Angry Doctor

Thursday, September 27, 2007

Acupuncture - still not working

Via Orac, another study that shows that while sticking needles into people may relieve their pain, it doesn't really matter whether you stick them in the correct acupoints on the right meridien or not.

It's not the first study that demostrates that the theory behind acupunture does not describe observed reality, but proponents continue to conduct such studies instead of using the resources to find out how exactly sticking needles into people relieve their pain - it's almost too painful to watch.


Saturday, September 22, 2007

Clearthought Singapore

Leng Hiong at Fresh Brainz has invited angry doc to join Clearthought Singapore, presumably a loose association of skeptical blogs in Singapore - he wasn't very clear on that bit...

angry doc thinks we are supposed to fight irrational thinking where we find them, promote public understanding of science and the scientific method, and help old ladies cross the road, but only when they want to get to the other side. Or something like that.

Now all angry doc needs is a superhero costume...


Wednesday, September 19, 2007

Them 3

Today carries a more in-depth look at yesterday's news story.

Ignorance will be no defence
... for those in high-risk groups who do not know they are HIV-positive
Tan Hui Leng

YOU never told your sexual partner you were HIV-positive — because you didn't know it yourself. But you will not be able to plead ignorance in the eyes of the law, if you already belong to a certain high-risk group.

The Ministry of Health (MOH) will be amending the Infectious Diseases Act to "clarify that ignorance of one's HIV status will not be a defence for those who engage in high-risk sexual behaviour", said Health Minister Khaw Boon Wan in Parliament yesterday.

In addition, he said in confirmation of earlier signals, voluntary HIV testing will be introduced for adult male inpatients at hospitals later this year.

The law now simply bars a person who knows he has HIV/Aids from having sex with another person, unless that partner is informed beforehand and voluntarily agrees to accept that risk. Anyone who flouts this law can, if convicted, be fined up to $10,000 or jailed for up to two years, or both.

The tweak to the law — first hinted at in 2005 by then-Minister of State for Health, Dr Balaji Sadasivan — comes as grim statistics show that 278 Singaporeans were diagnosed with HIV/Aids in the first eight months of this year. All of last year, 357 were diagnosed.

The latest update brings the total number of known HIV-infected Singaporeans to 3,338. The prevalence of such cases has risen to 0.07 per cent of the resident population aged 15 years and above — up from 0.02 per cent a decade ago.

But given the sparse details available so far, some observers and Aids activists wonder how effective the legislative change would be in helping to bring Singapore's HIV transmission rates down.

Like others, president of the Association of Women for Action & Research Constance Singam wanted to know more. Would HIV testing be made free as a corollary, for instance? "I believe the law ought to protect the innocent victims from the high-risk behaviour of their partners, but I am just not sure how this amendment is going to work," she said.

A spokesman for Action for Aids (Afa) said the group was waiting to hear the Government's stand on protected sex — that is, could a HIV-infected person who "diligently practises safer sex" be prosecuted under the amendments?

Dr Stuart Koe, a trustee of Afa Endowment Fund and CEO of, was concerned such a "blanket law will further stigmatise the disease by making all HIV-positive people — whether they know it or not — potential criminals".

Also, the virus' long dormancy period would make it "almost impossible to trace the route of transmission", making the law moot, Dr Koe argued. And it was possible wives would not report their husbands for fear they might be prosecuted.

Madam Halimah Yacob, chairman of the Parliamentary Government Committee for Health, told Today these issues must be studied carefully before any legislation is implemented. But she thought the criminalising of patients who have sex without knowing that they are HIV-positive could apply "only for really severe cases" — that is, "if a person's lifestyle is so high-risk" that the person would suspect his or her condition even without medical confirmation.

Meanwhile, with males making up nine in 10 of the new HIV infections last year, the MOH will launch voluntary HIV testing for adult male inpatients.

Said Mr Khaw: "From the public health point of view, all persons who are HIV-infected should know their status. First, they can receive early treatment. Second, they can be counselled on how they can avoid infecting their loved ones."

This would also help ensure the safety of healthcare workers. A recent study revealed that 0.28 per cent of more than 3,000 anonymous blood samples collected in hospitals — from patients who thought themselves free of the disease — were, in fact, HIV-positive.

