Subsidy and Other Preoccupations 17

Medicine is full of aphorisms.

Aphorisms like: "The cornerstone to diabetes control is diet", "Abstinence is the only sure way of avoiding HIV infection", and "Breast milk is the best milk for babies".

Aphorisms may be true, but most of the time they are also irrelevant as reality oftens intervenes. That is why we have diabetes medication, condoms, and formula milk.

The aphorism angry doc would like to look at today (prompted by the comments on this previous post) is: "Home care is the best care."

One of the cited causes of bed shortage in acute hospitals is the difficulty in convincing the families of elderly patients who do not need to stay in an acute hospital to discharge to either their own homes, or to a step-down facility or nursing home. Any junior doctor who has worked in an inpatient setting is familar with the 'placement problem'.

There are many valid reasons for application to a nursing home (surveyed in this study), including:

• needs medical and nursing care
• needs assistance in activities of daily living
• care person willing but unable to cope with physical care/behavioural problems
• care person working or has other commitments
• the elderly person does not want to burden care person(s)

Even when the family agrees to transfer a patient to a nursing home, discharge from the nursing home with access to day-care or home care services may again meet with resistance.

The problem is recognised and indeed anticipated by nursing homes, which actively plan for discharge.

But if we look at the profile of nursing home residents and the reasons for why they are admitted to nursing homes (surveyed in this study), most do indeed have valid medical or social reasons for admission, and many both.

Traditionally, our society has viewed the placement of the elderly in nursing homes negatively, and the medical community has advocated home care as 'best care'. But given the profile of the modern-day family, is this still a viable option? Will we not be better off, in the medium- and long-term, if we start looking at nursing home placement as a necessity for a large part of our elderly population (including our own family or perhaps ourselves eventually) and be financially and psychologically planned for it; or should we still hang on to the idea that "Home care is the best care"?

Subsidy and Other Preoccupations 16

angry doc still hadn't found a solution to our bed shortage problem, but he did manage to find this rather interesting article on 'right-siting'. Do have a read.

Sick, sick people 9

Dr Chin comes back for another round...


Aids and gays: A flawed response

I REFER to the letter written by Mr Wong Suan Yin, 'Aids: Stop the spread of misinformation'.

The letter misrepresents what I have said. It is not true that I made the statement that homosexuality leads to the spread of Aids and therefore criminalising homosexual sex will prevent the spread of Aids.

My article only mentioned that there is an increased risk of homosexuals engaging in anal intercourse in contracting the HIV virus. The reasons given for this is that anal intercourse is inherently unhealthy and studies have shown that homosexuals are more promiscuous.

Mr Wong has missed the point made by me in the letter and has gone off tangent with his own argument.

Unfortunately his argument is flawed. Let me clarify.

HIV virus is spread in three main ways.

1. From mother to child during birth

2. Sexual contact during intercourse, oral, vaginal and anal

3. Via blood either through contaminated blood, contaminated blood products, contaminated donor organs, tattooing and intravenous drug abuse

According to WHO statistics, there is a higher incidence of HIV in women and children in Third World countries compared to the rest of the world.

It is just as true that in Singapore and in the United States, there is a high incidence of HIV among homosexual men who engage in anal sex.

How do we reconcile this? Obviously there must be environmental factors involved that lead to differences between the two. Unfortunately WHO statistics from most Third World countries do not show the mode of infection.

There are so many unanswered questions. We do not know how many of the mothers contracted HIV because of drug abuse or how many of their husbands were drug abusers.

We do not know how many of their husbands had intercourse with high-risk individuals. We do not know the incidence of bisexual men who are married.

In some African cultures, bisexual behaviour is rampant. Culturally, in some countries, young men are sent by their fathers to prostitutes for their first sexual experience.

Some studies have shown that the incidence of HIV among young children is higher than that of mothers in Africa. This implies that children are getting HIV from sources other than their mothers. Contaminated needles? Contaminated dental equipment?

How many adults are infected through contaminated medical equipment due to poor health care?

All these cultural, social and environmental factors affect the behaviour and sexual practices of individuals and therefore account for the different figures seen in different countries.

We cannot apply these figures to the situation in Singapore because the environment is different.

Let me illustrate with an example.

We know that poverty leading to malnutrition and starvation is statistically one of the leading causes of death among children in the world. Obviously it is illogical to put all our resources in eradicating malnutrition and starvation to lower the death rate of children in Singapore. This will not help at all as it is not a leading cause of death in Singapore.

Similarly for the case of HIV infection, we have to look at the local context, what the local statistics are and what the risk factors for our population are. As I have previously stated, our local statistics and those of the US show that the group with the highest risk of being infected by the HIV virus is that of individuals who indulge in anal intercourse.

Currently anal intercourse is a criminal offence. The argument put forward that decriminalisation will make it easier to educate those who engage in such practices and lower the risk of HIV needs to be examined carefully.

As a doctor I wrote in to highlight the public health issues involved in this matter. As for public policy issues, this is not an appropriate forum. Parliament will consider all these issues in due course.

Dr Alan Chin Yew Liang


Dr Chin claims that his letters were written to "highlight the public health issues involved in this matter", but the fact is that he has done more than that.

He has stated categorically that gays are sick and need to be cured, and he has tried to give the erroneous idea that to decriminalise sex between men is to deny these sick people a chance to change.

Interestingly, when his arguments are rebutted, instead of retracting them, he offers the same exit line as Professor Lee did: parliament will decide.

Subsidy and Other Preoccupations 15

Great. angry doc devoted so many posts on means testing, and now they tell him it's bed availability he should be worried about.


Khaw: Treat hospital bed shortage with care
A bed for acute illness costs Govt $1,000 a day; heavy usage ups costs
Tan Hui Leng

The current high occupancy rate at some public hospitals is stressing doctors to discharge their patients, admitted Health Minister Khaw Boon Wan yesterday.

Occupancy has hit highs of more than 90 per cent for some hospitals recently, above Mr Khaw's ideal of 85 per cent. "When you run at over 90 per cent, it's very stressful," said the Health Minister, who was the chief executive of several hospitals from 1985 to 1992.

"Stressful in the sense that, every day, our doctors have to go down to beg the patients (to be discharged)."

Occupying a hospital bed for acute illness costs the Government an average of $1,000 a day, compared to "a few hundred dollars" for a community hospital bed.

This is "the cost to society", said Mr Khaw at the sidelines of an event yesterday. "If I don't actively shift patients down, our total cost will just be heavy."

Urging patients to cooperate with doctors to be relocated to suitable care institutes when they are fit enough to be discharged, he said: "Hopefully, people will be more circumspect."

"When we say we need to discharge you to a nursing home, it's not for frivolous reasons, we really need to free up those beds."

High occupancy rates do not allow for a sudden surge in patient numbers, he explained.

