Angry Doctor

Thursday, July 26, 2007

Sick, sick people 12

angry doc counts nine letters on the ST Online Forum on the topic of decriminalisation of sex between men today.

Interestingly, five of the letters were written by 'Drs', at least one of whom was a 'medical doctor'.

angry doc wonders if this is because more doctors (medical, dental, or PhD) than non-doctors wrote to the Forum, or whether the Forum editor prefers to publish letters written by persons with title of 'Dr'.

Whatever the reason, let's look at the letter from one of the 'Drs':

Straight people need to re-examine their heterosexuality

I REFER to the article, 'What will the future be for our children if we decriminalise homosexuality?' by Mr Benjamin Ng Chee Yong (Online forum, July 21).

I can see how Mr Ng may be disgusted with his observation of men (supposedly gay) loitering in the changing rooms of swimming pools, peeping at other men at the urinals and the physical abuse (molest by other men) he himself experienced during his youth. For that, he calls for continued criminalisation of homosexuality as he fears for the safety of his children.

What about the less than desirable sexual expressions of heterosexuals that we are all too familiar with? Girls are taught to avoid taking the elevator alone with men, and tough night curfews are usually set for them as parents fear their daughters may fall prey to molesters and rapists. Parents advise their daughters against skimpy bikinis so as not to attract advances of men with questionable intentions. And we all know the hanky panky that goes on in some KTV lounges, not to mention the open solicitation of prostitutes that line the streets of Geylang. These are sexual activities of straight people, yet no one has called for the criminalisation of heterosexuality.

As much as the proposition of criminalising heterosexuality may sound absurd, most straight people do not realise that they are applying the same untenable line of argument when they call for the continued criminalisation of homosexuality. Surely not all heterosexuals are molesters and rapists. Likewise, not all homosexual men go around molesting young boys in elevators. If all homosexuals are to be criminalised for behaviours of the minority among them, then the same should apply to the heterosexuals.

In discussing the repeal of Section 377A, straight people have to re-examine the fundamentals of their own sexuality. Firstly, they need to understand their basic sexual urges and how the urges are expressed or contained. While the majority are able to contain and express their sexual urges in ways that are not harmful to others in society, there is a minority who are unable to restrain themselves. Homosexuals are no different.

Secondly, straight people need to realise how fundamental their sexual orientation and preference are to their being. Most heterosexuals would say that they were not influenced in their adolescent years into liking people of the opposite gender. They are just naturally inclined that way. It's not something they have to decide. It is also not something they can change even if they want to. Likewise, homosexuals will tell you that their sexual orientation is not something they choose or can change.

Key to the debate on Section 377A is realising the commonality between heterosexuality and homosexuality. Homosexuality is as fundamental to gay people as heterosexuality is fundamental to straight people. Only when straight people learn to see gay people in this light will we make progress.

Dr Peter Goh Kok Yong

angry doc once had the privilege of 'counseling' a young man who was referred to him for the 'illness' of homosexuality. He was engaging in high-risk behaviour, and angry doc spent a bit of time educating him about safer practices.

When the session was over angry doc asked the young man what his plans for the future were. He replied, matter-of-factly, that he wanted to go to university, get a job, and support his parents in their old age.

angry doc was shamed by that reply; he would not have asked the question if his patient was straight, or at least not known to be gay. The young man knew it, but he was gracious about it.

His sexuality aside, the young man explained, he had hopes, aspirations and a sense of duty just like other young people of his age.

The heterosexual majority may not realise it, but we flaunt our sexuality everyday. Men's and women's magazines alike place scantily-clad women or men on their covers and articles like 'How to have better sex' between them, match-making agencies advertise their services, and hotels and resorts sell 'couples' packages.

Yet we go about our daily business dealing with each other without being conscious of each others' sexuality because we take it for granted, while we see sexuality as the main defining feature of gay persons, and some of us fear that they too will be allowed to display their sexuality as we do.

What we find fundamentally loathsome about 'sexual immorality' and sex crimes has probably less to do with orientation, and more to do with the fact that they are about using another person contemptuously, violating other persons' right over their own bodies, or the betrayal of trusts and bonds.

angry doc would like to thank that young man for teaching him a very valuable lesson that day, although his ego is still a little bruised by the fact that the young man did not make a pass at him.

