Angry Doctor

Thursday, August 31, 2006

Alternative MC

Another letter to the ST Forum asking for medical certificates from TCM practitioners to be accepted, this time by schools.

Schools should accept medical certificates of Chinese sinsehs

We were extremely dismayed to read the article 'Traditional Chinese Medicine (TCM) board suspends 2 Chinese sinsehs' (ST, Aug 26) about a physician's illegal dispensation of drugs and another's import of prescription drugs without a licence.

Although TCM has a rich history, it has a diminished status compared to Western medicine and such reports do not bode well for the public's perception of TCM.

Schools do not accept TCM medical certificates. But Chinese sinsehs' medical certificates are accepted by some employers.

If TCM has been around for thousands of years and has been effective for the Chinese, why are the medical certificates of Chinese sinsehs not accepted?

By rejecting their medical certificates, the government is restricting the choice of treatment of the individual.

Can the authorities explain the rationale for not accepting them in schools?

Tammy Tsang Yun Ying (Miss)

We've been through this topic before.

angry doc is not against the idea per se, but he wishes the proponents would argue their case more effectively. Or that the Forum Editor would not edit their letters such that their arguments seem disconnected, which may be the case here.

Now if you look at Miss Tsang's letter, you will find that the first two paragraphs do not actually argue for her case. In any case, western doctors get brought before the Medical Council for selling Subutex or bubble-tea at their clinics, but that has never prompted calls to not recognise MCs from western doctors.

Or is Miss Tsang saying that we should not publicise cases that will adversely affect the public's perception of TCM?

The argument that the current policy restricts a patient's choice to treatment is a partially-false dichotomy (is there such a thing?). The fact is one *may* seek treatment from a TCM practitioner and then see a western doctor for an MC. Many people do that. Some even tell their western doctors they do that. There is no law which prevents one from doing so. The patient will have to spend extra time and money to see a western doctor, but that does not strictly speaking restrict the patient from seeking treatment from TCM practitioners unless he really cannot afford the time and expenses of seeing a western doctor over and above those of seeing a TCM practitioner.

As for TCM having been around for thousands of years, well, so has the practice of applying cow dung to umbilical stumps. The antiquity of a practice is irrelevant to the issue.

Miss Tsang says that TCM is effective for the Chinese. angry doc hopes it works for patients of other races too. But he would argue that the effectiveness of the treatment of a particular medical discipline is also irrelevant to the issue at hand.

What the MC does is to certify that one is ill and unift for school or work. What you theoretically need is just someone who can tell if a person is ill and unfit for school or work. Whether that 'someone' can make you well again is again irrelevant - western doctors cannot cure the common cold or some cancers, but they can nonetheless certify a patient unfit for school or work on the grounds of them suffering from those illnesses.

So if angry doc were to argue for the acceptance of MCs from TCM practitioners, he would argue thus:

If you register and recognise TCM practitioners as being fit to judge if a person was sick (and to prescribe appropriate treatment for him), then you should recognise that they can also certify if that person was unfit for work or school. If you do not, you should, as Miss Tsang has requested, explain the rationale behind your decision.

I think that would be a stronger argument.

Labels: ,

Tuesday, August 29, 2006

Big Doctor is watching you 2

The details on the use of Medisave for outpatient medical bills are released today. I leave the readers to decide if the deductible sum and cap are fair or sufficient, because I am more bothered by something else that was announced.

Specifically, what was reported in this part of the Channel Newsasia report:

"To ensure doctors do not over-service patients, the ministry will audit larger clinics, and publish the data online.

Said Health Minister Khaw Boon Wan, "We will definitely be capturing information like how much the patients pay, what are their initial diabetes blood sugar levels, so that we can track over time. Then we can easily compile (the data) with computers and publish it - so and so cost so much; the average, median, whatever percentile. And then over a one-year, three-year, five-year period, do their patients actually improve."

and this part of the Today report:

"The online system for Medisave submissions could have unexpected benefits, pointed out Mr Khaw. When the doctor filled out the form to certify he was treating a patient for diabetes, for example, he would also need to record the patient's blood sugar levels.

Mused Mr Khaw: "Over a 12--month or six-month period, I can compile, doctor by doctor, the number of patients they handle and the percentage of patients who improve on blood sugar, who stay put or get worse, as well as the cost to the programme. And I can publish it in a simple paper."

This could improve the quality of healthcare as others could learn from doctors or clinics that were doing particularly well. "We need to be able to share their experience with the medical community so everybody learns and everybody improves," said Mr Khaw.

The data will be made available through the Ministry of Health's website."

Numbers, numbers, numbers.

Percentages, percentiles, performace indicators.

Mean, median, mode.

angry doc likes numbers, because they can tell him a lot. But one also has to be very careful in interpreting what the numbers are saying. For one thing, when you grade doctors or clinics by their performance, half of them automatically become 'below-average'.

Diabetes is a complex medical problem. There are patients who do well simply because their disease is mild, and there are patients who don't do well despite their efforts because their disease is severe, and then there are patients who don't do well because they can't be bothered.

In the ideal world each doctor or clinic has the same proportion of each type of patient. The reality may be different.

When you grade doctors by the numbers they return with no regard for their patient profile, the temptation for them to cherry-pick or 'play the system' is always there.

Unless you deny them the right to turn patients away.

But if you do that, the unlucky doctors who happen to have more non-compliant patients or patients with more severe disease will be penalised.

