And the funny-word of the day is... 2

HAVIDOL

(hat-tip to Dr Wes)

Notes from Dr RW

One of the blogs angry doc reads regularly is Notes from Dr RW.

Dr RW is, in his own words:

"A hospitalist in Northwest Arkansas opining on clinical topics, the interface between medicine and politics and whatever else grabs my attention."

Do have a look at his blog, in particular this series on the NIH/NCCAM trial on chelation therapy.

Waiting for Edta

An interesting letter to start the week on:


Drug-eluting stents - benefits outweigh the risks

I refer to the report, 'Drug-eluting stents - benefits outweigh the risks' (ST, Feb 22).

Success of the drug eluting stents (DES) and procedure depends on patient selection, clinical progress and stage of the disease, presence of co-morbidities, strict adherence to a healthy lifestyle, taking appropriate medication and vitamins and nutritional supplements.

It is a shame that many of the cardiac patients, while waiting for bypass surgery, have never been informed of an additional procedure that has been shown to be equally effective in the treatment of cardiovascular diseases involving the heart, brain, legs and other parts of the body where there is insufficient blood flow.

Nevertheless, some of these patients, who are in the know and against their attending doctors' instructions, have flocked to neighbouring countries for this treatment with success and at a lower cost.

I refer to the treatment which consists of an intravenous infusion consisting of the synthetic ethylenediaminetetraacetic acid, (EDTA) and magnesium salt and multi-vitamins and trace elements.

In short, this is the chelation therapy which our mainstream medical practictioners have dismissed, based on four short studies (which were later found to be biased, flawed and underpowered) and multiple editorials and comments (again based on these four studies) in mainstream medical journals.

There are doctors who have seen the benefits and efficacy of EDTA/multivitamins infusion in their cardiac patients (they have sought this treatment overseas). The costs were also lower. The number of patients in Singapore who will suffer from obstructive vascular diseases is going to increase and so will the costs, suffering and loss of productivity.

I suggest that this EDTA procedure be offered to cardiac patients while they are waiting for their bypass surgery.

From those patients who have gone through this procedure in the US, Europe, Australia and New Zealand, a significant number did not have to undergo bypass surgery when their operations were due.

For those mainstream medical practictioners who want proof of EDTA efficacy, I propose that the National Heart Centre do a double-blinded placebo controlled trial, recruiting those patients on the waiting list for bypass surgery, like what the National Institute of Health in the US (www.nih.org) is doing now.

I will end by quoting Associate Professor Tan Huay Cheem of the National University Hospital: 'In real practice, we can't always wait for clinical trial data.'

Dr Tan Soon Kiam


angry doc is not familiar with chelation therapy (except in the context of treatment for autism, but that's another story...), but a quick search on Pubmed reveals that there are more than four studies regarding the efficacy of EDTA chelation therapy for cardiovascular disease, and the results are not exactly encouraging.

In fact, even NIH, in this editorial on the the trial on chelation therapy mentioned by Dr Tan above, acknowledges that the current available evidence do not support the use of chelation therapy in cardiovasuclar disease, and that contrary to what Dr Tan has stated, chelation therapy is expensive; Dr Tan also omitted the fact that chelation therapy can have potentially 'serious side effects'.

In angry doc's opinion, the quote: 'In real practice, we can't always wait for clinical trial data' is not really appropriate in the context of EDTA therapy for cardiovascular disease; while absence of evidence of efficacy is not evidence of absence of efficacy, evidence of absence of efficacy *is* evidence of absence of efficacy. angry doc is more inclined to use this misquote:

'Nothing happens, no evidence efficacy is produced, no evidence of inefficacy is acknowledged, it's awful!'

Gongxi, No Facai?

angry doc doesn't quite know how to comment on this letter to the ST forum today without sounding rude, so he will just reproduce it here for his readers.


Clinic charged $42 for consultation over CNY

DURING the long weekend to celebrate Chinese New Year, an incident occurred which I feel I have to clear my doubts about.

It happened that my grandmother had gastric flu and had to consult a doctor. As it was a public holiday, we had to go to Tampines Central where there was a 24-hour family clinic.

