Angry Doctor

Thursday, June 28, 2007

The Invisible Man 3

Reader boon asks on an earlier post:

Do you know if there're any organisations or societies in Singapore which promote critical thinking?

angry doc must say he doesn't, so dear readers, of you do know of any, do let him know. Not that angry doc is keen to join one; he doesn't imagine a group made up entirely of critical-thinkers or skeptics to be society for a fun and easy-going evening, you see.

angry doc is aware, however, of several critical-thinking or skeptic sites and blogs, such as Skeptico's blog which he linked to in the earlier post, Respectful Insolence, which looks at 'medicine, quackery, science, pseudoscience, history, and pseudohistory', and the UK-Skeptics, whose article on pseudoscience angry doc would like to feature today:

What is Pseudoscience?
A theory, methodology, or practise that is without scientific foundation.
Jason Braithwaite PhD, John Jackson © 2006

Pseudosciences are practises that masquerade themselves as science but have little or no scientific evidence or cohesion to support them. They claim to be factual and scientific, yet do not adhere to scientific methodology and principles; notably the scientific principle of falsifiability.

It can be difficult for the non-scientist to discern whether something being claimed as scientific actually is or not. Fortunately pseudoscience has many recognisable features that are distinct from genuine science. These features are outlined below. Whilst not every feature will be common to every form of pseudoscience, any claimed scientific practise that displays at least some of these features is increasingly likely to be pseudoscientific.

You can read the rest of the article here.


Wednesday, June 27, 2007

Good for what ails you! 3

angry mum: I saw on the news just now about this old man in Taiwan with a chronic disease who was told by his doctor that he had to take his medicines every day 'till the day you die'.

angry doc: Uh-huh.

angry mum: Well, apparently he felt it was all so futile and he got so depressed that he refused to eat for three days.

angry doc: He was probably depressed to start with... Then what happened?

angry mum: His family brought him to see another doctor, who told him that that was no reason to be depressed since he has to eat every day 'till the day you die' too. He got better right after that; goes to show the power of positive thinking...

angry doc: Well, I tell my patients they have to take their meds every day till the day they die too, but that that day may come later if they stuck to their meds.

angry mum: Why don't you just tell them they will live longer if they take the meds?

angry doc: Er... because the meds don't guarantee they live longer, they just improve their odds of living longer.

angry mum: Yes, but they don't have to know that. If they died three months afterwards you can just tell the family he would have died a month earlier if he had not taken the meds.

angry doc: Have you been reading Mr Wang's blog?

Tuesday, June 26, 2007

Madness 3

angry doc nearly missed this letter from Prof Lee, published last week:

Don't be too harsh on families who abandon kin

THE article, 'Long-stay mental patients strain IMH' (ST, June 11), highlighting the plight of patients at the Institute of Mental Health who have been abandoned by their family, paints a sad story, placing the blame on irresponsible relatives and society in general.

Little does the reporter or the lay public know the burden of looking after a patient with chronic mental illness.

Mr Raymond Anthony Fernando's letter, 'Govt support needed to care for the mentally ill' (ST, June 22), is atypical only because he has chosen to shoulder his burden instead of dumping his wife at IMH.

By doing so, he sacrificed a significant portion of his life. His is not the worst-case scenario because his wife has recovered. For the families of mentally-ill patients who do not achieve a remission, the burden can be overwhelming.

While I do not condone the families abandoning their relatives at IMH, I can understand why they do so.

I would like to praise IMH for doing a great job in keeping these mentally-ill patients off the streets and giving them a decent quality of life. The alternative would be to deinstitutionalise these patients, as is the politically-correct policy in Western countries. This would result in many of the patients ending up as vagrants or bag-people, with maybe a few ending up in prison.

We need more chronic stay facilities, not just for chronic psychiatric patients but also adult patients with mental retardation and other handicaps who are now physically too big for their elderly parents to look after; likewise for demented patients who may be difficult to nurse at home.

While we would like the families to take on the care-giving responsibility, as a neurologist I have seen the lives of all the family members ruined by one ill relative, through no fault of their own.

Let's be realistic: If we find ourselves in the situation of these families, what would we do? If I were a patient, I would certainly not wish to burden my family or society. But as a 'First World' society, we owe our less-fortunate members a minimum quality of life with dignity.