Last week, Today reported that some hospitals were facing a surge in occupancy, hovering at a 88-to-97-per-cent occupancy rate recently, a problem compounded by seasonal diseases such as the flu and dengue.

To tackle the problem, the Health Ministry will add a total of 67 new beds to the National University and Changi General hospitals over the next few months.

Earlier this week, Mr Khaw told Parliament that there will be a new hospital in the west in the "next few years".

This is in addition to the new Khoo Teck Puat Hospital in Yishun, which is being built.

Even with the current squeeze, the Health Minister said he is in no rush to implement means-testing in subsidised hospital wards.

Although earlier reports had quoted him as saying means-testing could start in 12 months, Mr Khaw said this may not be the case. His current priorities are the ElderShield review and another round of MediShield review to revise patient co-payment from the current 40 per cent down to 20 per cent.

Details about the revamped ElderShield scheme would be available by the end of June or early July.

Possible changes to Medisave may be introduced in the revamp as the ministry mulls a staggered withdrawal rate for those with bigger balances, he added.


Now there is already a ruling in place at the hospitals which allows for patients to be charged at the full (unsubsidised) rate if they choose to remain in the hospital even after they are deemed "fit for discharge" (usually after a grace period of a week or so). That being the case, angry doc wonders why doctors need to beg patients to leave. Are the patients staying on despite the withdrawal of subsidy (in which case the expectation that means testing will ease bed shortage will be proven wrong), or is it a case of the the ruling not being enforced?

The decision for fitness for discharge is a medical decision; the decision on what happens after that decision is made is an administrative one, and angry doc feels that doctors should not be made to beg patients to comply with an administrative decision.

But this situation raises another question: is the bed shortage due to an absolute shortage of beds with respect to real medical needs, over-subsidy, or just an ineffectual execution of a system which we already have in place to reduce over-staying? And is means testing a solution to our 'bed shortage', or do we just need a healthy dose of moral courage in deciding who gets a bed?

Sick, sick people 8

(link)

Subsidy and Other Preoccupations 14

An article from The New Paper brings angry doc back to the topic of means testing.

As he has mentioned many times, angry doc is not a fan of means testing in its current proposed form, but here it is not so much the idea of means testing that troubles him as much as the poor arguments for means testing presented by the journalist here. angry doc will interspace his comments (in blue).


Monthly salary $9,300 Hospital ward C CLASS
S'pore's top earners make up 1 in 10 patients in subsidised wards. Time to start means testing?
By Leong Ching

WOULD you give public assistance to the boss of a multinational corporation?

Free meals to a lawyer living in a District 10 bungalow?

Subsidise the Lexus of a coffeeshop towkay?

No?

Then why would you be against means testing? It is just a way of making sure that anyone who needs a subsidised bed will get one.


Wrong, because means testing in its current proposed form will not make sure that anyone who needs a subsidised bed will get one. A rich man can still stay in a C-class ward even if he fails means testing, provided he is willing to accept the fact that he will receive less subsidy than someone who has passed the means test.

And wrong also because means testing does not test "need"; it tests "means". A poor man who passes means testing can still stay in a C-class ward and enjoy the full subsidy even if there is no compelling medical reason for him to be there.

So between a rich man who needs a bed and a poor man who does not need a bed, who is denying the poor man who needs a bed his bed?


Without means testing, some of the rich, and even the very rich, are enjoying government subsidies by choosing to stay in lower-class wards.

Yesterday in Parliament, two vital pieces of information emerged about health care here. First, we are short of hospital beds. Second, we are throwing government subsidies at certain well-off people.


The two issues are actually not directly related: a rich man who needs to be admitted will take up one bed regardless of how much subsidy we give him, just as the poor man. The amount of subsidy a man receives has no direct impact on the total number of beds in the system.


Said Health Minister Khaw Boon Wan: 'Our current bed situation is tight, particularly in the Tan Tock Seng Hospital as it is the only hospital serving the large population in the north besides its own catchment area.

'The over-crowding in TTSH in turn causes spill-over to the other hospitals, especially National University Hospital and Changi General Hospital.'

There will be relief, he noted, when the new general hospital in Yishun opens in three years' time. There is also another general hospital in the west being planned.

Each year, Singapore will need another 60 to 100 new beds - many in subsidised wards.

Beds in B2 and C Classes are heavily subsidised, the latter to the tune of 80 per cent.

How do we make sure that these wards go only to those who need them?

Another way of saying it - how can we make sure that those who can afford it, do go to the less-subsidised wards?

The policy objective is the same - but the political nuance is vastly different.


Nuances indeed. Here the writer continues to make the error of equating ability to pay with (non-)need, and that the bed situation is a result of "those who can afford it" taking up the beds of "those who need them".


The second way of saying it leaves it open to those who want to score political points.

'Sure, I can afford to go to a better class, but I don't want to,' they say. 'And you are wrong to make me.

'I may get a higher pay, but I want to spend less on health care.

'And if the next guy doesn't pay taxes and I do, I would be even more entitled to a C Class bed.'

These arguments are very appealing to the sandwiched middle class, who may be struggling to raise kids, care for ageing parents and find hospital bills an onerous expense.

This by itself does not contradict the principle that the rich should not get handouts. It merely tells us that we ought to be careful whom we call 'rich'.

For example, a family may earn $5,000 from two incomes, but they might deserve some subsidies if there are three little children and four old folks to take care of.

The devil is in the details. And here are more details to light the way.

The Ministry of Health yesterday released numbers to show the profile of the people who used CClass wards in 2004.

They were startling - they showed that 9 per cent of C-Class patients were from households whose earnings were in the top 20 per cent.

That is to say, nearly one in 10 patients who used C-Class wards came from a household earning close to $10,000 a month.

One-third of all C-Class patients were from the bottom 20 per cent of households.


Ironically, these statistics suggest to angry doc that we have too many C-class beds, not too few. Otherwise, why are only one-third of the beds occupied by the poor people?


According to the Department of Statistics, the top 20 per cent of households earned $9,300 a month, whereas the bottom 20 per cent earned $1,180.

So, in the democratic environment of a C-Class ward, a man who earns $9,300 a month enjoys the same handouts from the Government as the one who earns $1,180.

Is this fair?

Another quarter of C-Class patients come from the lowest 20th to the 40th percentile.

So, by and large, more poorer Singaporeans are using the most highly-subsidised ward.

But why are rich Singaporeans there as well, and in numbers as high as 9 per cent?

ALLOTMENT VS RIGHT

Some may argue that they are there because they are as frugal as the next guy. Why deny them the right?

Well, because a government subsidy isn't a right - it is an allotment, in the same way that public assistance and food rations are.

One MP asked Mr Khaw yesterday whether he was going to implement means-testing.