It is actually quite heartening to know there is still a clinic nearby when you need one, even on a public holiday.

When we reached the clinic, we found out it charged $42 for consultation alone. This charge applied from Feb 17 to 20, from 7am to midnight. It did not include any medicine or anything else.

I find it disturbing that patients are charged such a high amount just for consultation. Are the doctors different? Is the service provided different?

Just because the clinic is open 24 hours and has to stay open during public holidays, it does not have the right to raise consultation fees so high.

It is true that staff may have to be paid more during public holidays, but there were three staff members at the dispensary when two would have been more than sufficient.

I would like to know if there are rules or guidelines which private clinics have to follow regarding the charging of consultation fees during public holidays. I do not think it is right that patients who fall ill during this period are charged so much more.

It may be reasonable to charge $20, but $42 is far too much. On a normal day, $42 would be more than enough to pay for the consultation and medicine.

Andrew Chia Teck Fatt


Coincidentally, we discussed this same topic almost exactly a year ago. Some things will never change...

Quis custodiet ipsos custodes?

angry doc is always keen to find out about developments in the NHS, which he believes has a certain predictive value on how the local medical scene will develope.

And this piece of news certainly has got his attention:

(excerpt)

Doctors' regulatory power 'to go'

Doctors are set to lose the power to regulate themselves and senior medics will face regular MOT-style checks under a planned shake-up of regulation.

The overhaul, which will now be debated by parliament, has been announced by ministers following the Shipman murders and other medical scandals.

A stricter system of death certification is also to be introduced.

The General Medical Council is set to lose its power to adjudicate on fitness-to-practise cases.

The GMC will also have to change its membership to 50% doctors, 50% lay people in a move away from the much criticised profession-led regime.


You can read the White Paper here.

It will take angry doc all weekend to digest that, but on the first scan it consists of a series of motherhood statements with little indication of what actions will be implemented on the ground, with the exception of the part picked up by the BBC report, which is that doctors will, as a profession, lose their privilege to self-regulation.

Will the same thing happen to doctors in Singapore?

Certainly the threat of the loss of that privilege has been talked about, usually in the vein of 'if we don't watch ourselves, they'll put someone else to watch over us'.

Implicit in that sentiment is the fact that (probably) most doctors dread the idea of being regulated by laymen over their professional conduct.

angry doc certainly does.

Not, you understand, because he thinks Singapore Medical Council (SMC) is "more interested in looking after doctors than protecting patients" as is alleged of the GMC. In fact, angry doc has previously expressed concern over SMC's motives in the disciplinary process.

But motivation aside, if angry doc's 'fitness-to-practise' is to be called into doubt, he would still much rather be judged by people who knew what practising medicine is all about.

Still, a White Paper is but a written document; the test will be in the eventual implementation. angry doc has no doubt Dr Crippen will be keeping us updated on this topic.

Click here to donate

A few weeks ago angry doc had a patient who wanted to have his Advanced Medical Directive witnessed and his body donated to science after his death. He was quite disappointed when angry doc told him that he did not do the first any more, and that he had no idea how to have the second done.

But thanks to this letter from Prof Lee in the ST Forum today, angry doc now knows how.


Organ transplant: Unease over last-minute opt-out

THE recent incident in which a brain-dead patient's family tried to physically obstruct the operation to harvest his organs for transplant into patients needing them has revived the discussion about brain death and even led to calls to amend the Human Organ Transplant Act (Hota) itself.

Some doctors have called on the authorities to respect the feelings of the family of potential donors. Given a choice, the vast majority of families would object strongly if they thought this could prevent their loved one's organs from being removed. Even with the Hota, there is a shortage of organs forcing some desperate Singaporeans to go overseas in search of organs.

The only incentive at present not to opt out is that those who opt out go to the bottom of the waiting list if they ever need an organ. Justice would not be done if these people could still opt out at the point of brain death if their family objects vigorously.

For the few Singaporeans who want to go beyond the Hota and donate any organ that can be used for transplant, there is a separate organ donor form where one can specify which or all organs one wishes to pledge.

This used to be a paper form which could be obtained from the Ministry of Health (MOH) in the 1990s when I did so. Perhaps it is now available on MOH's website.