Assoc Prof Lee Wei Ling

You can read the article mentioned in the letter here (archived at this site, which aims to 'promote mental illness awareness and fight the mental illness stigma in Singapore).

We've looked at the issue of 'home care' before. As much as we would like to think that a patient is best cared for at his own home by his own family, angry doc believes that in some cases, home care is beyond the expertise and finances of the family.

Is having more chronic stay facilities the solution? Certainly it has to be part of the solution, but angry doc thinks that more importantly, we need to change our perception of what placing a relative into a chronic stay facility means.

If we see placement of relatives not as 'abandonment' or 'dumping', but a means to ensure that they receive adequate care and supervision while the other members of the family can carry on with the other tasks of their lives, it will probably reduce the sense of guilt and resentment experienced by all parties concerned. Placement does not have to mean abandonment, and family members can still visit or even bring the patient (or should I say resident) for home leave when the demands of life are lighter. Options like daycare or home-visitation programmes can also be explored.

It might take a while for us to get there, but when you come to think about it, daytime childcare is already almost universal here.

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Friday, June 22, 2007

Zen and the Art of Limb-Regeneration

angry doc apologises for the lack of posting; he has been busy over at Mr Wang's blog, discussing the topic of limb-regeneration.

Well, actually, he hasn't; the limb-regeneration part is a red herring.

The discussion, the way angry doc sees it, is about the scientific method and how we should test each claim and require evidence for them. Many participants seem to disagree, and the usual arguments abound, including (links to Wikipedia and Skeptico's blog):

Do hop over and have a read (especially if you are a quantum physicist; I think we sorely need the input of one there), but before that, angry doc would once again like to draw his readers' attention to the letter by Mr Shyamal Ghose which he featured in an earlier post.


Tuesday, June 19, 2007

Sick, sick people 10

AIDS, and with it the topic of men having sex with men and S377A, come into the news again.

Review needed for Aids education
Four suggestions to improve prevention programmes here
Letter from Assoc Prof Roy Chan

President, Action for Aids, Singapore

WE refer to the report, "Record HIV cases last year" (June 15). Action for Aids notes the increasing rate of HIV infection with concern and would like to reiterate our strategies to enhance prevention programmes in Singapore.

Firstly, there must be clear, unambiguous messages that include the consistent and correct use of condoms in educational campaigns. For too long, public education has skirted around the issue of safe sex.

While we have no problems with advice to have sex within marriages, it is inadequate if this is the only message — relegating the promotion of condom use to a back seat.

Shying away in embarrassment from dealing with youth sexuality more directly is also jeopardising the health of our young citizens.

The escalating rates of HIV infection and sexually transmitted diseases are the result of this shortsighted approach. Action for Aids is appealing to the relevant authorities to review their educational programmes urgently.

Secondly, there must be universal access to treatment. Advocating testing without providing affordable and effective anti-retroviral medication is simply inadequate.

Majority of the infected persons cannot afford HIV medication. Many resort to seeking cheaper generic alternatives from Thailand and Malaysia. Some others do not receive treatment at all. Furthermore, supplies of generic drugs may be inconsistent and quality cannot be assured.

Action for Aids believes that providing even partially subsidised medication will contribute to effective HIV suppression, maximise clinical response to treatment and reduce infectiousness.

Thirdly, there should be a clear direction from our leaders on the issue of Aids-related stigma and discrimination. The prevalence of such prejudice has a negative impact on prevention programmes. Appropriate legislation to address this should be put in place.

Lastly, those who run a higher risk of infection must be empowered to take action and responsibility. In Singapore, men who have sex with men (MSM) are at the greatest risk of HIV infection, in my opinion.

To engage them, they must be encouraged to seek counselling and testing, and be given relevant and appropriate information. Barriers that stand in the way of these efforts should be removed.

In particular, we call for the urgent repeal of Sections 377 and 377A of the Penal Code that criminalise homosexual behaviour. These have been obstacles to targeted educational campaigns and our ability to reach out especially to young MSM who are the most vulnerable.

angry doc wonders why Prof Chan felt the need to qualify his statment that men who have sex with men (MSM) are at the greatest risk of HIV infection with an 'in my opinion'. Perhaps it is an indication of how it is difficult to gather meaningful data on the local MSM population in a setting where admitting to being one is equivalent to confessing to a criminal offence.