He replied that it was 'at the back of my mind' but that he had many other issues to deal with - including the reform of Medishield and Eldershield.

'I will come to it,' he said.

One reason for the long percolation could be the political price. After all, the $9,300-a-month man would not take kindly to his low-priced hospital stay being taken away from him.


Except the "$9,300-a-month man" may end up with a $300,000 bill, which even at 65% subsidy (but before Medisave) will take "$9,300-a-month man" a full year's income to pay off. Hardly "low-priced", is it?


Madam Halimah Yacob, who chairs the Government Parliamentary Committee on Health, had warned that an extensive public debate was needed 'so that people are adequately prepared and are not caught by surprise by the change in policy'.

Last month, the Health Ministry said there would be some kind of means testing within a year.

I would say - let's start now, and start with the $9,300 man first, followed by the $5,000 man.


angry doc would say: start with looking at more aspects of the issue first, followed by getting your logic right, then start thinking about whether we should even implement means testing in its current proposed form.

Sick, sick people 7

Round 5... and angry doc is running out of suitable pictures for the series. Nevertheless, he thinks that since he has logged all the letters which had used medical reasons as justifications against the decriminalisation of sex between men and their rebuttals, he should continue for completeness' sake...

Irresponsible to suggest treatment based on one study

I AM writing in response to Dr Alan Chin's letter, 'Figures speak for themselves: Practising gays have higher risk of HIV'.

He went to great lengths to provide statistical data that male-to-male sexual activities have resulted in a disproportionately high incidence of HIV transmission.

Considering this with his other key point that homosexuality is not an immutable trait and that we should not deny anyone the right to change, Dr Chin seems to suggest that gay men should exercise the right to change their sexual orientation in view of the health risks they face.

With discrimination faced by gay people in many societies, it is interesting that not more gay men have exercised the right to change their orientation by evidence that most self-identified gay men remain gay.

One wonders who in their right mind would choose to suffer societal rejection if there was a way out. If reparative therapy to change one's sexual orientation is so pervasively successful as Dr Chin claims (he has not provided any statistical evidence though), why is it not adopted by most medical practioners as a treatment for homosexuality?

It is irresponsible for a medical doctor to suggest a treatment based on one study. Dr Chin has conveniently ignored the comments made by the author of the study, Dr Robert Spitzer himself, in response to misuse of his study results as published in the Wall Street Journal May 21, 2001 (verbatim).

'In reality, change should be seen as complex and on a continuum. Some homosexuals appear able to change self-identity and behavior, but not arousal and fantasies; others can change only self-identity; and only a very few, I suspect, can substantially change all four.

'I suspect the vast majority of gay people would be unable to alter by much a firmly established homosexual orientation.

'I did not conclude that all gays should try to change, or even that they would be better off if they did.'

The issue here is not about the right to change one's sexual orientation. Since when has that right been denied?

As a medical doctor communicating his views in a public forum, Dr Chin should have presented a more robust analysis of a scientific study done by someone else, especially when there already exists a wide spectrum of professional opinions on the study in question.

Peter Goh Kok Yong


and...


Criminalisation of gay acts: Need for equality before the law

I REFER to Ms Yvonne Lee's letter, 'Gay debate continues: Writer responds', (Online forum, May 17).

Ms Lee has quoted from the affidavit for a court case of one medical doctor, John R. Diggs, Jr, MD, that homosexual acts are inherently unhealthy.

A closer examination of the affidavit whose source is supplied by Ms Lee herself shows that Dr Diggs observed: 'People who engage in homosexuality have the same basic sexual equipment as people who do not.'

This meant that heterosexuals have the same sexual organs and some can also engage in what is regarded as 'homosexual acts' as well.

Unsafe sex by heterosexuals and homosexuals can result in the same medical and health risks like those listed by Ms Lee - promiscuity, multiple sexual partners, assault and battery and anal intercourse.

Homosexuals do not have the monopoly of such risks. In reality heterosexuals carry higher risks and spread sexually transmitted diseases including HIV/Aids to their sexual partners and unborn children.

In the discussion on natural drives, Dr Diggs wrote: 'We discourage heterosexual promiscuity, cigarette smoking, and intoxication of various sorts, even though there may be a natural inclination to do these things. Some claim a natural inclination, as adults, to sexually exploit children. This society discourages to the point of making it criminal.'

Dr Diggs is right that we should discourage heterosexuals from expressing such inclinations. At the same time I agree with him that we should do the same with homosexuals.

But homosexual orientation is not an inclination or a tendency that we must curb. It is just as natural an orientation as the heterosexual to engage in heterosexual and for some homosexual acts as well.

Sexuality is common and the health risks of sexual acts are the same. The distinctive difference is that of same-sex and opposite-sex acts.

Why do we criminalise one and not the other? This is where there is a need for equality before the law and justice needs to be seen to be served.

Dr Yap Kim Hao


angry doc finds it rather ironic that a Doctor of Theology is teaching a Professor of Law how to interpret an affidavit submitted by a Doctor of Medicine.

What interesting times we live in.

"Singapore's healthcare system" 2

Part 2 of Mr Leong Sze Hian's 3-part treatise.

Tough Club 4

Remember the Holistic Health Framework that angry doc blogged about a while back? The programme that promised us that "schools’ health promotion efforts will now include physical, mental and social health"?

Well, they certainly are keeping their promise, because they now no longer just pick on fat kids for being fat and make them run laps.

Now they pick on fat kids for being fat and stupid.


Obesity may have negative effect on children's academic performance: experts

SINGAPORE : Obesity in children may have a negative effect on their academic performance.

This was revealed at a seminar on obesity by the National Heart Foundation and the National Institute of Education.

Obesity among children in Singapore is on the rise: the number with weight problems having doubled in just 30 years.

Researchers at the seminar say obesity not only increases the risk of other health problems as they get older, but may also affect their brain activity.

Another finding is that obese children in America tend to suffer from inferiority complex and low self-esteem.

One researcher here suggests that parents can boost their children's confidence by praising them often to make them aware of their strengths.

Professor Ho Lai Yun, Senior Consultant Paediatrician, SGH, said: "Basically there shouldn't be any academic difference between children who are overweight and average weight. But because of the way we are treating them, they are already thinking they are not so good, they are already thinking that they're not so confident.

"So when you think you're not so good, the level that you set for yourself will be low, and of course you may not be performing well, compared to other children."


Wow. Fat kids have low self-esteem? angry doc would never have known that if all these experts didn't tell him so.

Still, he believes that's nothing a little institutionalised discrimination won't solve; we'll just keep picking on them until they lose weight and gain confidence now, won't we?

Sick, sick people 6

Question: In ancient Sparta, how did they separate the men from the boys?

Answer 1: With a crow-bar.

Answer 2: Via an institution known as the Krypteia.