Dr Lee Wei Ling


Indeed it is. Some browsing on the MOH site reveals that donating one's organ for transplant and to science comes under the Medical (Therapy, Education and Research) Act (or MTERA).

You can download the form here.

I learn something new every day...

The Invisible Man

Both of us being dateless on Valentine's Day, Al and I decided to catch a movie...


Al: Have you seen the invisible man?

angry doc: Er... the movie, or the book?

Al: The person.

angry doc: Er... there's no such person as the invisible man. He doesn't exist.

Al: How do you know he doesn't exist?

angry doc: Er... for one thing, no one has ever seen him.

Al: How do you know he doesn't exist if you've never seen him?

angry doc: How do you know he exists if you've never seen him?

Al: He's *invisible*! Duh? If you can't see him, then by definition that means he exists.

angry doc: I see... so the invisible man is very much like your capacity for critical thinking?

Al: Never mind, we'll see something else. What do you want to have for dinner? I feel like mee siam with hum.

angry doc: Good grief. We're not going to have that same conversation again, are we?

Quackbuster: Singapore 4

The passage of the Health Products Bill is reported in Today today (emphasis mine).


Health Products Bill passed, with room to grow

AS PARLIAMENT yesterday passed the Health Products Bill, some members on the Government Parliamentary Committee (GPC) for Health called for health supplements and foodstuff to come under the new law, which will initially govern medical devices such as stents and pacemakers.

Madam Halimah Yacob, who heads the GPC for health, questioned the exclusion of food products from the Bill — a view echoed by Dr Fatimah Lateef, MP for Marine Parade GRC. Dr Fatimah noted that ginseng drinks, for example, claimed "to lower blood pressure", while Mdm Halimah said milk formulas also made health claims.

Responding, Health Minister Khaw Boon Wan said the Sale of Food Act, administered by the Agri-Food and Veterinary Authority (AVA), already included restrictions and requirements on food product claims.

He added that the Health Sciences Authority (HSA) works with the AVA on products that fall into the grey area between medicines and food.

There were also calls from some GPC members to hasten the regulation of health supplements. Mr Sam Tan, MP for Tanjong Pagar GRC, suggested more public education campaigns for consumers.

Mr Khaw said a decision on whether health supplements would be included under the Act has not been made.

Acknowledging their regulation to be a complex one, he said: "We should carefully discuss the pros and cons and, in particular, study the experience in other countries. It is not a straightforward subject."

Dr Lam Pin Min, MP for Ang Mo Kio GRC, and Dr Fatimah asked for greater emphasis on post-market surveillance, for robust regulation.

Yet, over-regulation was also a concern, said Mdm Halimah, as prohibitive fees and complex registration processes would act as a disincentive for small businesses and start-up initiatives.

Agreeing, Mr Khaw gave the assurance that a balance would be struck between consumer protection and business viability.

Beyond these concerns, GPC members welcomed the legislation, calling it timely and necessary.

The new Bill aims to consolidate, over time, all four separate pieces of legislation that currently govern medicines in Singapore — namely the Medicines Act, the Poisons Act, the Sale of Drugs Act and the Medicines (Advertisement and Sale) Act — under one framework.

The HSA is seeking public feedback on the Health Products Bill (Medical Devices) until April 3. Email hsa_feedback@hsa.gov.sg with your comments.


Does ginseng lower blood pressure? Well, it has been found to lower blood pressure in several studies angry doc looked up, but not in any meaningful manner on the long-term, according to the findings from this study. It's a small study with a high drop-out rate, and so by no means 'landmark' or conclusive, but I thought it was a well-designed study with attention to blinding. Had the study been larger and had the results shown a significant improvement in blood pressure in the subjects taking ginseng, it would certainly make the medical profession sit up and pay attention. But as it is, even some segments of the alternative and complementary medicine community don't think ginseng will help reduce your risk of getting a stroke or heart attack.

Perhaps this is the kind of study proponents of traditional medicine should be conducting instead of arguing that traditional medicine should be exempt from scientific studies and free to make unproven claims of health benefits.

In the mean time, angry doc finds few allies in his battle against health supplements of unproven efficacy even amongst his blogging-friends.