Intervention programmes aimed at MSM have been shown to be effective in reducing risky sexual behaviour (see here and here), so if indeed S377A is an obstacle to educational campaigns locally, then it is an aspect of the issue we should look at.

Nevertheless, while angry doc is tempted to support Prof Chan's call for the repeal of S377A, he feels that to argue for the repeal of the law on grounds of public health would be intellectually-equivalent to arguing against decriminalisation on grounds of public health. Repeal of the law, in his opinion, should come from the fundamental principle of non-discrimination, and not be based on public health reasons.

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Wednesday, June 13, 2007

Cow Dung 2

angry doc doesn't usually read The New Paper, but once in a while a copy gets left in the tea room, and angry doc finds an article that interests him (emphasis mine):

Did geomancer's BAD ADVICE kill our daughter?
By Maureen Koh

DESPERATE to save their dying daughter, two parents turned to a fengshui master for help.

They hoped that by changing the 'luck' of the family, their young child might miraculously recover from her illness.

Following the geomancer's advice, they sold their four-room Woodlands flat in 2005 and spent nearly $10,000 over six months to rent flats in places such as Jurong and Bukit Batok, hoping to change their daughter's luck.

They also changed the Chinese characters of all their names.

In all, they paid $4,000 to the geomancer.

But last year, the girl died just four days short of her 6th birthday.

Now, her parents want to sue the geomancer, but have been told that a lawsuit could be futile.

There has been no precedent that would hold someone liable for practising an art or belief that cannot be proven scientifically.

The couple have asked that they not be named fully. They also declined to identify the girl's illness.

Their lawyer told The New Paper on Sunday: 'As fengshui practice hinges very much on belief, it would take a lot to prove any hint of a malpractice.

'It is not like there is a book of authority on the subject that one could refer to for verification.'

It seems the Lims are not the only ones who want to haul their fengshui master to court.

A Singapore businesswoman also wants to sue the same geomancer, claiming she went bankrupt because of his advice.


The Lims' troubles began in 2003 when their daughter, then a year old, was diagnosed with a serious ailment.

She was in and out of hospitals, but her condition didn't improve, said Mr Lim, 36, a sales executive.

His wife, 33, also a sales executive, added: 'My girl was very brave. Whether it was taking medicine or frequent trips to the operating theatre, she never kicked up a fuss.'

When doctors told them in 2005 recovery was unlikely, they prayed for a miracle.

A relative suggested they see a fengshui master.

Mr Lim recalled: 'The geomancer said the fengshui elements of our flat were detrimental to our daughter's health.'

Fengshui is a practice that prescribes living in harmony with the environment.

Anxious to save their child, the Lims said it did not take much to convince them.

'At that moment, we jumped at anything to save our daughter,' Mrs Lim said.

They asked their MP, Dr Mohamad Maliki Osman, to help them write to the Housing Board to sell their flat as they did not fulfil the minimum five-year occupation period.

They have since sold the flat.

But while they waited for approval, the family rented units in different places.

After moving out, the little girl's condition seemed to improve. The Lims were relieved.

Mr Lim said: 'We thought the fengshui master was right. We carried out renovation according to his advice, and even paid for some auspicious items that he said were necessary for our home.'

But their relief was shortlived.

Their daughter's health worsened when they moved into their new 'perfect home' in Marine Parade in 2005, as advised by the geomancer.

'The morning after we moved in, she suffered a relapse and had to be rushed to the hospital,' Mrs Lim recalled.

Five months later, the girl slipped into a coma and was certified brain-dead.

Fighting back tears, Mrs Lim said: 'The doctor told us that we had to make the decision to pull the plug, but my husband and I refused.

'In the end, we didn't have to do it. By night, she was gone.'

Grief turned to fury when the couple approached three other fengshui practitioners with the floor plan of their new home.

Mr Lim said: 'All three told us the same thing - that the room which was picked for our child had too much 'sha qi' (harmful energy).'

While they have gradually come to terms with their daughter's death, the Lims hope that by sharing their story, others would not be so gullible.

angry doc is pretty sure that the geomancer did not kill the girl - her unnamed illness did.

But this story illustrates an important issue in seeking medical advice: the issue of accountability.

If angry doc gives out the wrong advice and his patient suffers harm as a result of it, angry doc can be brought to court for it. It is for this reason that angry doc is required to have malpractice insurance. If he needs to go to court, his insurers will study the case and decide if angry doc's actions should be defended, and if so, how.

