Angry Doctor

Wednesday, April 23, 2008

Them 8

The proposed amendments to the Infectious Diseases Act were passed in parliament yesterday.

(emphasis mine)

Amended 'HIV' Act passed
New onus on personal responsibility, power of containment for ministry
Tan Hui Leng

HIV took the top spot in the minds of MPs yesterday when Health Minister Khaw Boon Wan read the amended Infectious Diseases Bill for the second time.

Will an HIV-positive man be charged if he showed up at a hospital's emergency department or if he infected healthcare workers? What about someone with multiple sex partners who practises safe sex? Will he be liable under the amended Act?

The Act was passed as the Minister revealed a new record: There were 422 newly-detected HIV cases last year, up from the 357 in 2006.

The Act now makes it an offence for any HIV-positive person to have sex — regardless of whether he knows of his status — as long as he has reason to believe he has been exposed to the risk of contracting the virus. He is not liable if he has informed his partner, who voluntarily agreed to the risk, or if he practises safe sex or tested negative before the act.

On the amendments to the Act, which stirred strong feelings when announced last year, Mr Khaw said the aim was not to persecute. "It is not our intention to go after every HIV-infected person," he told Parliament. "We will only act if there is a complaint from an aggrieved victim and only after a thorough investigation."

If an HIV-infected patient threatens healthcare staff, he may be charged with criminal intimidation under the Penal Code.

Questions posed by MPs included which types of people would have "reason to believe" they are practising high-risk behaviour.

Mr Khaw's answer: A man who has unprotected sex with prostitutes or other men; one who has unprotected sex with multiple partners; or one who shares injection needles with other drug addicts.

However, a "promiscuous" person who practises safe sex by using condoms every time he has sex is not considered a high risk.

On the latent nature in humans of the HIV virus — which causes Aids — that may affect test results, Mr Khaw said the standard practice is to have a second test after the three-month window. So as to be not liable for an offence, a person must have a negative result outside the window period.

The Health Ministry is setting aside $10 million more in the next two years for non-governmental organisations and healthcare institutions to be used for the care and support of people living with HIV.

The amended Act also expands the power of the Health Ministry to enforce social distancing measures soon after the first cases appear. It allows the selected or even blanket prohibition of gatherings or public entertainment or closure of premises islandwide.

angry doc notes that once again the minister thinks it necessary to make a distinction between "[a] man who has unprotected sex with prostitutes or other men" and "one who has unprotected sex with multiple partners". angry doc still fails to see the difference.

The new law does place the responsibility for testing and disclosure firmly onto the individual, which for a sexually-transmitted infection which may be largely asymptomatic in the early stage does not seem unfair to angry doc.

However, while this may serve to "[send] a strong message that no one has a right to put others at risk through his irresponsible behaviour", the minster already acknowledges that in practice, prosecuting a case will be difficult. Given that difficulty, will the amendments really make a difference in the way people behave, or reduce new cases of HIV/AIDS? angry doc awaits the ministry's next update on the HIV statistics in Singapore.


Thursday, April 17, 2008

Simple Solutions, Hard Decisions

angry doc managed to watch an interesting documentary titled "Five Ways to Save the World" yesterday. The documentary showed some of the hi-tech solutions some scientists have proposed to fight global warming, including a plan to "put a giant glass sunshade in space" that will "deflect a small percentage of the sun's rays back into space", and "artificial trees" that will remove carbon dioxide from the air which can then be buried deep underneath the ocean floor.

The show ended on the note that while all these hi-tech solutions are potentially viable, we already have a solution that is readily available: to reduce our use of fossil fuels.

Which brings angry doc to this news story:

More worrying than Al Qaeda
Pandemic could spark doomsday scenario: Expert
Sheralyn Tay

FORGET bombs and bullets — widespread death and panic is more likely to come from non-traditional sources.

Already, small-scale examples surround us — just look at the ongoing hand, foot and mouth disease outbreak, dengue and the rising cost of rice.

Speaking at the second Asia Pacific Programme for Senior National Security Officers yesterday, award-winning journalist Laurie Garrett (picture) said that a bird flu pandemic could trigger such a Hollywood doomsday scenario.

"Personally, I am a lot more worried about pandemic flu than Al Qaeda," said the senior fellow for global health at the Council on Foreign Relations in New York.

Ms Garrett, the only writer to have won the three Big "Ps" of journalism — the Pulitzer, Peabody and Polk Prize — said a pandemic of the deadly H5N1 strain of the bird flu virus would cause disaster on a scale far bigger than the world has ever known, surpassing even the greatest flu pandemic of 1918, which claimed an estimated 100 million lives worldwide.