"Every day, we treat about 4,500 inpatients in public hospitals alone," said Mr Khaw. "If the hospital study is representative, then some 12 unknown HIV patients come into close contact with healthcare workers every day."

Leaving aside the practicalities of how to determine who gave HIV to whom touched on in the article, angry doc wonders how effective the proposed amendment to the law will help arrest the rising incidence of HIV infections in Singapore.

Certainly legislation has an important role to play in public health control, but so do education, access to treatment, and support from the community.

We have seen some success in controlling tuberculosis based on those principles and on the recognition that TB is not just an individual's problem, and that the control of TB will benefit the whole community. Why can't we apply the same thinking to HIV and AIDS?


Tuesday, September 18, 2007

Them again

Why don't those people who are HIV-positive get themselves tested?

Could it be because of the stigma attached to being HIV-positive, or the fact that treatment is expensive and unsubsidised?

Or maybe we just aren't threatening them with enough punishment?

(emphasis mine)

Ignorance of HIV status no defence for high-risk behaviour soon

SINGAPORE: By year's end, all adult male patients admitted to hospitals will be asked if they would like to take a HIV-screening test.

Health Minister Khaw Boon Wan told Parliament on Tuesday he is also changing the Infectious Diseases Act soon so that no one will be able to claim ignorance of one's HIV-positive status as defence against charges of high-risk behaviour.

He said: "All individuals who engage in high-risk sexual behaviour must go for regular HIV-testing. The Infectious Diseases Act makes it an offence for someone who is HIV-positive to have sex without informing his sexual partner of his HIV status. I will soon come to this House to amend the Act to clarify that ignorance of one's HIV status will not be a defence for those who engage in high-risk sexual behaviour."

Currently, 3,338 Singaporeans are HIV-positive, with 278 infected in the first eight months of this year.

But what is worrying, Mr Khaw said, is the prevalence of undiagnosed HIV.

A Health Ministry study conducted early this year found this to be 1 in 350, or a prevalence of 0.28 percent.

In 2005, United Nations AIDS estimated that Singapore's total adult prevalence of diagnosed and undiagnosed HIV patients was at 0.3 percent - higher than the 0.1 percent for Australia, New Zealand, Japan and Korea.

Later this year, Singapore hospitals will start testing adult male inpatients on a voluntary basis.

Some MPs have asked if the screening could be made routine for the entire population, but Mr Khaw said this move may not be cost effective.

Dr Lim Wee Kiak, MP of Sembawang GRC, said: "Perhaps the Ministry could consider adding HIV-testing as part of the testing so the entire male cohort of Singaporeans can be screened regularly when they're doing their re-service or when they go back to NS (national service) at the age of 25, 30 or 35."

Replying, Mr Khaw said: "Population-wide screening or testing will, of course, have a trade-off that we have to make in terms of cost to the screening. And also you don't want to cause unnecessary inconvenience to the vast majority.

"That's why if you study the US CDC (Communicable Disease Centre) recommendation, they are careful in that even in hospital setting, they recommend voluntary but routine screening only if the prevalence is above a certain level.

"And in our case, our adult male prevalence rate has exceeded the threshold, but not for females. That is why we're doing (this) step by step.

"And I think the first step that we'll be doing before the end of this year is to start offering HIV-testing on adult males. With the benefit of those data, we can then plan our strategy, going forward."

Mr Khaw added that so far, no country has made HIV-screening compulsory.


Saturday, September 15, 2007

Life's a Gamble 4

Sometimes truth is stranger than any bogus story angry doc can come up with...

'Medisweep', anyone?
Lucky draw to encourage Medisave contributions from self-employed
Daphne Chuah

It is Singapore Sweep meets Medisave.

To encourage more low-income, self-employed Singaporeans to contribute to their Central Provident Fund (CPF) accounts, the Government is offering a typically Singaporean lure — a lucky draw.

By contributing at least 10 per cent of their Medisave liability, such workers could end up $5,000 richer. The Medisave Contribution Draw also aims to get informal workers to add to their account.

There will be three quarterly draws in June, September and December next year, where workers could win up to $3,000, and a grand draw in March 2009 with a top prize of $5,000.

Chances for each draw will be awarded in proportion to the amount of Medisave liability paid. But participants who pay up the liability in full before the deadline for the first draw, will have the maximum number of chances — 40 — in all four draws.