More importantly for the patient, if angry doc's actions cannot be defended, the patient can be compensated with a reasonable sum, which in a serious case can be more than what angry doc can afford without becoming bankrupt, in which case the patient will not receive very much at all.

This system works because doctors can be made accountable, and we can be made accountable because most of the time, there is a known cause-and-effect relationship in what we do and what happens to the patient. A court can look at the facts and decide if what a doctor has done is reasonable, or if what he has done had fallen short of the standard and resulted in harm to a patient.

angry doc used to be terrified by the idea that he could be sued for malpractice. Now he is proud of it.

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Tuesday, June 12, 2007

"Candy Everybody Wants"

angry doc apologises for the lack of posts so far this month. He is feeling rather lazy and mellow, so today, instead of writing, he would just like to share a bit of music with his readers.


Saturday, June 09, 2007

"Singapore's healthcare system" 3

The third and final part of Mr Leong Sze Hian's treatise on our healthcare system.

Saturday, June 02, 2007

The Invisible Man 2

Today angry doc would like to feature a letter that does not comment directly on healthcare, but which he thinks illustrates to a certain extent the difference between modern medicine and many forms of alternative medicine.

angry doc reproduces the relevant paragraphs below:

Writer has got it wrong
by Shyamal Ghose

"Science and religion differ on how they approach these questions. The processes they follow are diametrically opposite to each other.

Science follows a particular methodology for explaining the reality around us - the methodology of induction and deduction. Induction is based on data, and deduction on logic, which is formalised in the language of mathematics.

In fact, science is defined by this methodology, and not by the subject matter it studies, nor by its specific findings. As the scientist, John Casti, puts it in his book, Complexification, science is more of a verb than a noun.

Religion, on the other hand, has nothing to do with data or logic. Its approach to explaining the reality is based on speculation, dreams, mythologies, visions and subjective mysticism.

Dr Ho has got it completely wrong when he suggests that science defines reality by what can be studied by its method, that anything that cannot be so studied is denied existence, that all religious claims about transcendental non-material reality are 'defined away' and are 'not allowed' to exist.

This is a bad distortion of the scientific approach. In fact, Dr Ho turns the scientific epistemology on its head.

Science does not compartmentalise reality into that section which is amenable to its method, and that which is not and then 'define' away the latter. There is no reality, as experienced by human beings, either directly or indirectly, that cannot be studied by science. But it has one dogma. It will only follow the method of induction and deduction - data and logic - in trying to understand this reality.

But, why this dogma? What is so great about induction and deduction? Well, it is the only method that works. We survive in the real world (and have survived throughout the whole history of our existence on this planet) by applying consciously or unconsciously a myriad of technologies ranging from the simplest, such as a twig from a tree to scratch my itching back, to the most complex, such as the computer on which I am writing this.

All of these technologies are the result of understanding the nature of reality by applying the methods of induction and deduction, sometimes, almost intuitively, as in the case of the twig, and sometimes more deliberately, as in the case of the computer.

In contrast, there is not one single evidence of an alternative explanation of reality, through, mysticism, the supernatural, et cetera, actually working in the real world. There are millions of anecdotes, brilliant myths, evocative literature, but not one piece of verified evidence.

Now, in applying the principles of induction and deduction, there are many speculative hypotheses about the existence of various entities which do not pass the test - entities such as ghosts, angels and transcendental supernatural beings.

In this list could also be included things like unicorns and aether. Science does not believe in ghosts and spirits and God, not because they are not amenable to the scientific method, but because there is no evidence, empirical or logical, of their existence.

Science does not believe in unicorns and aether (any more), not because they are outside the scope of science, but there is no evidence of their existence. The supernatural is not 'ruled out by fiat', as Dr Ho says, but by lack of evidence.

Actually, the protagonists of religion and the supernatural are acutely conscious that they cannot stand up to the scrutiny of induction and deduction. So, they make out as if they are playing a different game, where the rules of induction and deduction do not apply; where a different epistemology rules.

They just postulate the existence of the supernatural and go on to build elaborate, but vague, speculative structures of concepts, not needing to be constrained at all, either by the demands of data or logic.

They package all that up in some obfuscating verbiage and call it a special kind of reality which science cannot penetrate, thereby hoping to gain legitimacy for their unbridled speculation. Dr Ho's article is another exercise towards that end.