The truth is control of chronic medical conditions requires effort from both parties - the doctor, and the patient. The proposed system does not seem to have taken that into account.


Monday, August 28, 2006

Alternative Mee Siam

Al and I were going out for lunch together the other day...

Al: Let's have mee siam with hum.

angry doc: There's no mee siam with hum.

Al: Sure there is! There's laksa with hum, so there must be mee siam with hum.

angry doc: OK, there may be; but I haven't seen any mee siam with hum before.

Al: You're just too close-minded to accept the possibility of mee siam with hum.

angry doc: No, I'm not - I'm perfectly willing to accept that mee siam with hum can exist. I'm just saying I haven't seen it before. Do you know where they sell mee siam with hum?

Al: I can't recall off-hand; read about it in a food guide before. But many people have had mee siam with hum before, and they all said it tastes great. Are you saying what all these people say mean nothing?

angry doc: Many people used to say the Earth was flat too; I'm just saying I haven't seen any proof that mee siam with hum exists yet.

Al: Can you prove that mee siam with hum doesn't exist?

angry doc: No.

Al: So you admit mee siam with hum exists!

angry doc: No, I admitted I can't prove that mee siam with hum does not exist. Can *you* prove that mee siam with hum exists?

Al: Sure. How would you like me to prove it?

angry doc: Well, you might take me to a place which sells mee siam with hum, so I can taste it for myself.

Al: Can't do that. You see, mee siam with hum cannot be proven to you through your senses of sight and taste – they cannot adequately measure and explain mee siam with hum.

angry doc: Why not? It's food, right?

Al: That's just the nature of mee siam with hum. You must have faith in mee siam with hum to know its existence.

angry doc: Well I don't.

Al: Now that's just double standards. You have faith in laksa with hum, yet you are not willing to have faith in mee siam with hum. Why do you insist on stopping other people from having mee siam with hum?

angry doc: I don't have *faith* in laksa with hum – I know that laksa with hum exists because I have seen, smelled, and tasted laksa with hum. And I'm not trying to stop people from eating mee siam with hum – I just won't recommend mee siam with hum to other people until I have tasted it myself and found it to be good.

Al: Don't you know that great and important people eat mee siam with hum?

angry doc: Great and important people also eat laksa with hum.

Al: You are impossible to reason with. In fact, I don't know why I bother – you are not a chef, so you obviously don't know anything about mee siam with hum.

angry doc: Are you a chef?

Al: No, but that's not the point. You think I'm crazy, don't you?

angry doc: No, I just don't think your arguments stand up to examination. And you still haven't told me where we can find mee siam with hum.

Al: Well, they used to say Galileo was crazy.

angry doc: Yes. They also used to say Rasputin was crazy – and I think they were right.

Al: So what do you want for lunch?

angry doc: Laksa with hum.

Al: You're just so indoctrinated by the big laksa-with-hum businesses that you can't accept that mee siam with hum might be just as good, or even better.

angry doc: Hey, since we're already in Katong...


Saturday, August 26, 2006

Two TCM practitioners suspended

... for practising Integrative Medicine?

Bonus Real-life Story

2 TCM practitioners suspended for using, having controlled medicine

The Traditional Chinese Medicine Practitioners Board has suspended the registration of two physicians.

The first is Huang Chunyun of Eu Yan Sang Specialist TCM Centre in Paragon.

A registered TCM physician and registered acupuncturist, Huang gave his patient capsules of medicine which contained substances not meant to be present in Chinese medicines.

The patient went into convulsions after consuming the medicine and had to be hospitalised.

In addition to the patient's complaint, the Health Sciences Authority also confirmed that Huang was charged in court with two counts of contravening Section 5 of the Poisons Act.

This was for selling without a licence capsules containing two poisons - glibenclamide and phenformin.

Huang was convicted and fined $3,000.

The TCM Practitioners Board later conducted a hearing on Huang's conviction, and decided to suspend his registration as a TCM physician and acupuncturist for two years, with effect from 21 March 2006.

In a media statement, Eu Yan Sang says the product distributed by Huang is not a product of Eu Yan Sang.

The company had first suspended Huang in June last year following an inquiry into his conduct.

On 9 January this year, Eu Yan Sang dismissed Huang for distributing a non-Eu Yan Sang product to a client, which was in contravention of the company's internal guidelines.

The second suspended TCM practitioner is Ong Yam Bing of Sheng He Health Products Department Store.

The registered TCM physician had returned from Batam with controlled medicinal products.

Ong was found to have on him 1,000 tablets of Phapros Amoxicillin Kaplet, 1,100 tablets of Pharpros Ampicilin 500 Kaplet, and 400 tablets of Primolut N containing Norethisterone.

He was prosecuted by the Health Sciences Authority under the Poisons Act, convicted, and fined $5,000.

The TCM Practitioners Board has suspended Ong's registration as a TCM physician for six months with effect from 21 July 2006. - CNA/ir

Perhaps they did not have enough faith in 'traditional' and 'natural' remedies?

Is phenformin considered 'heaty' or 'cooling'?

OK, enough gloating.

This is not the first time something like that happened, and it reveals certain prejudices.

Western doctors get into trouble for prescribing medicine non-judiciously all the time. But I've never heard of western doctors getting into trouble for advising patients to take herbal remedies.