Before a boy could be accepted as a full Spartan citizen, he was expected to spend two years in the Krypteia.

The Krypteia functioned as a sort of secret police which watched over the helots, the serf class of the Sparta state, and its members would go out under the cover of the night and murder any helot who were thought to be trouble-makers.

To legitimise this killing, the Spartan parliament would ritually decalre war against their own helots every year, so a Spartan who kills a helot would not be guilty of murder.

The helots thus lived under the constant threat of violence. Violence sanctioned by the state.

Because they were helots, not Spartans.

This was Spartan law.

Sick, sick people 5

Round 4...


Changing a person's sexual orientation: Conclusion flawed

I AM writing in response to Dr Alan Chin Yew Liang's letter titled, 'Figures speak for themselves: Practising gays have higher risk of HIV'.

I thank Dr Chin for keeping the discussion on an emotional topic grounded in rational discourse, and such an effort deserves a considered response.

First, with regard to Dr Chin's point about the higher relative incidence of Aids in homosexual people - the risk of contracting Aids among people who 'practise' homosexual sex is not a justification for continued criminalisation, but by safer-sex education and outreach programmes. This is exactly society's approach towards addressing the risk of contracting STDs among people who actively 'practise' heterosexual sex or that of lung cancer among people who smoke.

Dr Chin goes on to address the question of whether or not a person can change his sexual orientation, and quotes a study by Dr Robert Spitzer to draw the conclusion that 'even if one person can change, then homosexuality is not an immutable trait'.

Unfortunately, Dr Chin's conclusion is a skyscraper erected upon a foundation of straw. Dr Spitzer's study does not support Dr Chin's claim that homosexuality is not immutable because the sample population was not random but specially hand-picked for a special purpose.

Sadly, this is a mistake that is made so often by non-specialists that Dr Spitzer himself was compelled to respond. On May 21, 2001, the Wall Street Journal published a commentary by Dr Spitzer about his own study where he said (verbatim):

'In reality, change should be seen as complex and on a continuum.

'Some homosexuals appear able to change self-identity and behavior, but not arousal and fantasies; others can change only self-identity; and only a very few, I suspect, can substantially change all four.

'I suspect the vast majority of gay people would be unable to alter by much a firmly established homosexual orientation.

'I did not conclude that all gays should try to change, or even that they would be better off if they did.'

In other words, just because one person among millions might possibly be able to change his intrinsic sexual orientation and attractions after years of therapy, it does not therefore mean that everyone else is able to (or should even try, given the potential destructive consequences of failure). After all, can you imagine what it would take to make a red-blooded straight man stop being attracted to a Playboy centrefold?

Lastly, I will turn again to Dr Spitzer's commentary to address the issue of equal treatment (not protection, mind you!) for homosexual people:

'My study concluded with an important caveat: that it should not be used to justify a denial of civil rights to homosexuals, or as support for coercive treatment.

'Gay rights are a completely separate issue, and defensible for ethical reasons.'

I could not have said it any better myself.

Lee Jin Hian

"Singapore's healthcare system" 1

angry doc would like to bring to his readers' attention the first of a three-part treatise on Singapore healthcare system by Mr Leong Sze Hian over at theonlinecitizen site.

He will link to the future instalments when they are published.

Sick, sick people 4

angry doc is sick. Sick with disgust and anger.

It was one thing when the good professor tried to argue against decriminalisation of sex between men from a legal stand-point (see here for an analysis of her arguments in her earlier letter), but another altogether when she tries to use medical reasons and 'public health' as an excuse.

Her letter to the ST Forum today is lengthy (I will post a link to a site that analyses her whole letter when I can find one), so angry doc will only reproduce the relevant part (emphasis mine):


Gay debate continues: Writer responds

Second, there are medical opinions that homosexual sex (that is, anal sex) is inherently unhealthy.

One may argue that this is a 'private' matter, affecting only individuals who contract diseases such as 'gay bowel syndrome'.

However, this is a narrow view of what amounts to 'public health' concerns, given that the activities and diseases of individuals may affect the public at large.

Further, the possibilities of allocating public funds to resolve these sorts of health problems make this a matter of public concern as it could mean that funding for research into other illnesses like cancer and diabetes is reduced.

Concerned citizens who would like to be informed on this matter may usefully refer to the medical opinion of one Dr John R. Diggs, Jr's (August 16, 2000), which was set out in his affidavit in relation to a Massachusetts lawsuit (concerning homosexual activists' legal claims against parents who opposed sexual 'orientation' education in schools):

'There are a variety of significant medical and health risks associated with homosexuality and the gay 'lifestyle'. These include promiscuity, multiple sexual partners, assault and battery and anal intercourse. The sexual practices of male homosexuality consist primarily of oral-genital contact and anal intercourse. These practices are inherently dangerous because of the proclivity to produce occult and overt physical trauma, often spreading sexually transmitted disease. The rectum is particularly vulnerable to sexual trauma, where breaks in the protective membrane barrier facilitate blood exchange and, in turn, the transfer of infectious agents. Furthermore, certain male homosexual practices, such as 'fisting', that is, the insertion of the entire hand into the recipient's anal canal, are likely to cause more serious injuries... Studies have repeatedly shown that lesbians and gay men are at increased risk for mental health problems, including depression, substance abuse, and suicidal behaviour, compared to heterosexuals... Homosexuals perpetrate child sex crimes at a rate many times their number in the population...'

Yvonne C. L. Lee


Wow. Gays are so dangerous that they will rob us of our healthcare funding. But hey, smokers smoke themselves into getting cancer, and fat people eat themselves into getting diabetes, so why not jail them too?

Promiscuity, multiple sex partners, assault and battery, anal intercourse, spreading of sexually-transmitted disease, mental health problems, substance abuse, suicidal behaviour, child sex crimes... all these activities are by no means limited to homosexuals. If we have a problem with such behaviour, we should just target them, with legislation if neccessary if they involve victims: as it is assault and battery, substance abuse and child sex crimes are indeed illegal, and you can also be jailed for knowingly transmitting HIV. But to use the above passage to support the continual criminalisation of sex between men sounds like trying to sentence people for pre-crime.

Sick, sick people 3

Looks like Dr Chin is not one to give up so easily in his fight to help gay people:


Figures speak for themselves: Practising gays have higher risk of HIV

I REFER to Mr Siew Meng Ee's letter, 'Doctor using selective material to justify own conclusion' which was written in response to my letter, 'Homosexuality: disease or immutable trait?'. I thank him for his views that he has expressed.

Let me clarify what I have written. It is true that not all people who contract Aids are homosexuals and not all homosexuals have Aids.

Let's look at the statistics from the US' Communicable Diseases Centre (CDC) - in the year 2005, there were 45,669 cases of newly-diagnosed Aids cases of which 18,938 were from male-to-male sexual contact.