To be eligible, one has to be an informal worker with a monthly income of no more than $1,500, and living in a property with an annual value not exceeding $10,000.

Last year, informal workers formed 12 per cent of the Singapore workforce, or almost 300,000 people.

Some of those in the low-income group are more interested in a higher take-home pay, said Minister of State for Manpower Gan Kim Yong.

"Sometimes, by mutual agreement with their employers, they'd rather receive cash than contribute to the CPF, and this will undermine their financial security in the long term, when they grow old," he said.

While Germaine Low, 27, an independent job referrer, thought the odds of winning seemed "slim", she said: "I'll consider contributing as I need some assurance that my retirement period will be paid for."

The draw scheme will run for three years, to be followed by a review.


Tuesday, September 11, 2007

Angry, Angrier, Angriest

A post on Dr Wes' blog led angry doc to this story.

Perhaps angry doc should try to sue this doctor?

Death and Other Inconveniences 4

There is an old joke that runs thus:

In a campaign to discourage home births some years back doctors put up a poster in the antenatal clinic that proclaimed: 'the first three minutes of life are the most dangerous'.

Underneath the poster, someone wrote: 'the last three minutes are pretty dodgy to'.

angry doc wonders if that story was what inspired this letter to the ST Forum today:

Ministry should also study merits of enabling S'poreans to give birth at home

I REFER to the article, 'Dying at home: Ministry to look into changing rules' (ST, Sept 8).

I am heartened to know that the Health Ministry is looking into giving Singaporeans a say in how they want to live their last days and where they want to draw their last breath.

As a maturing society, Singapore is now looking into various ways to address the needs and concerns of an ageing population. Ageism is being confronted head-on and its assumptions are being challenged. Legislation is also being changed to allow older workers to be treated more fairly by employers.

In giving older Singaporeans the option of dying at home, I am prompted to ask the question: 'How about birthing at home? Isn't life and death but two sides of the same coin?' If people are allowed to die in the privacy of their homes among their loved ones and in familiar surroundings, we should also consider giving women the legitimate option of birthing at home.

Allowing for home birth does not at all indicate that we are moving backwards or that we are ignoring the advances which medical science has made in the area of gynaecology and obstetrics. Rather, similar to the option of dying at home, it simply means adding another option to birthing which complements current birthing options in hospital settings.

Young healthy women who have been assessed by their gynaecologists to have no likely complications in pregnancy will be able to consider this option if they so desire. However, that is only if the Health Ministry takes the lead and identifies the barriers to such an option, some of which are the reluctance of gynaecologists in certifying a home birth and the absence of trained and registered midwives who are able to work with gynaecologists in ensuring that the woman is able to safely birth her child at home.

Many women will still choose to give birth in a hospital but I am convinced that a growing minority will appreciate the opportunity to give birth at home.

In reviewing the option for people to die at home, I hope that, in the near future, the Health Ministry will also embark on studying the merits of enabling Singaporeans to give birth at home.

Low Poh Lyn (Mdm)

Dying at home and delivering at home are two completely different things except for this: if you screw up, someone dies.

So is home birth safe? Well, that's like asking: is the water safe to drink?

A woman in a developed country with access to comprehensive antenatal care, trained home birth personnel, and easy access to a maternity hospital in the event of any mishap will probably think home birth is safe and be more likely to want to deliver at home, and she would be right.

A woman in a developing country with little or no antenatal care, poor home birth support, and no easy access to a maternity hospital will probably think birth in hospital is a safer choice for her and her baby, and she too would be right.

What about Singapore?

Singapore has the lowest perinatal mortality and early neonatal mortality rates, and one of the lowest maternal mortality rates in the world. That doesn't tell us that home births carry a higher risk to mother and baby in the local context, but it does tell us that the existing situation where most deliveries take place in hospitals is a safe and sound one.

Will home births be as safe as hospital births? The number of home births we have these days are probably too small to tell us one way or the other.

So why are people calling for a return to home birth?

angry doc suspects that the answer is that the modern hospital system is 'a victim of its own success'. We have so removed the dangers and difficulties of a home birth and 'home death' from laymen, and made them so much 'easier', that they have the luxury to romanticise these life events.