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Monday, July 23, 2007

"not the province of the uneducated or the foolish"

Last weekend must have been a slow news day...

Bath or bao makes or breaks one's day
Doctors are more superstitious than they realise, a study shows
Tan Hui Leng

THE next time you see an abundance of unsold bao at a hospital food court, put it down to a superstitious medical staff.

They are probably avoiding the steamed dumplings as it bodes for a bao ka liao (Hokkien for "have the lion's share of") situation while on duty.

In a survey of 68 medical staff members, a National University Hospital (NUH) team has found that medical personnel are more superstitious than they themselves realise. The respondents comprise 54 doctors, nine medical students and five nurses.

The paper, written in a tongue-in-cheek fashion under the title, Take a Bao if You Are Not Superstitious, was published in the March edition of the Academy of Medicine's Annals journal, which every year at this time brings out a humorous edition. The study was carried out by neurologist Dr Lim Chuen Hian Erle and three colleagues late last year.

"Rare is the fledgling Singaporean medic or nurse who has not been initiated into this cult of superstitious practices," the authors wrote in a section called "Cum Grano Salis", Latin for "with a pinch of salt".

"We are told not to mention how good one's night duty is, never to eat steamed dumplings, called bao, on the same day, lest we bao ka liao all the cases, or worse, have to bao (Mandarin for wrap) corpses in their shrouds later that night.

"Those with bad luck are told to 'bathe in the seven flowers' (a traditional Chinese ritual for cleansing), though which flowers to use in the concoction are never elucidated.

"Presumably, it is the fragrance which engenders good fortune, thus explaining the propensity for some doctors to bathe before every call."

Indeed, although 83.8 per cent of the respondents disclaimed having a superstitious nature, about half avoided having items purported to confer bad luck during a call and 24 of them admitted to acting on their superstitions.

Although only six believed in the powers of the "bath of the seven flowers", 14 made it a habit to bathe prior to a call — in the belief that this protected them against a bad one.

Also, eating mee siam, a Malay noodle dish, is purported to siam (that is, chase away) bad luck, while soon kuay — a type of Chinese dumpling — sounds like "shun" (or smooth in Mandarin), suggesting a smooth-sailing night.

Superstitions in medical institutions are not unique to Singapore.

In 2002, a survey of British doctors revealed the observance of several superstitious beliefs and practices, among which were the inadvisability of stating that a call was quiet (lest the word be taken as an invocation to the fates to supply work) and rituals to ensure a good call, such as laying out one's clothes for the next day prior to turning in for the night.

A junior doctor at a public hospital here told Today that the superstitions, particularly that surrounding bao, should not be taken lightly.

"I ate a small bao before a night call a few weeks ago, despite having been warned years ago by my seniors," the doctor said. "I ended up attending to 40 patients in one night! That was a really bad call, I've never had a similar bad call after a non-bao diet." The doctor declined to be named.

"There was another doctor on call that night and I was the one who jinxed it by eating a bao, so I haven't told anyone about it!" the doctor added with a nervous laugh.

It is not just newbies who stay clear of tempting fate.

A neurosurgeon in the NUH study reported that he avoided eating beef on the day of his call, because beef, or niu rou in Mandarin, sounds like "neuro", which would jinx a neurology or neurosurgical call.

Another respondent, an oncologist, reported his belief that eating bread, or mian bao, protected one from the danger of a bao ka liao situation, since mian is Hokkien for "no need".

The results, the study concluded, demonstrate that "superstitions are not the province of the uneducated or the foolish", and that "we are more superstitious than we care to admit".

Although seemingly lighthearted, the NUH study makes for an interesting sociological study of hospital personnel.

Future studies suggested by the team include a randomised study examining the disparity between a doctor's perception of what went on during a call and the actual workload — measured by the number of admissions and the number of bleeps received by a pager, for instance — after eating bao, mee siam or soon kuay.