This means that 41.5 per cent of cases of Aids were transmitted by male-to-male sexual contact.

The estimated number of cases diagnosed through 2005 (this means the number of people at the end of 2005 having HIV) is 988,376.

The estimated number of this same group of people having Aids through male-to-male sexual contact is 454,106. This means that of the 988,376 diagnosed cases of Aids in the US, 45.94 per cent of these cases were contracted through male-to-male sexual contact.

The number of homosexuals in the US has been estimated to be 2.8 per cent ('the most widely accepted study of sexual practices in the United States is the National Health and Social Life Survey which found that 2.8 per cent of the male, and 1.4 per cent of the female, population identify themselves as gay, lesbian or bisexual.

See Laumann, et al, The Social Organization of Sex: Sexual Practices in the United States (1994).

This amounts to nearly four million openly gay men and two million women who are identified as lesbian.

This means that 2.8 per cent of the population in the US accounts for 41.5 per cent of the new cases and of the number of HIV cases in the States, 2.8 per cent of the population accounts for the 45.94 per cent of the people having Aids. When relative risk is calculated, this means that a person who engages in male-to-male sexual contact has a 2,400 per cent higher chance of getting Aids.

If we look at the Singapore figures for 2005, 2.8 per cent of the population accounted for 31 per cent of the new cases of HIV infection, 2.8 per cent of the population accounted for 22 per cent of the number of people diagnosed with HIV.

I believe the figures speak for itself, that practising homosexuals have a far higher risk of HIV with its numerous complications and increased mortality.

There are two main reasons for this.

1) The rectum is physiologically unsuitable for anal intercourse. Its fragility leads to increased risks of trauma during anal intercourse, accounting for the increased risks of infection, both bacterial and viral including HIV.

2) Homosexuals are sexually more promiscuous.

A 1978 study found that 75 per cent of homosexual white males claimed to have 100 male sex partners, 15 per cent 100-249 male sex partners, 17 per cent 250-499 male sex partners, 15 per cent 500-999 male sex partners and 28 per cent more than 1,000 male sex partners (Alan P. Bell et al, Homosexuality: A Study of Diversity among Men & Women pg 308 Table 7. New York 1978).

In a local publication, People Like Us: Sexual Minorities In Singapore, gay activist Alex Au Wai Pang wrote frankly about homosexual sexual values being different from that of heterosexual males. Both of Mr Au's articles in the book talk frankly about how many homosexuals are more promiscuous than their heterosexual counterparts.

With regard to whether homosexuals can change their sexual orientation, this is an issue that arouses the emotions of all concerned. As gay activists see it, if someone can change his or her sexual orientation, then homosexuality can be considered a lifestyle choice and thus does not qualify to be considered as a protected class under the law.

As why Dr Robert Spitzer's study was quoted, some background information as how this study came about is useful. Dr Spitzer is one of the most renowned psychiatrists in the US, who is called the father of DSM.

In fact, he was one of the key psychiatrists in deciding that homosexuality should be removed from the DSM. However, in the early 2000s, during an APA meeting, Dr Spitzer met some picketers who claimed that they had changed their sexual orientation.

Intrigued, he decided to do a study as, at that time, his view was that homosexuals could not change their behaviour.

He genuinely wanted to know if some homosexual men and women could change from homosexual to heterosexual, and that he wanted science to guide him. Certainly, with more than 275 publications to his credit, this esteemed scientist at Columbia University was more than able to conduct such a study.

With the limitations that are inherent to all such studies, Dr Spitzer employed the best rigours available for such research protocols.

His sample size was larger than those in previous studies. He was very detailed in his assessment and carefully considered the affective components of the homosexual experience.

Any bias in interview coding was virtually eliminated by near-perfect interrater scores. He limited his pool of applicants to those reporting at least five years of sustained change from a homosexual to a heterosexual orientation.

His structured interview clearly described how the participants were evaluated. His entire set of data is available for scrutiny by other researchers.

If his study methods are considered flawed, then all the original research material used by APA to justify the original change in classification is also flawed using the same argument.

Dr Spitzer's conclusions are simply this: Based on his study, there is evidence to suggest that some gay men and lesbians are not only able to change self-identity, but are also able to modify core features of sexual orientation, including fantasies.

His study was not designed to give the percentage of homosexuals that have changed. Dr Spitzer felt the percentage was low as it was difficult to find subjects willing to be interviewed.

One of the few rational, scientific commentaries on the Spitzer study was offered by Scott L. Hershberger. Dr Hershberger, a distinguished scholar and statistician, elected to respond in a Commentary to the Spitzer research (Hershberger's article was published in the same issue of the Archives of Sexual Behavior as the Spitzer study was) by conducting a Guttman scalability analysis. This is a scalogram to determine whether or not reported changes occur in a cumulative, orderly fashion.

Dr Hershberger's conclusion: 'The orderly, law-like pattern of changes in homosexual sexual behaviour, homosexual self-identification, and homosexual attraction and fantasy observed in Dr Spitzer's study is strong evidence that reparative therapy can assist individuals in changing their homosexual orientation to a heterosexual orientation.

'Now it is up to those sceptical of reparative therapy to provide comparably strong evidence to support their position. In my opinion, they have yet to do so.'

The Schidlo and Schroeder study, funded by the National Lesbian & Gay Health Association, was originally titled 'Homophobic Therapies: Documenting the Damage.'

The title was later changed to 'Changing Sexual Orientation: Does Counseling Work?' because they found that some people reported benefits to reorientation therapy including a change of sexual orientation. Biasness will be an issue as the aim of the National Lesbian & Gay Health Association is to prove that homosexuals are normal and healthy and reparative therapy is harmful.

There are thousands of testimonies of homosexuals who have changed their orientation. Even in Singapore there are testimonies of homosexuals who have changed their sexual orientation.

The point is that even if one person can change, then homosexuality is not an immutable trait and we should not deny anyone the right to change.

Dr Alan Chin Yew Liang


angry doc will not argue with Dr Chin's facts and figures, but he thinks Dr Chin is trying to confuse the issue when he wrote in his final paragraph that:

"we should not deny anyone the right to change."

Yes, let us doctors use our professional knowledge to stop sex between men from being decriminalise, for that would mean denying all these sick, sick people from getting the healthcare they need, wouldn't it?

Rational Rationing 3

angry doc actually wrote this entry shortly after the previous one in the series, anticipating that his readers will ask how he plans to incorporate the idea of fairness in deciding how we distribute healthcare resources.

Let's look at the issue of individual responsibility for a start, specifically at smoking.

angry doc believes we can make a case for discriminating against smokers when it comes to distributing healthcare resources on the grounds that:

1. There is a known cause-and-effect relationship between smoking and diseases

We know that smoking causes a number of diseases including heart disease, strokes, chronic obstructive pulmonary disease, and lung cancer.