The fact is Chinese 'herbal' medicines, Chinese 'proprietary' medicines (CPM) , and 'western' medicines are not subject to the same standards of regulation, or the same restrictions. You can find out more about regulation of herbal medicines and CPM and at the Health Sciences Authority site, or from this article (page 16 of the journal).

They all purport to be good for you. You put them inside or on you. So why the triple standards?

Labels: ,

Friday, August 25, 2006

Hospital to implement online bidding for clinic appointments

Bonus Bogus Story

Singapore -

Southern Hope Hospital has opened some of its subsidised clinic slots for online bidding.

Mr Bhidnau, the hospital's Senior Clinic Manager told Straight Times this at a press conference yesterday.

"After the introduction of the Feedback Score system, we received many requests from our patients to see our doctors with higher scores. As these were subsidised patients, we could not accommodate their requests and this had led to some unhappiness. Following a discussion with the hospital medical board, we decided to release eight slots or one hour from each clinic session for bidding by the patients to accomodate this demand," said Mr Bhidnau.

Patients are now able to make their bids for clinic appointments online via the hospital's website. Auction for the clinic appointments opens two weeks before the date of the consultation, and ends one week before. The starting bid for each consultation is $20, which is the standard consultation charge for subsidised patients. There is also a 'book it now' option whereby a patient can book the appointment for $60 before the auction ends.

"The 'book it now' option allows patients who do not wish to wait to secure their appointments. This is equivalent to the consultation fees at the non-subsidised clinic. We have also made $60 the maximum bid allowed to ensure the subsidised clinics remain affordable," explained Mr Bhidnau.

"So far the response has been positive, but there is no current plan to expand the system to more than one hour per session as we want to keep the costs of healthcare affordable."


Thursday, August 24, 2006

MOH reveals plan for mutual feedback system

Bonus Bogus Story

Singapore -

The Ministry of Health will implement a mutual feedback system as a part of the nation-wide shared electronic medical record.

Mr Yee Beh, a spokesman for the ministry announced this at the pilot lauch of the electronic medical record system (EMRS) at Southern Hope Hospital yesterday.

Under this system, doctors and patients may leave a feedback for each other after each clinical encounter. The feedback will be recorded on the electronic medical record, and will consist of a comment and a score. A doctor or patient will receive one point for a positive feedback, zero point for a neutral feedback, and minus-one point for a negative feedback. The current scores for the doctors will be posted at the MOH website and at the respective medical establishment the doctors are working at, while the scores for the patients will be available to the doctor on their electronic medical records.

"We got this idea from online auction systems. We believe this system will give greater transparency to the way our healthcare system functions, and allow doctors and patients to be more responsive to each other," said Mr Yee.

"Currently all medical centres have their own system of feedback for patients, but there isn't a single uniform system. By making this a centralised, standardised system, we allow feedback to be collected and interpreted more systematically and completely."

"Also, doctors do not currently have a way to communicate to each other regarding a patient's health-seeking behaviour. The implementation of a centralised EMRS allows them to give their input, and would facilitate better management of the patients."

"We give each party the chance to leave a score and a comment explaining why they left a positive, negative, or neutral score. This is more meaningful than a simple scoring system, and also allows other parties to have an insight on the clinical episode. As each doctor and patient is given the chance to leave a feedback for each clinical encounter, this will over time ensure that the feedback score is reflective of a pattern of behaviour, and not the result of a single good or bad encounter."

Mr Yee also explained that the system may also have wider application other than allowing doctors and patients to learn about each other.

"We are currently looking into incorporating the feedback score into the periodic performance review of our staff, and several insurance providers have expressed interest in using the score to classify clients into different risk groups for purpose of determining premium rates."



angry doc hasn't been sleeping well this week. He’s been having dreams. Too many dreams. Some he cannot recall, some which he can, like this one below...

MOH: What's wrong, angry doc? You look preoccupied.

angry doc: It's the latest press release from the ministry…

MOH: The Data on Affordability of Healthcare?

angry doc: Ya.

MOH: What's the matter? You don't think healthcare is affordable?

angry doc: Well, it's not that – but I don't think the data tell you that.

MOH: It's pretty straightforward, isn't it? The average Singaporean has more than $13,000 in his Medisave account, and the average hospital bill for B2 or C class is below $1,100. An average Singaporean can afford to stay in a hospital once a month for a year, or once a year for twelve years.

angry doc: But an average Singaporean does not stay in a hospital once a month, or even once a year. In fact, the
Health Facts tell us that fewer than 10% of all Singaporeans are admitted to the hospitals each year; and we know that some Singaporeans are admitted more than once a year. If the average Singaporean chalked up the 95th percentile bill of $2,747, he would deplete his Medisave in four admissions. The averages look good, but the outliers are the ones who need the most help.

MOH: If. He might not chalk up the 95th percentile bill, he might not be admitted four times, and you forget that he might still be contributing to his Medisave in the meantime. To be fair, we need to work on averages here when presenting the data to the public. And even if he was a 'non-average' patient who had depleted his Medisave, we have Medifund. We have been giving out more money from the Medifund, you know?

angry doc: Then again, even if he did have money in his Medisave account, he might still have to pay out of his own pocket because of the withdrawal limits.