You can read the original paper here.

angry doc is of course familiar with the superstitions - he has not eaten a bao since the day he became a doctor. Not, he hastens to add, because he thinks it really makes a difference to the quality of the call he has, but because he sees such traditions as part of the subculture of being a junior doctor in Singapore. The rituals of having an shower early in the call, avoiding bao or commenting on how the call has been 'good so far' are all little acts of bonding between people who have to share the same adversity that is an overnight call in the hospital. It's part of our collective identity.

His postulation on the persistence of superstitious practices in the medical profession aside, angry doc agrees with the authors' observation that "superstitions are not the province of the uneducated or the foolish". Ultimately, superstitions and beliefs in the supernatural, pseudoscience, and unproven therapies all stem from the same lack of critical and scientific thinking and the acceptance of flawed arguments based on logical fallacies, and an education is not always an effective talisman against that.

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Friday, July 20, 2007

Take my rights... please!‎

angry doc is once again amazed by how fear of a perceived threat can cause us to trade our dignity for the illusion of security...

Have docs test for HIV without patients' consent

I READ with concern the article, 'Most with Aids virus don't know they have it' (ST, July 18). It is disturbing to learn that there is a significant number of HIV-infected people who have not yet been diagnosed.

These people endanger themselves, their sexual partners, families and possibly health-care workers. As they are undiagnosed, they may not get the right medical treatment. This affects their health and lives.

Early diagnosis and treatment of HIV can save lives and reduce the possibility of misdiagnosis. This will benefit the infected individuals and society as a whole.

Though there is currently no mandatory testing, doctors should be able to conduct HIV tests on patients, without the need to get their prior consent.

There should be screening and diagnosis points built into our medical system. For instance, patients undergoing operations, including eye operations, can have their blood tested automatically as part of the treatment process.

Patients displaying symptoms of HIV infection should also have their blood tested during medical treatment, without the need to seek their consent.

More can be done to educate people, especially the ones with at-risk behaviour, about the need to undergo blood tests.

In this way, HIV infection can be diagnosed and treated earlier. It can also reduce the spread of HIV and the increase in Aids cases.

Edmund Lim Wee Kiat

The cause of Mr Lim's concern can be found in this news article (emphasis mine):

Should Aids testing be mandatory?
Tan Hui Leng

AMID startling statistics that one in 350 hospital patients are HIV-positive, at least one voluntary welfare organisation here has called for mandatory testing of high-risk groups, in what some have described as a highly controversial and intrusive move.

The group — Focus on the Family — said it would be submitting a proposal, drafted together with doctors, to the Ministry of Health (MOH) soon.

High-risk groups, such as men who visit sex workers and sexually-active gay men, should go for compulsory testing, said its director, Mr Tan Thuan Seng.

"We should not allow people who choose high-risk lifestyles to avoid testing and thereby subject innocents in their households and medical workers to unfair risks of infection," said Mr Tan.

"These undiagnosed infected are walking time-bombs as they have the potential to knowingly or unknowingly infect others."

On Tuesday, it was revealed that a recent MOH study of over 3,000 anonymous blood samples collected in hospitals showed that 0.28 per cent of those who thought they were free of the disease were in fact HIV-positive.

This was followed by the news that the MOH is investigating the case of a man suspected of spreading the virus knowingly.

However, MPs and Aids volunteers Today spoke to were concerned about how the identification of such HIV-positive carriers is intrusive and stigmatises those affected.

"In implementing it, it's hard to not intrude into the privacy and rights of individuals," said chairman of the Aids Business Alliance, Mr Zulkifli Baharuddin.

Mr Benedict Jacob-Thambiah, an Action for Aids volunteer and the programme director of Heat Consultants, which provides HIV education at the workplace, agreed.

"Mandatory testing of any group only serves to stigmatise, isolate and deepen discrimination. It is not something I would advocate as I do not think any Singaporean should be subject to something that is patently wrong. It does no one any good," he said.

Since December 2004, pregnant women have been subjected to opt-out HIV tests as part of standard antenatal screening here. Only one case of mother-to-child transmission has occurred, and that was because the mother refused her HIV test until very late in her pregnancy, according to the MOH.

Last year, Singapore experienced a record high of 357 new HIV-positive cases.