2. The choice to start and continue smoking is an individual one

We recognise that by imposing a minimum age for smoking, and while we actively try to persuade people from smoking by use of graphic warning on cigarette packaging and health education campaigns, we have not banned smoking outright. In addition, smoking is not an essential need.

Now in the context of a pooled risk system, angry doc thinks he is justified in proposing that those who willingly subject themselves to additional risk should contribute more to the pool.

How to implement this then?

First, we need to identify a list of 'gazetted diseases' for which a definite cause-and-effect relationship with smoking is proven.

Once we have done so, we can move on to the next step: define how smokers should 'contribute more to the pool'.

Currently we have a few tiers in our subsidised healthcare system: in the outpatient setting we have three rates for citizens, permanent residents, and foreigners (at 'full-', 'half-', and 'none-' subsidised rates, which in terms of consultation translates to about $8, $12, and $16 respectively), and in the inpatient setting we have three subsidised rates ('C-", 'B2-', and 'B1-" classes, which translates to 80%, 65%, and 20% subsidy of the total bill). For convenience, we will refer to the highest subsidy rate in each case as C, the next as B2, and the least as B1.

If we stick to the existing system, we can stipulate that non-smokers are eligible for C rate.

For smokers, we can stipulate that they are only entitled to B2 or higher rate for the first outpatient visit or hospitalisation once the diagnosis of a gazetted disease is made.

For subsequent visits or hospitalisaion, patients who have stopped smoking (or have stopped smoking for a specified duration) are still entitled to B2 or higher rate, but those who are still smoking will only be eligible for B1 or higher rate.

No smoker is denied healthcare, nor is there any discrimination in the treatment he receives.

Now the difficult part: how do we identify smokers?

Given the disincentive of being a smoker, it can be assumed that smokers will not be forthcoming or honest when asked about their smoking status. A more legalistic approach is required.

We can stipulate that all citizens and permanent residents (since foreigners are not entitled to healthcare subsidy) who wish to purchase cigarettes (or tobacco products) be required to make a once-off statutory declaration that he has been informed of the consequences of smoking (both medical and the proposed legal ones) and that he intends to start smoking and bear personal responsibilities for doing so.

Subsequently a smoker will need to produce a photo-ID each time he purchases cigarettes. Each purchase is logged.

A smoker can circumvent this system by getting someone else to buy cigarettes for him, but the person who does so will himself bear the consequences of being logged as a smoker. To prevent smokers from pooling their risk by having one 'designated smoker' buying for the rest, we may factor in the amount of cigarettes purchased over time into our consideration for subsidy (i.e. you can bear the risk for a friend by buying the cigarettes for him, but your co-payment rate will be higher if you are deemed a 'heavy smoker').

angry doc can already see some objections to this system:

1. It imposes a 'double jeopardy' on smokers, who already pay a duty for cigarettes

angry doc cannot deny that. Under the proposed system, a person is penalised for both his decision and the results of his own decision.

2. It infringes individual privacy and liberty

It infringes privacy, but not liberty. A smoker is still allowed to smoke if he accepts that he will receive less subsidy as a result of his decision.

pathdoc raises other questions:

"How many cigarettes a day for how long constitutes a smoker? How long must one stop smoking before he is considered a non-smoker? Is the smoker of a cigarette a day to be treated the same as one who smokes 100 a day? What about the type of cigarettes? Does the nicotine level matter? What about cigarette filters that claim to remove most of the tar?"

angry doc thinks those answers can be answered objectively by looking at data on smoking and pathogenesis. We may need to further grade the co-payment rate based on how much one smokes, but overall he thinks the policy is sound.

What do you think?

Sick, sick people 2

A good rebuttal to Dr Chin's letter in the ST Forum today:


Doctor using selective material to justify own conclusion

I AM writing in response to Dr Alan Chin Yew Liang's letter, 'Homosexuality: Neither a disease nor an immutable trait' (Online forum, May 8).

I am shocked that a medical doctor by training would make such flawed statements.

He first wrote that 'a disease is defined as an impairment of health or condition of abnormal functioning' and 'homosexuality certainly fits the definition of a disease as there is an increased mortality rate mainly from Aids; the life expectancy of a homosexual and bisexual male is up to 20 years shorter compared to a normal male'.

I do not see how Aids is linked specifically with homosexuality. Aids affects humans, regardless of sexuality. Not all homosexuals contract Aids, and not all Aids sufferers are homosexual.

I am rather disappointed that he did not list the methodology of the study he quoted.

One key assumption was that 95 per cent of HIV deaths were attributed to gay and bisexual men, which was the case in Canada from 1987-1992 which was the height of the Aids epidemic in North America.

From the data collected by the Ministry of Health, from 1985 to June 2006, out of the total of 2,652 HIV-infected Singaporeans, 673 are homosexual or bisexual. How appropriate is this study in today's context in Singapore?

Subsequently, he stated that 'being a homosexual (statistically speaking) puts one at risk of suffering from poor health and dying early'.

Geschwind and Behan (1982) published the first study showing that people suffering from immune disorders and/or dyslexia were more likely to be left-handed.

In the first part of the study, the frequency of disease reported in left-handers was 2.7 times that of right-handers. This was especially true for thyroid and bowel disorders. In addition, left-handers reported learning disorder nine times more often than right-handers.

A second part of the study handed the questionnaire to the general public. However, only those who had a hospital diagnosis for an immune disorder were chosen. For this study, the rate concerning left-handers and immune disorders was 2.3 times that of right-handers.

From Dr Chin's line of reasoning, we would therefore conclude that left-handedness is a disease and require treatment as well.

Dr Chin also stated that 'a review of the history of events shows that the decision was not based on scientific evidence, but in fact was the response of an organisation under siege by gay activists'.

What he failed to note was that the research by Dr Robert Spitzer that he later cited was also rejected by the American Psychological Association when it issued a statement cautioning that 'there is no published evidence supporting the efficacy of reparative therapy as a treatment to change one's sexual orientation'.

It was noted the study was retrospective, that it lacked controls or independent measurements, and was based entirely on self-reports by people who were motivated to say they had changed because of their affiliation with ex-gay or anti-gay groups.

In 2001, Jack Drescher, M.D., Fapa Chair Committee on Gay, Lesbian and Bisexual Issues of the American Psychiatric Association, wrote a letter to the Finnish Parliament which discussed the Spitzer study:

'As for the scientific merits of his study, I believe it is significantly flawed. One flaw is that the majority of subjects in the study had one 45-minute telephone interview with Dr Spitzer and no follow-ups.

'Other than Dr Spitzer, I can find no reputable researcher who will agree that this is an accurate way to assess whether a person has changed their sexuality. That point was underscored in another study presented at the same symposium.