MOH: Yes. We realise that and we've increased the withdrawal limit this year as part of the reform. At $400 a day, the average Singaporean can pay for a three or four day stay and pay for almost all of it with his Medisave. You still don't think the figures tell you that healthcare is affordable?

angry doc: No. They tell you that hospitalisation is probably affordable for the 'average' Singaporean. But hospitalisation is only a fraction of the nation’s total healthcare costs. In fact, if the 315,149 admissions to public sector hospitals in 2005 were all under B2 or C class (which I am sure they are not, but for argument's sake…), and the mean bill size is close to the median bill size of $1,100, we are looking at about $350 million. And if the nearly 100,000 admissions to private sector hospitals were close to the median bill size of $2,400, that will give a sum of $240 million. Adding the two gives us 590 million, or about 13% of the total annual health expenditure of about $4.3 billion?

MOH: It does. But we're talking about 13% of the total cost, for what you've noted earlier to be probably fewer than 10% of the population. Hospitalisation cost is a disproportionately high part of the total cost, and what most Singaporeans worry about too.

angry doc: It is, but then almost 100% of Singaporeans will need outpatient care, including those who need hospitalisation care. And 87% is a higher percentage than 13%.

MOH: I agree. Which is why we are also going to allow Medisave to be used for outpatient bills. We'll provide the figures when we have them. You need to be patient.

angry doc: OK.

MOH: Tell me - do you think I am really trying to make healthcare affordable here?

angry doc: Honestly? I do. I just don't think the data published make a very convincing argument that healthcare as a whole is affordable.

MOH: They are only the first set of data. Do *you* think healthcare is affordable?

angry doc: For the vast majority, I think it is, even when you take into account the fact that 'affordability' is largely a subjective term. I think for most people healthcare is something they would rather not have to pay for rather than something they really cannot afford to pay for.

MOH: There will always be those who believe healthcare should be free.

angry doc: So why did you bother to publish the data then? These people are not going to be convinced by the numbers anyway.

MOH: Well, I know you like numbers - they fire your imagination.


Tuesday, August 22, 2006

Evidence-based Complaint Resolution

Dear Sir,

1. We refer to your complaint letter against Dr Angry dated 31 Jun 2006.

2. We have spoken with Dr Angry, and his account of the events during the consultation differs from the one given in your letter.

3. As there is no third-party witness of the consultation to verify which of the accounts is accurate, we decided to perform a statistical analysis to determine who may be at fault.

4. Dr Angry has three clinic sessions a week, and he sees an average of 20 cases during each session. This gives a monthly total of 240 cases. He receives an average of two complaints per month. This translates to a complaint rate or Unsatisfactory Clinical Encounter Rate (UCER) of 0.83%.

5. Our record shows that the visit on 31 Jun 2006 was your fourth visit to our clinic. This is also your second complaint letter against one of our staff. This translates to an UCER of 50%.

6. Given the figures, it is fair to conclude that the probabilty of the cause of the unsatisfactory outcome originating from you is greater.

7. We hope you will reflect on your attitude, and seek counseling on your dysfunctional health-seeking behaviour. We can assist you with a referral to a mental health specialist at our centre.

8. Thank you.

Assistant Director
Corporate Communications


Saturday, August 19, 2006

One Year

Three hundred and sixty-six days.

Two hundred and ninety-two posts.

New friends both local and overseas, both online and in the flesh.

Still angry.

Thanks for reading.

Friday, August 18, 2006

Exodus 22:18

Once in a while something comes along that bugs angry doc enough to wake him up from his sleep, and to keep him awake.

This letter published in the ST Forum yesterday did that.

Some docs under drug probe

I REFER to the letter, 'Medical council should probe Subutex doctors' (ST, Aug 15), by Mr Peter Chean Ee Meng.

The Singapore Medical Council (SMC) is currently investigating a number of doctors for wrongdoing in the prescription of addictive drugs like Subutex.

The SMC is determined not to allow errant doctors to tarnish the medical profession.

SMC had, recently and in the past, successfully prosecuted a number of doctors for overprescribing additive drugs, e.g. Dormicum.

We thank Mr Chean for his comments and his point that doctors' duty is to act in their patients' best interest.

Dr Lau Hong Choon
Executive Secretary
Singapore Medical Council

It made angry doc read through the relevant sections of the Medical Registration Act again.

angry doc is aware that the SMC is authorised to inquire into complaints against doctors and to punish them if they are found or judged guilty, but he is not sure that it is the function of the SMC to 'prosecute' doctors, or that they should be proud to have been 'successful' in doing so in the past.


Tuesday, August 15, 2006

Confidence Goods

A letter to the ST Forum today gives me an excuse to rant about the issue of confidence.

Beware of medical tips from sales staff in health stores

I get urinary tract infection quite often and have undergone various tests like urine culture and uroscopy to make sure I don't have kidney stones.

My doctor recommended that I take cranberry extract as it is known to ease the problem.

I visited a GNC store to buy cranberry extract and the staff recommended that cranberry extract, garlic and acidophilus would work even better to kill the bacteria that cause the infection.

I completed the course and went for my urine test but bacteria were still detected in my urine. The doctor mentioned that garlic tablets would kill the effects of acidophilus.

I wonder whether the staff in health stores give the correct information or they just want to make a commission out of the sales.

Can health experts advise us on the adverse effects of medication if taken with the wrong food? I have been told that those taking high blood pressure medication shouldn't take grapefruit due to the acidity in the fruit.

Most people whom I've spoken to aren't aware as the pharmacists just dispense the medication.

Should we take medication as prescribed or must we do our own research on how well the medicine would work for us?