Making testing compulsory — even for small high-risk groups — could pose some implementation problems, said deputy chairman of the Government Parliamentary Committee for Health, Dr Lam Pin Min.

"It's hard to identify persons in the high-risk groups unless they declare it themselves," he said. "It also makes it very difficult to draw a line on whether you visit sex workers or are sexually liberal or promiscuous.

"So, if you make it a law to self-declare, does it mean that you're breaking the law if you're in one category or the other?"

Those Today spoke to were all in favour of better public education, particularly as the HIV/Aids situation here is not seen as dire.

"I don't think the situation has come to the point where there is a real epidemic that requires an intrusion into private lives," said Aids Business Alliance chairman Zulkifli. "We always try to persuade and cajole people, and, in most cases, they respond."

Compulsory testing, vaccination, and quarantine for infectious diseases are not new. Society accepts that the risk of certain diseases (like measles, tuberculosis, and SARS) spreading to the population justifies the suspension of individual liberties. angry doc, having been brought up in that environment, has no problems with that. The question, to his mind, is then this: is the risk of a HIV epidemic high enough to justify compulsory testing?

Whether we test universally or only individuals identified as 'high risk' (presumably meaning everyone else but ourselves?) is another matter which we will perhaps discuss another day.

Now the 1 in 350 figure is likely skewed and may not be representative of the population at large, but let's work with it since it is obviously the figure that has gotten everyone worried.

HIV is speard primarily through bodily fluids during sexual intercourse, introduction of infected blood into the body via transfusion or needle, or from an infected mother to a baby.

Let's look at sexual contact, which is the main mode of transmission for HIV here.

The probability of transmission per coital act for a man having intercourse with an infected woman is estimated to be 0.0013 in this study*. In other words, the risk of a man catching HIV from a woman not known to be HIV-positive from a single episode of intercourse, using a prevalance of 1 in 350, is in the region of 1 in 270,000.

But of course, you can argue that one single sexual encounter with an infected partner is enough to give a person HIV, in which case it doesn't really matter whether the figure you are looking at is 1 in 270,000, 1 in 350, or even 1 in 2 (either you get it, or you don't).

The fact is, the risk of a person catching HIV is not just a function of the prevalance of infection in the population, but also a function of risk-behaviour. Compared to diseases like SARS, we as individuals do have a much high degree of control over the risk of HIV-infection we are exposed to without having to impose compulsory testing (and presumably compulsory something-else afterwards).

After all, you can't catch HIV just because someone coughed at you.

* - angry doc had earlier used a figure of 1 in 200,000 in his caluclation, but on further reading he found that this calculation included the prevalance of HIV in the community. As noted in the study he has linked to, the transmission probability per act ranged from 0.0001 to 0.0020 in other studies. angry doc apologises for the error.


Thursday, July 19, 2007

Sick, sick people 11

Well, here we go again (emphasis mine)...

Homosexuality: Legalising something that is not right does not make it right

THE views I have regarding the current controversy of decriminalising gay sex is purely personal. However, I will not be surprised if other like-minded Singaporean mothers share my views.

I had the opportunity to travel and live in North America, and experienced life in cities where homosexuality is openly acceptable.

While in San Francisco for a medical conference, my attempt to explore the city was marred by the Gay Pride Parade. There were rainbow flags all over the city, and the public transport system was paralysed because of the event.

My spouse and I lived in Toronto several years ago, while on a work attachment at a reputable hospital in the city. When we first arrived, we stayed at a hostel at Church Street. The irony was that it's the street where homosexuals hang out in.

I attended an eye-opening play at a gay theatre, about the gay lifestyle, performed by gays. The play was written by a 14-year-old school girl, and received good reviews for its literary merits on national newspaper.

A local paediatrician colleague openly introduced her lesbian partner to us.

Most of the bookshops in North America will have significant sections for gay and lesbian literature, and not infrequently, they are right next to the children's books section.

I returned fully convinced that Singapore is still the best place to raise my children.

However, with casinos coming in, and now the push for the legal acceptance of an 'alternative lifestyle', our younger generation's moral compass will sway even more uncertainly.

As a paediatrician, I remain an advocate for the well-being of our children. Today's children and adolescents already have enough health and psycho-social issues to grapple with. They don't deserve the added problems of homosexuality and rising HIV infections.