Then, the virus' fatality rate was 2 per cent — H5N1 has killed 77 per cent of the people infected with it.

The H5N1 is believed to be similar to the 1918 flu virus, but is considered by experts to be the worst to have ever surfaced, said Ms Garrett, who described it as being able to cause a fatal "thermonuclear" reaction in the body.

In chickens, for example, the virus causes massive internal bleeding, turning the combs on their heads black.

The world is only beginning to understand the problem, she said. For one, countries are still responding only at the local level, said the author of The Coming Plague and Betrayal of Trust.

"We have yet to react on a global scale and global infrastructure is not even there yet," she said. "For example, we don't have the capacity to mass vaccinate the whole population. Just look how hard it is for us to do measles and polio, the routine child vaccinations."

There aren't enough sterile syringes to go around, she added.

Petrol, manpower and other logistical infrastructure are also inadequate to execute mass vaccine campaigns, while containment and quarantine facilities are sorely lacking.

The worldwide shortage of healthcare workers and the lack of understanding about how the disease is transmitted and prevented will only exacerbate these problems.

The solutions to these gaps are multi-level, said Ms Garrett. But some valuable lessons from the Severe Acute Respiratory Syndrome (Sars) outbreak underscore the importance of infection control and preparedness.

"What's already in place on a day-to-day basis for routine threats is important, but will not be able to deal with the flu pandemic," she said.

If countries are unable to respond to small outbreaks, such as a rise in flu cases or dengue fever, the effect of a flu pandemic would be "devastating".

"Much more" is also needed to guide the public health responses, she added. For instance, do masks really work, and is hand-washing the best way to stop transmission?

Ultimately, "low-tech" solutions — basic hygiene, personal responsibility, social resilience and community solidarity — remain critical in the face of disaster, she said.

angry doc is not sure how big a threat bird flu will eventually turn out to be, but as the article mentioned, he can already see the cracks in our walls from the Hand-Foot-Mouth disease (HFMD) outbreak.

Despite having our standing surveillance and notification system (yes, the government knows when you are sick) and our ability to put out information to the public via the mass media, we seem to have difficulty breaking the chain of transmission of HFMD.

During the last serious outbreak in 2000, the government had to close down all "childcare centres, kindergartens, enrichment centres, play groups, wading pools and play areas" for a duration of 16 days. While it is not proven that this action directly contributed to controlling the outbreak, it did end soon afterwards.

angry doc thinks it reflects poorly on us as a society that it takes a government action to enforce something which seems like common sense - keep your children at home during an epidemic.

angry doc remembers patients whose parents were more worried about them missing their lessons or exams in school, or arrangements for childcare while they are at work than the public health implications of HFMD, and who would pressurise doctors to give their children the 'all clear' note to return to school, while they still had their ulcers and rashes. angry doc understands their anxiety and concerns, and realises that they stem from an unforgiving system where things are expected to function at peak capacity, leaving little room for occasional illnesses which are actually life's normal occurrences. Still, at the end of the day it is a decision that must be based on one's sense of proportion and social responsibilities, and so angry doc must salute parents who make that decision to voluntarily keep their children away from school during such epidemics.

On the same note, angry doc wonders if the solution to the feared bird flu pandemic may lie in a simpler if more painful decision to end large-scale poultry farming*, instead of a more hi-tech but less certain one like mass vaccination with a yet-unproven vaccine against the disease, as is being undertaken now. Of course, there is no reason why we can't pursue both approaches at the same time - who know? the Japanese may be the ones laughing when the pandemic does strike. If an effective vaccine is found, it will only be part of the solution - making enough of the vaccine and getting it to all those who will need them is another problem to be tackled. And if an effective vaccine cannot be found before the pandemic, then we will perhaps be remembered as the generation who lost so many of their own because of their unwillingness to renounce a steady supply of fried chicken.

* - According to the WHO site "[t]o date, most human cases [of bird flu] have occurred in rural or periurban areas where many households keep small poultry flocks" and not in large-scale poultry farms as angry doc thought. angry doc apologises for the error.


Wednesday, April 16, 2008

So. Much. Anger.

Another one joins the blogosphere...