Schroeder and Shidlo's study (in press) found that many individuals who claimed to have changed sexual orientation during a first telephone interview changed their story at a second, follow-up interview.'

Dr Spitzer himself said in subsequent interviews: '...the kinds of changes my subjects reported are highly unlikely to be available to the vast majority (of gays and lesbians)... (only) a small minority - perhaps 3 per cent - might have a 'malleable' sexual orientation'. He expressed a concern that his study results were being 'twisted by the Christian right'.

In 2005, he told the Washington Post that supporters of reparative therapy have misrepresented the results of his study. He said: 'It bothers me to be their knight in shining armour because on every social issue I totally disagree with the Christian right... What they don't mention is that change is pretty rare."

As a member of the medical profession, Dr Chin's statements would carry more weight, and I would have expected a higher standard, instead of selectively reading research and studies that justify one's own conclusion, and ignoring that which does not.

Siew Meng Ee


Mr Siew takes on Dr Chin's arguments one by one, and he does a good point of rebutting them. angry doc doubts this letter will convince Dr Chin or those readers who have agreed with him to change their minds about homosexuality, but nevertheless he thinks it is important work.

angry doc believes that all the reasons given by people to oppose the decriminalisation of men having sex with men - it's not natural, it's nurture not nature, it's a psychiatric illness/psychological disorder, it spreads diseases, etc. - are not the real reason behind their opposition; they are but justifications. And as soon as you rebutt one justification, they will come up with another one.

On the other hand, angry doc doubts that many homosexual persons will decide to 'go straight' even if it can be proven conclusively that homosexuality is not genetically determined, or that it is associated with a shorter life expectancy.

All the science and statistics are just tools and justifications for both sides, and if we are not careful, we risk becoming confused by them and losing sight of the real issue behind "the recent discussion".

"red, white & screwed"

To all prospective medical students...

Before you even think about what kind of doctor you want to be in the future, perhaps you should first think about what kind of medical student you want to be.

Here's angry doc in med school:



(Hat-tip to Susan from Orac's blog. See the whole series here.)

Sick, sick people

Apart from a video of a cartoon, angry doc had not directly commented on the "recent discussion on the issue of homosexuality". angry doc doesn't think this blog is a place to 'show his politics'.

However, this letter compels him to change his mind (emphasis mine):


Homosexuality: Neither a disease nor an immutable trait

I WRITE with regard to the recent discussion on the issue of homosexuality. Homosexuality, until recently, was regarded as a disease.

A disease is defined as an impairment of health or condition of abnormal functioning.

Homosexuality certainly fits the definition of a disease as there is an increased mortality rate mainly from Aids; the life expectancy of a homosexual and bisexual male is up to 20 years shorter compared to a normal male (R.S. Hogg, et al, 'Modelling the impact of HIV disease on mortality in Gay and Bisexual Men' International Journal of Epidemiology 1997).

There is also an increased morbidity rate, with a greater risk of suffering from sexually transmitted diseases, including Aids, and increased risk of psychiatric illnesses such as depression, suicides and drug abuse.

Simply put, being a homosexual (statistically speaking) puts one at risk of suffering from poor health and dying early.

In 1973, homosexuality was removed from the Diagnostic And Statistical Manual of Mental Disorders (DSM) by the American Psychiatric Association (APA).

The question we have to ask is: How did this come about? One would think that the APA would not have taken such a step unless there was strong scientific evidence to justify such a move.

A review of the history of events shows that the decision was not based on scientific evidence, but in fact was the response of an organisation under siege by gay activists. Ronald Bayer's book, Homosexuality And American Psychiatry: The Politics Of Diagnosis, documents the political nature of this battle over DSM.

Dr Bayer defends this move by APA, saying: 'Psychiatry may, under certain circumstances, act upon society, using its cultural influences to challenge social values and practices.'

It is clear from this that the removal of homosexuality from DSM was a political settlement and not due to scientific evidence. Thus, homosexuality should still be regarded as a disease.

The question is, if homosexuality is a disease, can it be treated?

There have been numerous documented cases of people who have changed their sexual orientation.

Dr Robert Spitzer, who was very much involved in the 1973 removal of homosexuality from DSM, found in a 2001 study, that 'there is evidence that change in sexual orientation following some form of reparative therapy does occur in some gay men and lesbians'.

It follows from this that homosexuality is neither a fixed trait nor is it immutable.

Dr Alan Chin Yew Liang


Now what Dr Chin wrote may be true, but it is also irrelevant to "the recent discussion on the issue of homosexuality".

Because the "discussion" isn't really about whether homosexuality is a disease to be cured or not, but whether or not men having sex with men deserve to be jailed for life for doing so.

Substitute the word 'homosexuality' with 'promiscuity', and much of what Dr Chin wrote will still make sense.

Now substitute the word 'homosexuality' with 'smoking', and the words 'AIDS' and 'sexually transmitted disease' with say 'lung cancer' and 'chronic obstructive pulmonary diseases', and much of the letter will still make sense.

Promiscuity and smoking may well fit into the definition of 'disease' as given in the letter (and in fact smoking has its own ICD-code), but we do not jail people for promiscuious behaviour, nor do we jail smokers, do we?

But why let a simple fact like that stop us doctors from using our expert professional opinion to help put those sick, sick people away for the rest of their lives, right?

Rational Rationing 2

The earlier post on rationing of healthcare has brought some comments concerning the escalating costs of healthcare and how to contain them.

But regardless of how we choose to manage the problem, whether it is by cutting angry doc's pay or expanding our pool of resources by increasing government expenditure or increasing end-user co-payment, or by restricting access to healthcare, we still need to decide how we ration the resources within that pool. angry doc believes that 'fairness' is a factor that needs to be taken into consideration when making the decisions.

(Outside of the pooled risk system, however, angry doc cannot find a reason to object to patients who are able to afford to pay receiving care regardless of their need or individual responsibility.)

Now, leaving aside the source of funding and the absolute size of the pie (to borrow an expression used by a commenter), how do we make a decision on how large a slice of the pie a patient gets, or if he gets any at all?

Our current two-tier system allows those who can afford to pay more to buy a larger slice of the pie at a premium to do so. While this does allow the pie-maker (baker?) to recover a larger portion of the cost, in theory allowing him to make a bigger pie next year from the budget he has been given, it does not change the fact that the pie is subsidised, and that it does not take into account how hungry the buyer was.

Or should that be a concern at all?

Should the baker distribute the pie solely with the aim of minimising loss? Or should he give more of the pie to the hungriest? What if we were in a famine and the hungriest will still die soon even if we gave them the pie? Should we then give the pie to those to whom it will do most good?

Should we take into account individual responsibility? Should those who get hungry from say playing soccer all day pay the same price for pie, or should they be made to pay more because they have made themselves hungrier by playing soccer during a famine?