When local schools teach that homosexuality is an alternative lifestyle, and my children's teachers are open about their homosexual relationships, I will quit my immensely satisfying career to home-school my children.

When local church/religious leaders sanction same-sex marriages and ordain homosexual ministers, I will quit going to church and will not send my children to a mission school.

The day Singapore becomes like San Francisco, foreign talents can come in all they like, but there would not be much left to keep me in Singapore.

I am not aware of any convincing medical literature that proves that homosexuality is genetic. Mankind has struggled with homosexuality since biblical times.

I am not expressing my views from a position of strength. As human beings, we all have our struggles and temptations.

However, legalising something that is not right does not make it right, does it?

Dr Ang Su Yin


How dare those gays:

- hang rainbow flags in the city!
- paralyse the public transport system by having a parade!
- hang out on Church Street!
- write and perform in plays about homosexuality!
- openly introduce their partners to us!
- publish and sell books about homosexuality!

Surely they deserve imprisonment for doing all those things which only heterosexual people are entitled to? Let us doctors quit our jobs and punish Singapore with a shortage of doctors if they ever dare to decriminalise sex between men.

No, Dr Ang, legalising something that is not right does not make it right, but neither is something that has been criminalised in an archaic law automatically wrong.

Children do not deserve the problem of rising HIV infections (which is attributable mainly to heterosexual transmission), and angry doc believes they do not deserve to be brought up to discriminate against other people in the name of God either. And that is my purely personal view.

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Well, I suppose it had to happen.

Like a few other doctor-blogs, Angry Doctor started out with rants about patients, but gradually moved on to examining our healthcare system, medicine in the social context, and eventually quackery and pseudoscience.

It just happened. Certainly it was not by design, intelligent or otherwise.

I guess with increased readership comes the awareness that one can perhaps make a difference, and that one should exercise that privilege responsibly. So one began to blog more about quackery and pseudoscience.

One would also like to introduce Fresh Brainz, a local science blog by Mr Lim Leng Hiong, whom angry doc considers a fellow-combatant in the fight against quackery and pseudoscience. Do drop over and have a browse.


Domo arigato, Mr Emoto

OK, so it's not strictly-speaking a medical issue, but angry doc just can't resist...

A post on Mr Wang's blog has prompted angry doc to look at the topic of Mr Emoto's ice crystal experiments and a study on the same topic by Dean Radin.

angry doc is unable to access the paper, but he did find this site where you can learn more about the research methodology. angry doc did not give any of the pictures a score of more than 2 (on a scale of 0 to 6). According to Dean Radin's blog, the average score of the treated sample in the study was 2.9. Do scroll through the 50 images and see what your average score is.

If the findings have convinced you that happy words and thoughts can make your water better, you may want to write happy words on your water bottle.

Alternatively, you can save yourself the trouble and just buy a water bottle with a happy word printed on it, thanks to Mr Emoto's work.


Tuesday, July 17, 2007

A little learning...

The title of this letter to the ST Forum today caught angry doc's attention the moment he opened the webpage:

Check your heart condition - go for a CT scan

THE Sunday Times on July 15 reported yet another case in which a healthy soldier collapsed and died of a heart attack during a taekwondo exercise.

I am saddened by all these good men and women, some relatively young, who left their loved ones all of a sudden without a chance to even say goodbye.

We have read enough cases to know this silent killer does not respect age, gender or fitness level. Some of these individuals have even gone through very recent health checks like treadmill stress and blood tests and they were certified a clean bill of health by their doctors. Some don't even have any complaints of any chest pains or tightness whatsoever before the heart attack.

Here is my personal view of this matter from a layman's perspective which, I hope, would trigger readers to think carefully of what they know, rightly or wrongly, about this deadly killer disease.

Here are some common myths that I often hear people bringing up in the course of discussing this topic on heart attack:

'My cholesterol level and treadmill stress test results are OK - my heart condition therefore should be OK.'