H. Bhaskaran (Ms)

There's UTI, and there's UTI; but let's assume that Ms Bhaskaran had been properly evaluated and that her doctor was correct in advising her to take cranberry tablets for prophylaxis against UTI. There is actually evidence to show that it is effective and cost-effective. I won't post a link here - just google it up and see for yourself.

Now let's move on to the health store staff. There is also some evidence that acidophilus does protect against UTI. Again, I leave you to google that up.

Now the garlic. Garlic kills bacteria. Acidophilus are bacteria. So angry doc was a little surprised to find that there is some evidence that garlic can (under in vitro condition) enhance the action of acidophilus used in the context of candida infection. You can google that one up too.

The interesting thing here is, Ms Bhaskaran concludes that her doctor was correct about the garlic and that the health store staff was wrong.


Because her doctor has an M.B.B.S. from a reputable university? Because he is made to undergo Continuing Medical Education to ensure he keeps up to date with the latest information?

Or is it because he has been right about so many things else before? Or because he wasn't the one who tried to sell her the cranberry, acidophilus, or garlic?

Now if Ms Bhaskaran did do her 'own research' by googling up the topics as I suggested you do above, she will find many websites with information on them. How will she know which ones are just advertisements, and which ones are 'proper' research information?

How do you know whether you can trust your doctor? How do you know whether the medical information you read is correct and unbiased?

Labels: ,

Saturday, August 12, 2006

Interesting question

Well, the reply from SGH on the issue we discussed earlier is published in the ST forum today:

Test results free, if requested at consultation

I REFER to the letter, 'Charging extra for medical report unfair' (ST, Aug 7), by Mr Paul Chan Poh Hoi.

We agree fully with Mr Chan that patients are entitled to know their medical conditions. Hence, patients are given copies of their laboratory test results or radiology reports, at no charge, when they make the request during consultation at our Specialist Outpatient Clinic.

However, if their request is subsequent to the clinic visit, a small processing fee is imposed for efforts needed to verify the authenticity of request, trace the records for the right set of information to be given and mailing of the results to patients.

Copies of X-ray films are also available for a small reproduction fee.

Medical reports, whether general or specialist, go beyond test results. They are prepared after review of the medical history documented in the patients' medical records. Charges are levied for both types of medical reports.

Wong Loong Kin Chief
Financial Officer
Singapore General Hospital

Says it more succintly than angry doc managed to.

Another letter also published today asks a rather interesting question:

Do medical test results belong to patients?

I REFER to the letter, 'Charging extra for medical report unfair' (ST, Aug 7).

The issue of patients not receiving a copy of their medical test results is not a new one. Patients still do not receive a copy of the results of extensive and sometimes expensive investigations, as a norm. When discharged from hospital they usually receive a one- or two-page summary with very little useful information.

Very often, a family physician will have to send a note with the patient to ask for more information at his next appointment. Patients often ask, 'You mean we can ask for the results?' To be fair, this situation is common, both with public and private health-care providers.

For a meaningful discussion of this matter, one question must be answered with a 'Yes' or 'No': Does information belong to the patient? - and I am not referring to medical records or notes that the doctor makes during the care of the patient but to the results of medical tests and investigations.

Until this issue is clarified, we will not see progress on this matter. Would the Ministry of Health care to respond?

Dr Ajith Damodaran

I must say I don't have the answer to that one. Under the SMC Ethical Code a doctor cannot withhold medical information from a patient or another doctor whom the patient wishes the information to be communicated to.

This helps us circumvent the question, but doesn't really tell us who actually 'owns' the data that is the test results. I'll be awaiting the Minstry's respond too.


Friday, August 11, 2006

Bullets don't kill people...

Several articles on the classification of Subutex as a Class A Controlled Drug in the papers today, but this line in particular from this article in Today catches angry doc's eyes:

"(Subutex) manufacturer, Schering-Plough, said it was not aware of any death in Singapore from injection of Subutex alone."


Ammunition manufacturers are not aware of any deaths from bullets alone; but we all know bullets fit inside guns.

Labels: ,

Thursday, August 10, 2006

Putting the Genie back...

... into the drug bottle.

Subutex is now a Class A Controlled Drug, and will have to be taken in the presecnce of a doctor or pharmacist.

You can read the full Ministry of Health press release here, and the Channel NewsAsia story here.

According to the CNA story:

"Medical sources tell Channel NewsAsia that some clinics in Singapore have made as much as one million dollars a year by selling Subutex to their patients."


Labels: ,

Monday, August 07, 2006

A penny for your thoughts?

I wasn't planning to discuss this topic which came up in the ST Forum a few weeks ago, and as a result I did not archive the original letter and the reply from the hospital. I can't claim to be accurate in my retelling of the accounts given by each side, but briefly, a patient wrote to the ST Forum complaining of being charged more than $70 for copies of her investigation results. The hospital replied that the $70-plus price-tag sounded more like the fee for a specialist medical report ($78.75 to be exact) and not for copies of investigation results; in any case, there was no record of a request by that patient for a medical report.

Curious. Was the patient mistaken, or did someone illegally bill her for some photocopies which should not have cost that much? There wasn't any point in speculating, and I thought that was the end of the story.

Then two letters on the topic are published in the ST Forum today.

The first one asks:

How does SGH arrive at $78.75 for a copy of specialist medical report?

I refer to the letter "$78 fee applies only to special medical report" (ST, July 28).

It would be of great interest to major stakeholders of SGH, we patients, to know how the rate of $78.75 is derived.