Quackbuster: Singapore 3

The Health Products Bill was passed in parliament today and becomes the Health Products Act.


HSA gets more teeth to pull unsafe health products off shelves

SINGAPORE: The Health Sciences Authority (HSA) now has more teeth to pull off the shelves medical products that have been tampered with illegally, with or without the support of the medical companies involved, thanks to the Health Products Act passed in Parliament on Monday.

The Act also toughens penalties against those who break the law.

Violators face a $100,000 fine or a three-year jail term, or both.

Previously, the maximum fine was $5,000 or $10,000 and a jail term of up to two years or both.

Under the Act, all medical devices like pacemakers and stents will also be regulated.

Other categories, such as medicines, will be added over the years.

During the second reading of the Bill, Health Minister Khaw Boon Wan took questions from Members of Parliament, some of whom called for the Act to be expanded to include health supplements and prevent a repeat of the Slim 10 case a few years ago.

Sam Tan, MP for Tanjong Pagar GRC, said: "I appreciate the need to be circumspect and not to over-legislate and hence urge the government to consider other measures such as stricter advertising guidelines for health supplements to ensure no superlative unfounded claims are made. The government can also step up public education on the do's and don'ts of taking health supplements."

On whether to regulate health supplements, the Health Minister said that this was a complex issue and instead of rushing into it, Singapore would first study the experiences of other countries and weigh the pros and cons.

Another alternative would be to educate Singaporeans to be more savvy and discerning when making product choices.

One MP voiced concern about regulation costs for businesses, especially smaller companies.

Halimah Yacob, GPC Chairman for Health and MP for Jurong GRC, said: "The HSA could also consider extending some financial assistance to the small businesses to help them set up a system to comply with the registration and licensing requirements.

"This is a win-win strategy as the real objective of the Bill must be that businesses hold high standards and with penalties kicking in only if there are violations. Hence it is better to try and help businesses to comply in the first place, rather than to rely on penalties alone to keep them in line."

Replying, Mr Khaw said: "We should not over-regulate, not only medical devices but also for other heath product categories that may eventually be added. There is a cost to regulation, whether in terms of licence fees or other costs in complying with regulatory requirements.

"We must strike an appropriate balance between consumer protection and business viability. That is why we are taking a risk-management approach to regulating health products: doing the minimum for low-risk products and applying stringent regulations only on the high-risk products."

The HSA will also continue its post-market surveillance of products to ensure they remain safe for consumers even after they have received the all-clear.


angry doc must confess to being disappointed.

It seems the law will currently apply only to 'medical devices' (are biomagnetic bracelets 'medical devices'?) and will not extend to cover health supplements in the foreseeable future.

Law-makers and healthcare professionals do not always have the same point-of-view when it comes to health products and supplements of unproven efficacy.

To the legislators it's a matter of balancing the welfare of the consumers with the profits of the businesses.

To angry doc it's a simple matter of whether the seller is lying.

angry doc does not see health products and health supplements sold with 'unfounded claims' as 'low-risk products'. Turning a blind eye to such products perpetuates magical thinking and the belief in unscientific systems of medicine.

I guess it just means angry doc will have to blog harder then...

Gongxi Facai 3

A bit of good news to end the week on.


Healthier wages for health workers
Nurses among those to enjoy a pay hike this year

WITH workers across most sectors looking forward to pay hikes this year in a buoyant economy, there's now good news for nurses and allied health workers, too.

From this month, 14,000 of them under the two major healthcare clusters will be paid between $30 and $250 more a month each — in a move aimed at addressing the perennial shortage of nurses.

Nurses will enjoy a 3-to-7-per-cent increase in salary, while allied healthcare professionals, such as physiotherapists and medical social workers, will a get 2-to-6-per-cent pay rise. This will be on top of their annual wage increments.

The last time these professionals had their pay adjusted across the board was in 2001.

Healthcare assistants — who perform tasks previously handled by nurses, such as changing and feeding patients — will get an additional monthly allowance of 2.5 per cent over their normal salary increases.