Certainly the choice to give birth and/or die at home is always available, but let us not promote that choice without presenting all the facts.


Saturday, September 08, 2007

Death and Other Inconveniences 3

A more in-depth article on the news story yesterday that provides a more realistic view on dying at home. angry doc highlights the bits not covered in yesterday's news:

Dying at home - why not?
Health Minister Khaw wants to make it easier for the terminally-ill
Tan Hui Leng

MODERN healthcare may save countless lives — but it has taken away something precious from the process of dying as well.

Although death is a taboo subject, Health Minister Khaw Boon Wan noted: "There was a time when death was an integral part of family life. People died at home, surrounded by their loved ones. Family members experienced death together, mourned together and comforted one another.

"In a way, modern healthcare has made dying a lonelier process as more people die in hospitals. Their loved ones have less opportunity to be with them and often miss their last moments of life."

Which is why Mr Khaw would like to make matters easier for terminally-ill people who would prefer to die at home.

"If need be, we shall change the rules and processes that currently hinder dying at home," he declared.

"After a full and meaningful life, I would certainly wish to die at home, among my loved ones, in familiar and peaceful surroundings."

Speaking on Friday at the opening of the Children Hospice International's Congress, the Health Minister threw the spotlight on palliative care.

He believes that, like him, Singaporeans would prefer to die at home. But only 28 per cent got their wishes — 55 per cent breathed their last in acute hospitals.

"While dying in hospitals is natural for fatalities due to accidents, heart attacks and other unforeseen events, the terminally ill have time to prepare for their final moments," he said. As such, families and healthcare workers "should strive to meet their final wishes".

The Ministry of Health (MOH) will study the matter in greater detail, said Mr Khaw. One problem could be getting hold of a doctor to certify the death, when it comes, at home.

As Dr Noreen Chan, chief executive and medical director of Dover Park Hospice, pointed out, family members may not know which doctor to call after clinic hours.

And not all doctors would have applied for the necessary Certificate of Cause of Death book from the Immigration and Checkpoints Authority, she said.

Another obstacle could be costs — patients in acute hospitals get subsidies, but homecare and hospice patients are means-tested. And insurance does not usually cover step-down care services such as homecare. So, patients are more inclined to stay — and die — in acute hospitals.

"Distortions" such as these need to be studied and the MOH will hold focus group discussions, Mr Khaw said.

There are other problems. While a patient may prefer to die at home, this is not always easy for the family, said Dr Chan. "Family members may be unable to provide the care, either physically or psychologically, as it may just too much for them ... It can be very stressful on the family, for example, if the patient is in pain or become delirious."

At the Dover Park Hospice, staff counsel and help family members — from teaching them how to care for their loved ones in their last days, to broaching the subject of funeral preparations.

Mr Khaw thinks more public education on hospice and end-of-life care is needed.

As for the bigger picture, the MOH will support and grow palliative medicine as an attractive and effective medical sub-speciality.

It will extend palliative care and benefits beyond oncology — the study of cancer — to other terminal-stage chronic conditions, such as chronic obstructive lung disease and heart failure. Manpower to support the growing demand will also be ramped up.

"We need to train many more nurses, counsellors, medical social workers and therapists," said Mr Khaw. "We need to support them with long-term career paths and meaningful salary schemes to attract and retain them."

Medical director of Hospice Care Association, Dr R Akhileswaran, said this would be a boost to the sector. "In palliative care, we always have problems finding doctors to work in the speciality," he told Today.

"With it being a sub-speciality, there will be a clearer career path and maybe more doctors will look at it as a long-term option."

This will, in the long run, benefit the patients — Dr Akhileswaran estimates that more than 90 per cent of his patients would prefer to die at home.

"It's a basic human tendency that a person in his last days would prefer to spend them with his own family, rather than in a strange place," he said.

It's not easy, it's not cheap, and it's not going to be pretty.


Friday, September 07, 2007

Death and Other Inconveniences 2

angry doc is not obsessed with death.

Intrigued, perhaps.

Amused, certainly.

But not obsessed.

The minister, however, seems to be.

MOH may change rules hindering patients' preference to die at home

SINGAPORE: Surveys in Japan and London have found that most people prefer to die at home.

But in Singapore, statistics show that 55 per cent died in hospitals and about 28 per cent died at home.