Now, anybody has the right to withdraw from the real world and create an artificial construct for his own pleasure. It is like playing Monopoly with its make-belief currency and special rules of property ownership based on the throw of a dice.

Everybody is entitled to such indulgence. Enormous trouble would arise, however, if the player attempted to use the Monopoly money for real-world transactions. Unfortunately that is what happens when religion claims to have explanations for the real world phenomena and thereby provide answers to questions of values, morality and purpose."

"Dr Ho ends his piece by advocating humility on both sides of the debate. Here also, let us take a reality check. Science is the most humble and humility-generating human endeavour. Since it relies on data which are ever changing, all scientific truths are 'contingent' - till such time as contrary data do not overthrow current truths.

There are no absolute truths which are unquestioned for all times to come. No matter how exalted the position of Einstein, one verified evidence of contrary data, no matter how lowly the student or research worker who generates it, will overthrow the theory of relativity, and replace it with some other that is better able to explain the new data.

Science is the only human endeavour that progresses by trying to prove itself wrong. It accepts a theory only if it has failed to do so - and even then, temporarily. The only absolute for science is its epistemology - data and logic.

Contrast this with the posture of religion. All religions claim absolute, universal, eternal truths which can never be questioned. Even though different religions propagate different wisdoms, they all claim that their truth has come directly from God. How much hubris is required to claim that a book that was written 2,000 years back has the answers to the problems of life today! There is no humble egalitarianism in religions. All religions arrogantly claim special dispensation from God for their adherents.

So, how should we deal with religion then? With great respect. Everybody should study religion - all religions. But only as history; as a part of mankind's brave striving to make sense of his reality.

It does not matter that the religious explanations of this reality do not hold water any more in the light of modern scientific epistemology. The subsequent invalidity of a hypothesis does not detract from the glory of exploring it in the first place.

Ptolemy and Newton are no less revered figures today, even though their schemes were overturned at a later date. The problem arises when religion is yanked out of its setting in history and is made to masquerade as an explanation of eternal reality and a prescription for modern life."

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Friday, June 01, 2007

Subsidy and Other Preoccupations 18 or Edited 3‎

Yesterday Gerald posted the text of a letter he had sent to the ST Forum on the bed shortage situation on the comments section of an earlier post, thinking that they have decided not to publish it.

After reading the letter, angry doc agreed with him - the tone of the letter was... less than complimentary, he thought. But it turns out angry doc is wrong; he had forgotten about the tireless editor of the ST Forum page...

Means test won't resolve social-overstayer issue

I refer to Ms Khalik's [the] article "Means Test the Solution to ease hospital bed crunch" on 25 May 2007. I agree with the Health Ministerthat public hospitals are designed for the acute care of patients, and that patients who are fit for discharge may be better served by step-down facilities such as community hospitals.

However I disagree that means testing is the solution to ease the hospital bed crunch. As currently envisaged, it will apply to everyone [every subsidised patient] staying longer than 5 days, regardless of whether they are fit for discharge or not [1]. As the Minister himself brought up, an elderly patient may need weeks to recover. Is it fair to penalise a patient who needs the bed, but takes longer to recover?

Furthermore, means testing applies only to a subset of patients, namely those who can afford to stay in private wards but choose to stay in subsidised wards. It will not apply, for example, to the destitute old man who qualifies for C class and is fit for discharge, but whose family refuses to bring [take] him home. Means testing will not help free up beds occupied in such a way.

Lastly, inpatient means testing has yet to be implemented, and difficulties are already anticipated. We should concentrate onfulfilling its basic objective (namely to ensure that subsidies go tothose who need them), rather than tack on additional goals.

Therefore I would like to bring to your attention [highlight] a policy that directly addresses the problem of social overstayers and is already in place in our public hospitals. It is available on the website, and can be found (aptly) under the "Social Overstayers" heading at - I quote "Patients who are fit for discharge but insisted on staying on will be charged the full cost of the period of their overstay, from the 7th working day after the hospital has assisted in finding a placement ina step-down care facility."

Rather than use the bed shortage to justify the introduction of means testing, the Health Minister should instead familiarise himself with [we should tap] methods that are simple and already available, and ensure that they are carried out smoothly.

Gerald Chen Zexin

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