It was mentioned that this fee is for time the specialist spends to retrieve the record. I believe that with the advancement of IT in SGH, the specialist is most likely able to retrieve the record from the computer with a few clicks of the mouse.

That would probably take at most five minutes. At the rate of $78.75 per five minutes, it seems to me that this fee is derived from the average earnings of a specialist.

At $78.75 per five minutes, it translates to $945 per hour and $7,560 per day (assuming an eight-hour working day). This is very close to the rate of my specialist doctor friend's average daily earnings.

If indeed the fee is based on the specialist's average earnings, the question would be whether it is justified to do so? I feel a nominal fee of $5 would suffice for five minutes of simple work.

Tony Halim

And the second one states:

Charging extra for medical report unfair

I REFER to the letter, '$78 fee applies only to special medical report' (ST. July 28), by Mr Wong Loong Kin, chief financial officer of Singapore General Hospital. I find the statement that charging for test results and medical reports is a standard practice in restructured hospitals puzzling.

It seems to mean patients are not entitled to know their own medical condition - for better or worse - and do not need a copy of medical test results to keep or for a second opinion.

The patient pays for the whole package, including interpreting and generating the medical report. Charging extra or not giving him the report seems to run contrary to medical practice regarding the patient's right to know his own health.

I did an MRI 64 slice scan on my by-passed heart in Mount Elizabeth Hospital recently. I was given a copy of the complete report plus a CD. When I wanted to understand more about the report and CD, I was a given a full explanation while viewing the CD at no cost.

Why should it require a specialist to extract relevant information from medical records for the report when a printout or photocopy will do? At the end of the day, the patient is privy to his own full medical condition.

With the implementation of e-filing of all medical data, I hope hospitals will make it a practice to furnish a copy of patients' medical reports for the benefit of both parties.

Paul Chan Poh Hoi

Good grief. Where to begin?

Well, let's start with definitions first. There are actually a few different things we are looking at here. They are:

1. Medical Records, which refer to the notes kept by the doctor for each consultation, documenting the patient's symptoms, signs, his opinion, and his treatment.

They are the 'intellectual property' of the doctor making the notes, and do not belong to the patient.

The Medical records are not usually released, except by a court order.

2. Investigation Reports, which refer usually to the laboratory or radiology results. In the case of the former it is usually just a list of values with no opinion, and in the latter a description of the findings, followed by the opinion of the radiologist reading the X-rays. (I know, gross simplification, but we're after a general idea here.)

The Investigation Reports (or rather copies of the reports) are often released, usually with a small charge.

Personally, I don't see why the cost for producing a copy should not be built into the cost of the investigation, and a copy be given to the patient by default though.

3. Medical Report, which refers to an account, written by a doctor after reviewing the Medical Records and any Investigation Report, detailing (depending on what exactly is required from the party asking for the report) the history of the patient's illness, his diagnosis, progress, past, present and future treatment, and sometimes an opinion on how the patient's condition is likely to progress.

It is not routinely done for every patient after every consultation, but usually for specific purposes such as insurance claims and legal proceedings.

A Medical Report is not merely a sum of the Medical Records and the Investigations Reports. I am loath to use the term, but the doctor 'value-adds' to the raw information that is the Medical Records and Investigation Reports. It definitely takes more than 5 minute and a few click of the computer for the doctor to retrieve and gather the necessary data, process it in his head, and to present all that information in a coherent account, which may have to be read and understood by a non-medically-trained person.

In fact, even after providing the report, a doctor may be called upon to clarify any queries raised by the receiving party, and sometimes to resubmit a report if amendments or clarifications are required, with no extra fee.

I'm not sure if $78 is too high a fee to charge for all that work, but I do feel $5 is too little.

How much, I wonder, does Mr Halim's specialist-doctor friend think he should be paid for a specialist medical report?

How much do you think the doctor's time and effort are worth?

As for Mr Chan's letter? Well, it seems he has confused Medical Records with Medical Reports. I do wish he would look up the facts before
suggesting improvements to our healthcare system in the future.


Saturday, August 05, 2006

Not uniquely Singapore

Someone asked in a letter in Today today:

"Was any study carried out on the effects of Subutex use and abuse in other countries before it was introduced? If so, what were the findings?

If the findings were adverse, why did the authorities go ahead to use it? If the findings were initially not adverse, did the authorities monitor the experience of other countries in the past few years?"

angry doc did a little googling, and it turns out that Georgia (the one in Europe, not the one in America) has a Subutex-abuse problem too.

In fact, so do Finland, Nepal, Sri Lanka, Bangladesh, Britain, Germany, and New Zealand according to the article.

Labels: ,

I've got that sinking feeling...

Another weekend article for angry doc to mull over in Today today. This one is titled
'It's sinking in - Traditional Chinese Medicine is gaining acceptance, but on Western medicine's terms'.

The article is rather long (and so I won't reproduce it in full here) and it took angry doc a few readings to digest, but the author's main point seems to be that acceptance of traditional Chinese medicine (TCM) into the 'mainstream' is dependent on western doctors.

Here's how her argument goes:

The author starts by telling us that cells from the herb cordyceps is being cultured in Science Park.

(But of course the fact that a herb is being produced for commercial purposes is not proof of its efficacy, just of it commercial value - it might just as well be rhino horn cells being cultured.)

This is followed by an account of a young double-degree holder who decided to become an acupuncturist because acupuncture worked for her mother.

(An admirable personal decision, no doubt, but hardly scientific evidence that all of TCM 'works'.)