In all, the pay hikes will cost the Health Ministry an extra $28 million a year. Yesterday, in a joint statement, the SingHealth and the National Healthcare Group called the latest adjustment "a major step towards better aligning the salaries of these key personnel with the improving job market and optimistic economic forecasts".
With nurses' salaries typically ranging from $1,100 to about $6,000, the move was welcomed by many like Ms Lindy Toh, a staff nurse at Tan Tock Seng Hospital.

The 26-year-old, who worked in the civil engineering industry for three years before making the switch in 2005, said: "When I was choosing my course of study years ago, my family stopped me as they didn't have a good impression of nursing because of the pay and the perception of what nurses do.

"I think the enhanced pay package will motivate and encourage more people to take up nursing."

This is what Health Minister Khaw Boon Wan hopes to achieve. "There's always a shortage of nurses not just here, but globally, so let's keep on training and recruiting as many as we can," he said.

While the industry has met its manpower targets in recent years, Mr Khaw said there was still a need to recruit foreign nurses.

He believes that the upbeat economic outlook will last for a few years more, and that will mean more foreign patients coming to Singapore for treatment. That could lead to the private sector trying to woo workers from the public sector.

Conceding that allied healthcare had been a lower priority in the past, Mr Khaw said this was an area of focus on for the next three years, given the ageing population.

So, the Health Ministry is now looking at those who are willing to make mid-career switches to become physiotherapists, speech therapists and optometrists.


angry doc hopes he will benefit from this move in the form of more Chinese New Year snacks from the nurses, who will have more cause to be generous in the coming festive season.

How much is that kidney in the window?

(source: http://caglecartoons.com/)

angry doc could almost hear Prof Lee's sardonic voice in his head as he read her latest letter on the ST Forum page today.

An organ is no different from a life-saving drug

THE debate about allowing the sale of organs has revealed an amusing aspect of human nature: 'If my welfare is not compromised, I can afford to espouse the politically correct view', human organs are sacred and should not be traded like a commodity.

However, the cold reality is that there are people suffering and dying because no organ is available in Singapore. These patients do not think it wrong that they buy an organ.

A similar situation is where pharmaceutical companies require strong laws upholding their patents to survive and make a profit. This is a major incentive for them to set up factories and do R & D in Singapore. They spend millions, and sometimes billions, to create new drugs. Patents allow them to make back their money. Otherwise, new cures may not be found.

On the other hand, the patients who can benefit from but cannot afford these new drugs which are still protected by patents rant, rave and, in certain countries, riot because they feel their health is more important than economic justice.

I suggest that we be cool- headedly but compassionately logical. What makes an organ more sacred than a medical device or medicine that can save a life? The supplier of the organ or the pharmaceutical company producing the new drug must be appropriately remunerated or there would be no incentive to part with the organ or undertake the R & D required to produce a safe and effective drug.

Whether the public and patients like it or not, these are the facts. Everyone stands to lose if we choose to ignore these facts and use arbitrary moral arguments to support a certain stance and enforce the illogical stance by law.

Assoc Prof Lee Wei Ling

Prof Lee summarises angry doc's view on the whole organ-for-sale debate succintly in her first paragraph.

angry doc's first response to Prof Lee's comparison between drug patents and organs was that one involved direct risk to a human being while the other didn't. But of course he is wrong - drug trials involve human test subjects, and occassionally adverse effects and deaths do result from them.

angry doc admits that he is squeamish about the whole idea of a living-donor organ transplant, let alone a transplant where the donor is paid to undergo the surgery. It comes from an old belief that healthy persons should not be subject to surgical risks. Of course, how much donor mortality and morbidity is considered acceptable is a subjective judgement.

As an exercise, do ask yourself how much donor mortality and morbidity risk in a liver transplant you would consider acceptable, and then compare your answers with the figures in this article.

So is it safer, or riskier than you had thought?

Big Doctor is watching you 3

We've visited this topic before, but angry doc thought he might bring his readers' attention to it again since it made the news last night.


Govt to introduce medical standards enabling info-sharing of patients' records

SINGAPORE: The Health Ministry is taking the next step in making sure that electronic medical records "talk" to each other.

It will provide a national IT backbone for doctors from hospitals and GP clinics to tap into these records, and the aim is to improve long term care since a family doctor will now know exactly what a patient has gone through in hospital.