There is no direct correlation of cholesterol readings to plaque forming and clotting properties in our blood. Plaque forming in the inner walls of our blood vessels may rupture over time and cause blood clots to form at the site and if the clot is large enough to block the flow of oxygen-rich blood to the heart muscles, the heart muscles may die and be replaced by scarred tissues. Other non-clotting related causes like spasms causing blood vessel constriction leading to a heart attack is not discussed here.

The exercise stress test - also called a stress test, exercise electrocardiogram, treadmill test, graded exercise test or stress ECG - is a test used to provide information about how the heart responds to exertion. It usually involves walking on a treadmill or pedalling a stationary bike at increasing levels of difficulty, while your electrocardiogram, heart rate and blood pressure are monitored.

This test is able to detect a heart condition 15-75 per cent of the time, depending on many factors and may not be able to accurately diagnose a problem below 50 per cent blockage in your arteries. So that may explain why some people still suffer from a heart attack soon after passing a treadmill stress test.

I learnt of a local marathon runner having a mild heart attack and yet passed the treadmill stress test three times via three different cardiologists.

The treadmill stress test may not be stressful enough for some fitness fanatics to show up any signs of the heart under stress during standard physical exertion tests. I was told that eventually this person went through an angiogram and finally found two out of three arteries with more than 90 per cent blockage. He underwent a heart bypass and lives to tell the story.

Moral of the story is that if you are super fit, you may not have a standard stress test to tell you that you may have a heart condition.

Most doctors usually will not recommend further examination if one passes the treadmill stress test. If abnormal stress signs of the heart are found, the doctor would normally recommend an angiogram to be performed.

Angiogram is a gold standard test used for some time already to determine whether one has a blockage or not. Angiogram is an invasive test where a thin catheter with a scope is threaded into your body to look at the problematic region and is able to provide only a two-dimensional view of the state of blockage in your blood vessel. It has a 10 per cent risk where it could puncture your blood vein or artery along the way to the site and some people actually died from it.

'I am physically fit and health conscious - I run 5 miles daily and exercise regularly.'

I strongly believe that if one who is very active in sports and yet does not know whether one has plaque forming in his/her blood vessels (some as microscopic as less than 1 mm in cross sectional diameter), one has a higher propensity of succumbing to a heart failure compared with one who is less active.

One may be able to run five miles a day effortlessly when one is 18 years old but when one is older... 35 or 50 years old, more effort may be required as fitness level degrades over time.

As you age and when you are not as fit or are unwell, your heart actually pumps faster with the same degree of physical exertion. With the plaque building up and the tendency of the plaque rupturing getting higher each day, the risk of a heart attack increases over time. I believe the same can be said in the case of a stroke affecting the blood flow to the brain through the left and right carotid arteries.

If you are active into sports or into strenuous exercises and especially if you have a family history of heart attacks or stroke, stop what you are doing immediately and ask yourself: 'Do I have plaques forming in my blood vessels today? How do I find out if a treadmill test is not accurate enough and angiogram is risky?'

Fortunately, there is a non-invasive imaging technology today called the CT scan. It is able to radioactively scan your heart with a three-dimensional computerised view of your heart and surrounding veins and arteries and also able to perform a cross-sectional analysis to show levels of calcium blockage in any part of the veins and arteries. The technology is getting better each day in terms of imaging resolution and lower radiation dosage.

Some people are concerned that the high level of radiation may shorten one's life - effective radiation dose of 2mSv which is about the same as an average person receiving from background radiation in eight months.

But think again, isn't it better to know beforehand that you do not have blocked veins and arteries that may potentially cause you to suffer a heart attack and after which, if you survive, may require you to undergo all kinds of invasive tests and surgeries? The benefit of accurate diagnosis far outweighs the risk.

My wise doctor told me it is a no-brainer for people of a certain age (>40) and those with a family history of heart attacks or strokes not to use this technology that is available today. It costs about $1,100 per scan and getting cheaper, no fasting required, requires one injection of contrast and 30 minutes of your time to go through this relatively simple examination. The doctor will go through the results and you will also be given a computer disk with your heart images to take home.

I personally went though a comprehensive insurance health screening recently which included a treadmill stress test and immediately after the test, which I passed, I paid for an additional CT heart scan and an ultra-sound test on my carotid arteries. I passed all the tests.