The article goes on to describe how TCM is being integrated into our traditional (western) medical practice, with public hospitals having TCM centres on their premises, and more western doctors taking up TCM courses.

However, the author notes, this is not a 'full embrace' of TCM, since:

1. The Ministry of Health's position on TCM is as follows:

"There is a sizeable number of people who will use TCM whether you like it or not, and that is why the MOH needs to regulate TCM practitioners, and make sure that the practitioners are trained and are qualified to give that kind of treatment.

"That is the only reason why the MOH regulates practitioners — not because we support TCM or promote TCM. In fact, all we want to do is to make sure that people who want to use TCM use it safely."

(I won't gloat, because one can say the very same thing about western medicine, or some of the practices within western medicine.)

2. Only about 25% of western doctors accept TCM, and the rest are 'wary' and sceptical of TCM because it 'operates on the different paradigm of meridians and energy, which is foreign to Western medicine'.

The author concludes that "it's how the Western medical camp embraces TCM that will determine its future direction".

Wow. All of the sudden the 75% of doctors who do not accept TCM are guilty of preventing it from being 'fully embraced' and accepted into the 'mainstream'.

Well, if that's really the truth, then angry doc is proud to be one of those obstructionist jerks. At least in his professional capacity anyway – how I feel about TCM as a person is largely irrelevant, since I am licensed as a western doctor.

As I have mentioned before, whether TCM is accepted into the 'mainstream' or not is largely a social issue and not a medical one. A lot of people already 'use' TCM, and I don't think it bothers them an awful lot whether or not we western doctors agree with them as long as TCM works for them. Insurance companies are free to decide if they will accept claims for TCM treatment, and individual employers are free to decide if they want to accept medical leave issued by TCM practitioners. I don't have a problem with that.

What bothers me however is the author's suggestion that there should be a 'full embrace' of TCM by western doctors.

That's rubbish. (Yes, I don't usually use such strong language, but it's the weekend.)

Western doctors should be wary and sceptical of medical disciplines that operate on a different paradigm. That’s why we underwent years of study and training on foundation sciences. That's why we continue to subject new drugs, new devices, and new treatment protocols to studies and trials.

All that is not to say that all TCM therapies and pharmaceuticals do not work, or that none of TCM should be studied or integrated in our medical system. We have an existing system of testing therapies to see if they work, and TCM therapies and pharmaceuticals should be tested individually, and not accepted as a 'full' package because it has a paradigm different from our own.

I don't buy the argument that the therapies and treatments must be accepted together with the whole philosophy to work. Medicine may be an art and a science, but it is not medicine without the science. And while science is a subset of philosophy, not all of philosophy is science.

Western medicine used to come with a philosphy of 'humours', but we've left that behind. You may argue that modern western medicine comes with its own philosophy, but you don't have to believe in the concept of antibiotics for penicillin to cure your infection.

If a method of diagnosis, a modality of investigation, or a mode of treatment works, it should work regardless of whether you believe in the philosophy behind it or not.

We all should be very worried if western doctors embraced an entire medical discipline wholesale just because a lab is making a herb used by it commercially, or that one therapy in that discipline worked for one double-degree holder's mother.

Labels: ,

Friday, August 04, 2006

Good Intentions

As promised, the Ministry has unveiled the first part of its "complete solution" to the Subutex-abuse problem, as reported in Today today. I reproduce the article in full as it provides a rather good summary of the Subutex problem.

The cure that got out of hand
Moves to curb heroin treatment which became an addiction
Tan Hui Leng

It was supposed to treat heroin addiction and, for that reason, was made widely available in Singapore clinics.

Instead, Subutex has become the new drug problem and the Government is now considering listing it as a controlled drug.

"Together with the Ministry of Home Affairs, we are finalising a robust set of measures," said Health Minister Khaw Boon Wan yesterday. "We are proposing to classify buprenorphine (Subutex's chemical name) as a Controlled Drug under the Misuse of Drugs Act, making the illegal import, distribution, possession and consumption of buprenorphine an offence."

This means that those caught carrying or using the drug without a prescription will be flouting the law. It marks a major turnaround for a drug that, when it was introduced in 2002, could be obtained freely on the prescription of any general practitioner.

It worked on the same areas of the brain as heroin, without the addictive effects. The condition was that it should only be taken by dissolving it under the tongue.

Instead, abusers of Subutex crush it with other drugs — such as sleeping pills — and the drug cocktail is then injected into their system for a high sensation.

With about 3,800 Subutex users in Singapore today, there is a concern that there may be more abusers. There may also be a need to look at what to do with those using the drug and whether they will need help.

"The introduction of Subutex is a classic example of a good intention that has led to an unintended detrimental outcome," said Mr Khaw who was at the Berita Harian Achiever of the Year Award."It was a well-meaning decision with the interests of the heroin addicts at heart. But the good intention has unfortunately yielded opposite and unexpected results."

This is because while some heroin addicts appeared to have benefited from Subutex, many others seem to have merely shifted their addiction from heroin to Subutex, he explained. Furthermore, injections significantly raise the risk of spreading infectious diseases.

"This status quo is not acceptable," he added. "Let us tackle this problem fundamentally and nip it before it becomes unmanageable."

Some curbs were introduced last year. Subutex users were registered and told to get their medication only from approved clinics. Doctors who prescribe the drug have to key in patients' details into an online system so that they do not obtain multiple doses by going to different clinics.