The new system, still being developed, will give your family doctor access to your health screening results, medical treatments and the drugs you have been prescribed.

This seamless care will become more critical with an ageing population, and with family doctors managing chronic diseases.

Right now, electronic medical records are linked only at public hospitals.

"We need to build an IT infrastructure that enables electronic medical records to be shared. We don't need to share everything that a hospital may know about a patient because it might not be relevant, so it's about sharing what needs to be shared that's relevant to the patient's long term care," said Yong Ying-I, Permanent Secretary, Health Ministry.

However, the Health Ministry's stand is that the system needs to make sense, so doctors will be roped intensively to develop it, to make sure it is usable.

In fact there is no single vendor who can provide such an integrated system right now.

"The clinicians themselves must feel ownership for this; they must believe that this is something useful to them. IT is a supporting element; it is not the driving element. What the clinicians want to do, what the doctors want to do must be the main objective and we want to support that," said Chan Yeng Kit, CEO Infocomm Development Authority.

Regarding privacy of medical records -- there will be authentication framework so that only those approved will be given access to the information.

The system is part of the Health Ministry's vision of One Singaporean, One Family Physician, One Electronic Medical Record.


Nothing new there, but angry doc just happened to notice that the system is described a 'backbone'.

Coincidentally(?), the NHS version of a nation-wide electronic medical record system is called 'The Spine'. You may follow the link to read Dr Crippen's take on that system.

Gongxi Facai 2

'Fa cai' has many medicinal benefits and is important for CNY celebrations

Your report 'HK group calls for total ban on fa cai' (ST, Jan 31) comes at a time when Chinese all over the world will be celebrating Chinese New Year (CNY) in about a fortnight's time. 'Fa cai', or black moss, is usually eaten during the reunion dinner, the eve of CNY. Be that as it may, fa cai or Nostoc flagelliforme is still freely sold in our supermarkets and neighbourhood grocery shops in Singapore and Malaysia.

Black moss is a terrestrial cyanobacterium that has been and is still used as a vegetable in Chinese cuisine for many years. 'Fa cai' grows very slowly in desert steppe and in arid regions of north-western China. Extensive harvesting of this vegetable has damaged its natural distribution and further exploitation has been prohibited by the State Council of the People's Republic of China. When fa cai is removed from the ground, the surface soil is no longer bound together and is vulnerable to natural erosion. Uncontrolled harvesting of this vegetable has resulted in the transformation of huge areas into dry deserts.

Most commercial fa cai sold in the marketplace is now adulterated with non-cellular strands of a starchy material. Because of government restrictions on the sale of this vegetable, fa cai has been adulterated with non-nutritive fillers.

Black moss contains much protein, carbohydrates, some phosphorus, iron and potassium. It is recommended by Chinese sinsehs for people suffering from hypertension and chronic bronchitis. The iron content of black moss aids blood-cell production and therefore women suffering from mild anaemia after childbirth use black moss in cooking or make soup with it. The Chinese believe that black moss darkens the hair and that is why old women usually eat it to decelerate the greying of their hair.

Come Chinese New Year, the diehard Chinese will insist on eating black moss (which brings wealth), dried bean curd (which brings happiness), chicken (which brings happiness and a happy marriage) and eggs (which promote fertility).

No wonder our grandparents and parents will go all out to ensure that we have black moss for every celebration of CNY.

Heng Cho Choon


angry doc can't really tell from the letter whether Mr Heng is in favour or against the consumption of facai this festive season.

In any case, 'protein, carbohydrates, some phosphorus, iron and potassium' may be had from a variety of other food-types that are more common, and whose cultivation have less of an environmental impact.

Like say a banana.

But what the letter illustrated was the irrational belief held by some Chinese that things that are rare and hard to find are necessarily good for you (or is it the other way round?). Never mind that it may instead by harmful to you (see here and here; although it has been found to be safe for rats).

angry doc is also amused by the belief that such foodstuff contain so much goodness that a single serving once a year at reunion dinner will confer real health benefits, or even magically increase one's wealth.

Hopefully that same small serving is insufficient to cause any harm either.