Health Minister Khaw Boon Wan said that anecdotally, up to 90 per cent of patients in Singapore prefer to die at home.

In view of this, he may change current rules and processes that hinder them from doing so.

Mr Khaw was speaking at the official opening of the 18th Children Hospice International Congress in Singapore.

Citing his recent trip to a so-called village of long life in Japan, known for its many centenarians, Mr Khaw recounted how many Japanese lamented that despite their strong preference to die at home, few got their final wish granted.

He said: "At the Ogimi village, I did not find villagers squeamish when talking about it (death). They laughed and joked about it. They realised that treating death as taboo does a disservice to both the dying and the living, adding to loneliness, anxiety and stress for all.

"After a full and meaningful life, I certainly wish to die at home, among my loved ones, in familiar and peaceful surroundings."

No survey has been done in Singapore yet on the preferences of where patients want to die. But Mr Khaw said that he did not expect Singaporeans' preference to be much different from the Japanese and Londoners who prefer to die at home, according to surveys.

"Judging from other countries' experience, for the terminally ill, those who have time to think of their last moments, I think most point to this preference, which is understandable. You want to die where your loved ones are around you and in familiar surroundings. The reality of modern healthcare is that that wish is seldom achieved," he said.

So, Mr Khaw wants to survey Singaporeans on their preferences so that his Ministry can accommodate the last wishes of the terminally-ill.

In fact, Singapore is thinking of setting up a register where people could record their preferences of where they want to die, as recommended in a London report.

To make hospice and home palliative care an important part of Singapore's healthcare delivery system, Mr Khaw said his Ministry will support and grow palliative medicine into an attractive and effective medical sub-specialty.

It will extend palliative care and its benefits beyond oncology to other terminal-stage chronic conditions such as heart failure and chronic obstructive lung disease.

The Ministry will also ramp up the manpower needed to support the growing demand. More nurses, counsellors, medical social workers and therapists will be trained.

Singapore will also do more to educate the public on hospice and end-of-life care. - CNA/ir

It sounds idyllic, doesn't it?

Lying on a bed with white sheets, surrounded by your loved ones, sunlight streaming in through the open window...

You address each of them in turn, telling them how much you love them and thanking them for all they have done to make your life a full and meaningful one.

And when you are done, you look out of the window towards the sky. Then with a smile on your lips, you breathe your last breath.

Except it's just as likely that the first anyone even know you were dead was when your tired and burnt-out family came to serve you your morning pain medication, only to find you stiff in a pool of your own urine and faeces.

Yes, people probably prefer dying in their own home to dying in a hospital.

But how many people have the skills and energy required to nurse a dying relative at home?

How many people *prefer* to look after their own dying relative at home to leaving it to healthcare professionals in a hospital or hospice?

People die in hospitals for the same reason they stay in hospitals: they require skilled, round-the-clock care.

To train and support laymen to care for their dying relatives at home will require much resources. It may be a worthwhile cause, but let's not imagine that it will be a simple matter of "chang[ing] current rules and processes that hinder them from doing so".


Monday, September 03, 2007

The Ritual

The doctor looked at the patient with an impassive face as she described her symptoms. He is familiar with the ritual.

Crippled by an unexpected, unpreventable, and largely untreatable illness in the prime of her life, the patient had been denied many of the things in life that her peers have and continue to enjoy.

Still maintaining eye-contact, the doctor thumbed the pages of the casenotes absentmindedly as the patient continued; her myriad of vague complaints may be symptoms pointing to the diagnosis of an obscure systemic disease, except they are not - she had been 'worked up' extensively by the previous doctors, as the thickness of her file attested to, and nothing has turned up.

She was probably depressed, the doctor thought.

Certainly he too would be depressed if the same fate had befallen him. Yet despite the difficulties she faced she had managed to find and hold a job that has kept her busy and provided for. She has also kept her quarterly appointments to the clinic faithfully.

Finally, she paused.

"Am I dying, doctor?" she asked.

"We all are," the doctor replied.

The patient gazed at the floor for a good five seconds, then turning to the doctor again, said,"I know what you mean, doctor."

She leaned back in her wheelchair, the cue for her maid to wheel her out of the consultation room.

The doctor allowed himself to smile as he bade the patient goodbye.

The ritual is completed.