For those who have been spending $100-$300 on a treadmill stress test, my advice is to save the money to do a CT heart scan instead. You may want to know that you can also use your CPF Medisave savings to subsidise the CT heart scan up to $1,100 limit.

Do yourself and your loved ones a favour, get a CT scan of your heart today. Keep fit and eat healthily... but check your heart condition first.

Quek Kwang Seng

Mr Quek put a lot of facts and figures in his letter, but the issue is really more complex that that.

A multislice CT angiography may have high sensitivity and specificity, but the positive predictive value and negative predictive value will vary according to the population being examined; and it is here that Mr Quek's line of argument unravels.

Mr Quek had begun his letter looking at 'yet another case' of a healthy person who suffered a sudden cardiac death, but he also acknowledges that the advice from his wise doctor applies to "people of a certain age (>40) and those with a family history of heart attacks or strokes".

If we screened only people with risk factors, we will not reduce the number of sudden cardiac deaths in 'healthy' people. If we screened all 'healthy' people, the cost will be enormous, in the region of a $1 billion or more given our population, while the number of deaths we stand to prevent will be small.

And that is not all.

Coronary artery disease (CAD) is a progressive disease: just because you have a clear CT angio today does not mean that you will not develop a problem later on. At the same time, persons with 'positive' scans but are otherwise asymptomatic may not benefit from intervention in the form angioplasty. The cost is therefore not $1,100 for a lifetime, but $1,100 every few years or so. Is it more effective to screen and treat risk factors for CAD with that money, or is it more cost-effective to detect the disease when it is already established? Certainly that is something we need to study.

A multislice CT angiography is good at picking up (or excluding) coronary artery calcification and plaque burden, but CAD consitutes only about 80% of sudden cardiac death cases; the other 20% of cases are attributed to (among other things) electrophysiological abnormalities, which may not be detected with a multislice CT.

There are other issues in Mr Quek letter that need to addressed, and no doubt angry doc's readers can find a few themselves. angry doc suspetcs that right now, someone from the Heart Centre or Heart Institute is drafting a reponse to the ST Forum to forestall an influx of healthy people flocking to their clinics to ask for the miracle heart scan. Doctors will need to spend a lot of time over the next few weeks explaining to patients why they do not need that special scan.

angry doc believes Mr Quek wrote his letter with his heart in the right place, but a little learning can mean a lot of work for doctors...


Monday, July 16, 2007

Do you have Chronic Cubicle Syndrome?

Part 1

Part 2

Part 3

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Saturday, July 14, 2007

How much is that doctor in the window? 9

angry doc wasn't planning to blog about this topic, but since Prof Lee thinks it's important enough for her to write to the ST Forum (emphasis mine)...

Why single out doctors as being mercenary?

IN THE letter, 'Concern over senior docs going into private practice' (ST, July 12), Ms Annie Koh Seok Kien laments the increasing numbers of doctors leaving restructured hospitals for private practice.

The past two years have seen an increasing number of foreign patients, driving up the income of specialists in private practice, while the remuneration of doctors in the public sector has remained largely unchanged. The income gap between medical specialists in the private and public sectors is now blatantly obvious to the entire medical fraternity.

Students apply to medical school for a variety of reasons. Whatever the initial reasons, when they graduate and subsequently set up families, even those who remain extremely altruistic have to start planning to accumulate wealth as any responsible parent would.

Even if their initial aspirations were to send their children to a local university, as the potential for earning more arises, their aspirations may now be to send their children to top universities overseas.

These are natural instincts which ensured survival of homo sapiens over milleniums. Even politicians and civil servants whose ambition is to serve the nation harbour these same aspirations. Why single out doctors as being mercenary?

Indeed, there are some doctors who are unscrupulous. This is possible in private practice where there is no regulation to prevent overcharging. These are not the doctors we would want to retain in the public sector.

Speaking for the doctors at the National Neuroscience Institute, a restructured hospital, as long as the difference in income is not too great, the working conditions reasonable and fair, and there is a sense that we are providing the best patient care we can, we are happy to stay on in the public sector to serve all patients who need us.