One such clinic is run by General Practitioner Dr Chee Weng Sun. He said to make sure his patients are not abusing Subutex, he makes them take it correctly in front of him at the clinic itself, during their first month of treatment. Subsequently, the prescription is on a weekly basis. Follow-up consultations include thorough checks to ensure that there are no injection marks on the patients.

As part of Doctors United Against Drug Abuse, a group lobbying against prescription drug abuse, Dr Chee is hopeful that the new measures would curb Subutex drug abuse. He noted that listing Subutex as a controlled drug would prevent black market trading. Currently, there is nothing to stop anyone from bringing it into Singapore.

But like others, Dr Chee is concerned that completely cutting off access to the drug may impact on recovering drug addicts. Currently, it is seen as the most effective method to reverse heroin addiction.

The Health Minister has also pledged that the authorities "will go all out to help abusers wean off the drug and to lead a drug-free life". A comprehensive rehabilitation programme supervised by a panel of psychiatrists will be set up and implementation details will come next week.

"We all want to wean them off but it's easier said than done," said Dr Chee, who sees 30 Subutex patients a month and has managed to take some of them off the drug.

Noting the high relapse rates for drug abusers – even those who go cold turkey, he said that whatever measure is implemented must ensure that heroin addicts who really need Subutex get them and are treated under supervision. Their doctors should then try to wean them off the drug gradually.

Otherwise, recovering heroin addicts may turn to other drugs, such as sleeping pills. Mr Freddy Wee, assistant director of Breakthrough Missions halfway house, concurred.

"The first thing that the Government should do is to help them quit first, put them in rehabilitation for six months, 12 months, whatever it takes," he said.

"If you don't deal with this than a black market will ensue because drug addicts will do whatever they can to satisfy their cravings."

The report on the Channel News Asia site is also interesting.


Recovering heroin and Subutex addicts like Benedick Wong welcome the stricter controls over Subutex.

He said: "I think to put it as controlled drug is very good. I feel that the Government should control it and the doctors shouldn't prescribe it so freely. It's totally too free. Some doctors tell you, 'don't take it too often, you know, you'll get addicted'. But they'll give it to you. Every two weeks you go, the doctor gives the prescription. So that doctor already knows you're misusing it.

"A normal person won't take sleeping pills, especially Dormicum, you won't consume it this way! The Government and CNB have to keep track. If the doctor keeps prescribing it, they should ask, 'why do you keep prescribing it'. Let the doctor give an explanation."

Dr Lim Boon Hee gives us his view on what the 'explanation' may be in a letter to Today too.


"It is a grim reality that some private clinics will not survive if their main source of income — derived from these former drug addicts who visit them for Subutex, Dormicum or codeine cough mixtures — is cut off by the impending control measures."

Under the Misuse of Drugs Act, controlled drugs are divided into a few classes, each of which carries punishment of varying severity for persons convicted of trafficking or abuse of the drug. It would be interesting to see which class Subutex will be put into.

Labels: ,

Thursday, August 03, 2006

W.W.H.D. 2a

Assuming you didn't go with option E in the preceeding part of the question...

"The patient returns to your clinic and informs you that his company still refuses to reimburse him for the planned surgery.

You advise him to proceed with the surgery nonetheless to avoid the long-term complications of the condition.

He repeats his request for you to write a memo stating that he was referred to your clinic from the polyclinic, and tells you that he will default follow-up and treatment of his condition if you do not do so."

What should you do?

A. Relent
Your first priority is the patient's health.

B. Stand your ground
Reiterate that you cannot provide the memo he wants, but keep his case open and give him an open date to see you.

C. Terminate the patient-doctor relationship
Tell him you cannot continue the patient-doctor relationship given the circumstances, and refer him to your best friend/worst enemy.

D. Explore other pathologies
Continue the consultation with a view to exploring if he needs to see a psychiatrist.

What would Hippocrates do? What would you do?

Wednesday, August 02, 2006

W.W.H.D. 2

Here’s another one they will never ask during the Final M.B.B.S. MCQ paper.

"You are an orthopaedic surgeon in a restructured hospital.

A young man is scheduled for bone-grafting for non-union of a scaphoid fracture. He asks you for a memo to his company stating that he was referred to your clinic from the polyclinic.

You check his notes. He had in fact presented to the Emergency Department for chronic pain in his wrist a few months after his initial injury, and had been referred to your clinic from there.

You ask him about this discrepancy in his history and he explains that as per his company policy, the company would only pay for his surgery if he was referred to a specialist through a polyclinic, but not the Emergency Department."

What should you do?

A. Be honest
Tell him you cannot provide such a memo.

B. Use a little imagination
Write a memo stating that even though he was not referred to your clinic from the polyclinic, had he gone to a polyclinic, he would have been referred to your clinic.

C. Use a little creativity
Advise him to visit a polyclinic to obtain a referral to your clinic, then provide a memo stating that he had been referred to your clinic from the polyclinic, but leave out the relevant dates in your memo.

D. Lie a little
Write a memo stating that the patient's condition was so urgent that he needed to be seen at the Emergency Department and could not have waited to be seen at a polyclinic.

E. Lie a lot
Write a memo stating that the patient had been referred to your clinic from the polyclinic.

Will your answer differ if his injury was sustained during work? Will your answer differ if his injury was not work-related?

What if he tells you neither option B nor D will carry any weight with his company?

What would Hippocrates do? What would you do?