OK, the analogy is getting ridiculous and angry doc is going to stop milking it now, but he hopes he has gotten his point across: there are many ways to split a pie, and our current system is not the only possible one.

How we want to distribute our health resources is important, because it ultimately gets translated into health financing policy that affects most of us. Our current system seems to have an over-reliance on income and ability to pay as criteria, and not enough on need and individual responsibility.

angry doc doesn't think that is fair.

angry doc thinks we can do better.

Measure of a doctor

An article on the issue of physician renumeration in Medical Economics.

(Hat-tip to Dr Wes.)

Fair and Obvious

A reader left a comment on an earlier entry which got angry doc thinking. angry doc reproduces the parts in question below (emphasis mine):


"Healthcare costs will continue to rise because we can do more for patients, but there is a price. Healthcare in Singapore is affordable if our expectations are modest. It only costs $4 to see the polyclinic doctor if you are elderly, $8 for others. Hospital care in the subsidised wards is also very cheap by international standards and considering the quality of care, but obviously you cannot expect to have rituximab, Gleevac or Herceptin.

If you are poor and develop Her2+ breast cancer, you can get your surgery and standard chemotherapy. If you can afford it, you get Herceptin. If not, you get by with what you can afford. That is fair."


angry doc must confess that it is neither obvious nor fair to him that someone in a subsidised ward cannot expect a better quality of care just because it is more expensive.

If we defined a system of healthcare financing in which care (note that I say care, not service) directly correlates with ability to pay as one that is fair, then it would be obvious that the situation above is fair.

But we need to ask ourselves the question: Is that system fair?

If there was no alternative to a healthcare system where care is only given to those who are able to pay, the question would be purely academic. However, what we have here is a system of healthcare financing in which tax-dollars in the form of subsidy can be used to (as it were) 'artificially inflate' a patient's ability to pay and thus allow him (or rather her?) to 'afford' to pay for that care.

And that raises the next question: Why shouldn't we pay for her care?

The 'official' answer is clear:


The financing philosophy of Singapore's healthcare delivery system is based on individual responsibility and community support. Patients are expected to co-pay part of their medical expenses and to pay more when they demand a higher level of service.


OK, maybe it's clearly stated, but the underlying philosophy is hidden: moral hazard, or the idea that people will abdicate their individual responsiblity to take preventive healthcare measures to keep themselves from falling sick, and/or that they will utilise the healthcare system unnecessarily if they did not have to pay for at least part of the cost.

Let's address each part in turn.

Now angry doc thinks a patient who had a heart attack from smoking, eating too much, and not exercising enough effectively 'asked for it'. He might even say that he 'deserved' it. But should he say that that patient obviously should not receive the best care for a heart attack there is if he cannot afford it?

Or if he could afford it, does that mean that angry doc is going to stop thinking that he did not 'ask for it' or 'deserve' it?

Given that there is a well-known cause-and-effect relationship in lifestyle choices and pathogenesis here, and in the context of a subsidised healthcare system where risk is pooled, angry doc might be persuaded that he should be given less subsidy for his treatment, but he would be reluctant to deny him the treatment altogether.

But what if it was a disease where there is no effective preventive measure against, or what if the patient had done all that was possible to prevent that disease, but is nevertheless afflicted?

Currently the system does not make that distinction. All it says is: if you can afford it, you can fall sick all you want; but if you cannot pay for it, you cannot expect to receive the most expensive (and presumably best) care whether or not you are responsible for your illness.

With regards to the second part of that philosophy, angry doc's question is: is cost a determinant of abuse?

In other words, between a man who goes to a polyclinic and feigns an illness to obtain medical leave for the cost of $8, and a woman with Her2-positive breast cancer who requires Herceptin at the cost of $30,000 a year, who is abusing the system?

angry doc believes most of his readers will say that the man is abusing the system, but as it stands the system puts minimal barrier in the way of the man, and a very high barrier in the way of the woman. Is that fair?

You may argue that a high fee at the primary care level may deter people from seeking primary healthcare, but if that's the case, why let cost be a deterrence to someone seeking life-extending secondary care? Why would anyone ask for Herceptin if she didn't need it?

Fairness is a moral concept, and angry doc thinks it is vain to think that we can use economic means as a substitute for moral judgement to try to achieve fairness.

angry doc cannot claim that he has a workable system to use fairness as a measure to ration healthcare all figured out, but until then, he doesn't see why we should regard the current system as obviously fair, or as fair at all.

Why am I still here?

A reader asks angry doc: if you were given a choice and in view of the current benefits and welfare received by the doctors here, will you still choose to become a doctor or at least practise in Singapore?

I think what he or she is asking is:

1. If you knew then what you know now, will you still choose to become a doctor?

and

2. If you decide not to practise in Singapore, will you practise in another country?

Short answers: 1. - Yes, 2. - Maybe.

But in themselves the answers don't really tell us anything about practising medicine in Singapore, so I thought I might just ramble on a little...

Working conditions for doctors vary quite a lot depending on your seniority, specialty, and place of practice. Certainly they vary enough for people to decide their choice of specialty and workplace based on 'lifestyle' considerations.

If you are an employee, you can negotiate contract terms. If you are your own boss, then you can make most of the rules yourself.

Bear in mind also that any choice a doctor makes does not have to be permanent: there are specialists who decided to become GPs, and there are GPs who have decided to become specialists; doctors move to the private sector all the time, and there are GPs and private specialists who return to the public sector. My guess is for most doctors, they will eventually find and settle for a spot they are comfortable with.

The details of the work vary, but fundamentally the job description is the same: a doctor identifies medical problems and finds solutions for them. Certainly some parts of the job are not covered by that statement (health promotion, solving social problems, signing certificates and examination forms), but primarily, a doctor is distinguished by his ability to make a diagnosis and formulate a treatment plan, and that's something that is intellectually challenging, and emotionally satisfying.

OK, it's good for the ego.

And why shouldn't it be? We are helping people. That's what I signed up for. I know I could do the same driving an ambulance or fighting fire, but I'm not a good driver and I look fat in yellow.

Despite my frequent rants about clueless patients and illogical policies, I know things will probably never be perfect. I don't expect a job to be all fun and happiness with no stress or aggravation; if it was like that they won't be paying me - I'll be paying them. Any other job will probably be the same, but at least in this one I get plenty of opportunity to help people, even if I don't always end up helping them.

So yes, if I knew then what I know now, I will still have become a doctor.

Will I practise somewhere else though?

Well, it's not perfect here in Singapore, but if you read the blogs of the other doctors I link to, you'll find it's not perfect in the US, the UK, and Australia either.

angry doc believes doctors everywhere face the same problems, plus problems unique to their place of practice. angry doc is not sure he wants to trade one set of problems for another set of problems right now.

Happy Labour Day, steelworkers