a family's consent to sign an AMD. I witnessed his AMD.

That same afternoon his son actually came back to see me, hoping to find out why his father had asked him not to accompany him into the consultation room like he had always done before. I told him he had to ask his father himself.

"But he wouldn't tell me!"

I knew that was going to happen - people often underestimate their family members' ability to tell that something is 'wrong' with them. I told him that as an adult of sound mind his father was entitled to privacy of his medical status and I could not reveal any information without his consent. I encouraged him to continue to talk to his father. The poor man probably went home thinking his father has cancer or something.

Curiously, I have never seen an AMD 'in action', as it were. Most of the ICU patients whose treatment I was involved in either got well, or died before the issue of an AMD was even brought up. Still, it would be interesting to see what further discussion Mr Reginald's letter would generate.

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Friday, May 12, 2006

angry doc as… 3

The Bank Teller

Teller: Good morning. How can I help you, sir?

Customer: Yes, I would like to make a withdrawal.

Teller: Certainly. Now if I can just see your passbook…

Customer: Er, I don’t have the passbook.

Teller: Well, then if you could let me have your account number and some form of ID…

Customer: Er, I don’t have an account. Not with this bank anyway.

Teller: No account? Sorry sir, I’m afraid I can let you make a withdrawal then.

Customer: Why not? It’s not like I don’t have any money – it’s just with the other bank! A good bank would let me withdraw the money.

Teller: I’m sorry – you’ll have to make the withdrawal at the other bank. Or ‘a good bank’.

Customer: Can’t you be flexible and let me withdraw some money?

Teller: No, sir. It’s not my own money to give away.

Customer: In that case can you give me some of your money?

Teller: Kindly leave the bank.

Wednesday, May 10, 2006

angry doc as… 2

The Car Mechanic

Mechanic: How can I help you today?

Owner: Can you have a look at my vehicle please?

Mechanic: Sure. Where is it parked?

Owner: This is it.

Mechanic: Er… sir, that’s a bicycle. We’re a car workshop here.

Owner: I know… it’s just that the bicycle shop I usually go to is closed on weekends, and I thought since you guys are open…

Mechanic: Er… OK… looks like you busted the wheels quite badly. What happened?

Owner: I had a fall last weekend when I went mountain-biking.

Mechanic: This happened last weekend? Why didn’t you bring it to the bicycle shop during the week?

Owner: Er… I wasn’t free during the week… and the bicycle shop isn’t open on weekends…

Mechanic: Yes, I remember… but I’m afraid I can’t change their opening hours.

Owner: Er… so can you fix my bike?

Mechanic: No. We don’t have the spare parts. We’re a car workshop, remember?

Owner: So what should I do?

Mechanic: You can take it to a bicycle shop on a weekday, or I can give you the address of one that opens on weekends.

Owner: No thanks - I prefer my usual bicycle shop.

Mechanic: The one that doesn’t open on weekends? Do you need some form of transportation then? I can let you have the workshop ‘loaner’.

Owner: No thanks – I don’t drive. Is there a bicycle I can borrow though?

Mechanic: Kindly get out of my workshop.

Monday, May 08, 2006

angry doc as...

The Taxi-driver

Taxi-driver: Where would you like to go, sir?

Passenger: Yishun.

Taxi-driver: OK. Shall I take the CTE?

Passenger: No, take the ECP.

Taxi-driver: Er… the ECP doesn’t go to Yishun, sir.

Passenger: Sure it does! They told me so!

Taxi-driver: Er… who are ‘they’, sir?

Passenger: Some people I know.

Taxi-driver: Er… have you ever been to Yishun?

Passenger: No.

Taxi-driver: Er… have these people been to Yishun?

Passenger: No.

Taxi-driver: Are any of them taxi-drivers?

Passenger: No.

Taxi-driver: Do they drive?

Passenger: No.

Taxi-driver: Well, sir, I drive to Yishun all the time and I can tell you the ECP doesn’t take you to Yishun. Shall we take the CTE then?

Passenger: Er… OK.

Taxi-driver: Good. Where in Yishun would you like to go?

Passenger: Science Centre.

Taxi-driver: Er… but the Science Centre is not in Yishun.

Passenger: Sure it is! They told me so!

Taxi-driver: Kindly get off my taxi.

Tuesday, May 02, 2006

First Day

Good luck, doctors.