But if the gap gets greater as it is threatening to, I would not hold it against any of my colleagues with families who leave for the private sector. I only hope that in private practice, they will still be guided by their conscience when dealing with patients.

The price of medical care does not follow the rules of supply and demand because the consumer (the patient) can never be fully informed and usually goes to the doctor with total trust, submits to various procedures recommended and seldom questions the fees that are eventually charged. That is the reason why private practice can be so lucrative.

Associate Professor Lee Wei Ling
National Neuroscience Institute

Well, angry doc doesn't think 'why single us out?' is a valid defence, nor that the freedom to overcharge patients is the only or primary reason for doctors joining the private sector.

By the same token, it doesn't mean that all those who leave the public sector are greedy and unscrupulous, or that those who remain are all virtuous and self-sacrificing.

Doctors in the public and private sectors are not opposites of each other, nor is the relationship between the public and private sectors always antagonistic. In fact, as this article by The Hobbit explains, the two may be much more dependent on each other than we sometimes realise, and the existence of an 'attractive' private sector may not always be to the detriment of subsidised patients, as Ms Koh feared.

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Thursday, July 12, 2007

Cow Dung 3

angry doc: Well, you have cancer.

patient: Cancer? Are you sure, doctor?

angry doc: Quite.

patient: But how did you know? Isn't there like some sort of test you should do to prove that I really have cancer?

angry doc: Well, what you can't prove does not equate to not existing.

patient: OK... but there's a treatment for this, right?

angry doc: Sure; just rub cow dung on your forehead every morning.

patient: Cow dung? I'm sorry doctor, but that sounds like vodoo medicine to me!

angry doc: Well, we shouldn't so quick to dismiss everything non-mainstream as voodoo.

patient: OK, maybe it's not voodoo, but is there evidence to show that it works?

angry doc: While I understand the importance of evidence-based medicine, I thought it would be good once in a while to be more open to hypothesis that are not proven.

patient: But doctor, this is my life and my health we are talking about here!

angry doc: It's always about you, isn't it?

Well, that conversation didn't really happen. In fact, much of what angry doc said didn't actually come from angry doc, but from readers' comments in two previous posts (here and here).

The truth is, we all require evidence of one sort or another when we deal with people in our daily lives; we just happen to have less stringent criteria for accepting someone's claims as valid evidence when we want or wish for them to be true, and vice versa.

You wouldn't let angry doc get away with diagnosing and managing a patient in the manner as in the scenario above, so why should you make an exception for people who make claims they do not have valid evidence for?


Monday, July 09, 2007

You say tomato...

Al and I had burgers for lunch yesterday...

angry doc: Hey Al, you know a thing or two about Chinese medicine, right

Al: Ya, why?

angry doc: So is the tomato considered 'heaty' or 'cooling' under TCM?

Al: Mildly cooling, why?

angry doc: How did they know that?

Al: What do you mean?

angry doc: I mean, the tomato is a New World plant, right? That means it wasn't known in China until like 500 years ago, right? So how did the ancient Chinese know whether it was 'heaty' or 'cooling'?

Al: Er... maybe they tested it after it was introduced into China.

angry doc: How did they do that? It's not like there's a pH paper for 'heaty' or 'cooling', or some lab test they can use to detect how much 'heatiness' a gram of tomato has or something, right?

Al: Er... maybe they conducted experiments? Gave some people who were 'heaty' some tomatoes and see if they cooled down?

angry doc: You reckon? I'm just wondering whether they had a proper study with good methodology and control and all that, and whether the study was validated in subsequent studies. Think you can dig up some papers or references?

Al: I don't think they had randomised controlled trials back in the 16th century; I mean, it's just a vegetable, right?

angry doc: Don't you think it's important, man? I mean, people eat tomatoes all the time! Not to mention the ketchup. And did you know that China is the world's largest producer of tomatoes?

Al: Actually, I didn't.

angry doc: And it's a fruit, not a vegetable.

Al: Er... whatever. Can I have some of your fries?

angry doc: That depends; is the potato considered 'heaty' or 'cooling'?

Al: Forget it, I'll get my own fries...


Monday, July 02, 2007

Thoughts, Reality, and a video

angry doc believed, and so Skeptico posted this...