Monday, April 07, 2008

Confidence Goods 13

We've discussed this issue in the comments section of a previous post, but it's worth another mention:

(emphasis mine)

MOH draws lines on aesthetic practices
Doctors have to follow rules, customers of salons have recourse for bad treatments
Alicia Wong

IS it a turf war between plastic surgeons and other doctors, or is it about patient safety?

Even as the Ministry of Health (MOH) has said that there will be guidelines on the practice of aesthetic medicine following its ruling on 11 treatments, it has now drawn another line in the sand.

This time, it is between doctors and beauty salon operators. The ministry has told Today that it does not regulate practices at these establishments as most of the products they use are generally not intended for medical purposes. Hence, they do not come under the Health Products Act 2007. But those that do, such as medical and laser devices, are already governed by regulations to prevent misuse.

The MOH's priority is on regulating aesthetic practices in the medical profession. "The Academy of Medicine and the College of Family Physicians are jointly working on formulating guidelines ... When these are ready, doctors are expected to abide by the guidelines," said an MOH spokesman.

But although beauty salons are not subjected to any guidelines, consumers do have recourse if treatments go awry.

If you suffer "physical harm", you may be able to file a civil suit against it or its beauticians for negligence to recover damages for personal injury, said the spokesman. You may even be able to take civil action against the beauty salon under the Consumer Protection (Fair Trading) Act if it has carried out unfair practices such as making a false claim. You can also file a complaint with the Consumers Association of Singapore.

And if you feel the salon has performed a rash or negligent act that might have endangered your life and the personal safety of others, you can report it to the police. Under the penal code, the beauty salon operator may be fined, imprisoned or both.

The MOH may also put a stop to the business if any practice it is carrying out is found likely to be causing the spread of any infectious disease.

Meanwhile, some players in the beauty industry told Today that the recent publicity has led to an increase in business.

Among them is Spa Haven, which provides needle-free mesotherapy and endermologie. Mesotherapy is a technique used to inject substances, including medication and hormones, into the skin for a variety of purposes. Endermologie involves the use of a motorised massager to rid the body of cellulite and toxins. The MOH says these two treatments are "medically unsubstantiated".

In fact, the centre will raise its prices by more than 20 per cent now that some doctors may not want to perform these treatments, said Mr Chris Soh, 30, who is in charge of business development at Spa Haven. Currently, the centre charges about $250 for a mesotherapy session and $150 for an endermologie session.

Consumers told Today they would continue with their beauty treatments. Mr Clarence Chong said he would continue using the controversial micro-needling dermaroller because he finds it "safe". Others, such as banker Elaine Tan, 37, said she is not put off, but she will choose established names over smaller establishments.

This article shows the curious state of affairs where we recognise that certain treatment being sold by beauty salons are "medically unsubstantiated", yet do not move to prosecute the purveyors for "making a false claim" - in other words, they are allowed to make unsubstantiated false claims unless the buyer feels cheated and move to file a civil suit against them.

But of course there are purveyors who circumvent this bit of legislation by not making outright claims which can be proven to be false by using weasel words such as "toxins", "energy", "vitality", "beauty" - things which are not objectively defined and therefore unmeasureable - or by adding a disclaimer in small print at the corner of their advertisement.

angry doc doesn't think that such practices will change despite the recent media attention, but he hopes that more people will learn to ask questions about the services they buy, be it from doctors or beauticians.


Sunday, April 06, 2008

Science and how we know we are wrong 2

Fellow Clearthought blogger Leng Hiong recounts the story of "luminiferous aether" in his post today.

angry doc has always thought the Victorian concept of the aether as something akin to the Chinese concept of 'qi' - an invisible entity whose existence will explain a lot of what we see.

Eventually though scientists were able to put the theory of aether to the test, and when the observations failed to confirm their theory, they were able to abandon that theory and move on to consider other theories and eventually find better ways of describing the universe we live in. Perhaps there is a lesson there for proponents of TCM.


Whose "Medicine" is it anyway?

A letter from Dr Tan Cheng Bock was published in Today yesterday:

(emphasis mine)

More stringency needed in managing aesthetics
Dr Tan Cheng Bock

THE recent debate on aesthetics and medicine has prompted me to write this article.

I write out of concern for the future of medical practice, and how changing medical practices can affect our National Health Programmes and the management of infectious diseases in future.

I do not perform aesthetic procedures, I only practise medicine.

Aesthetics is a lifestyle industry, it is not medical practice. It does not heal but only enhances appearances. The practitioner of aesthetics is not treating sick patients but healthy individuals who want to change and improve their looks. Hence, we have procedures, for example, to remove fat and pimples and whiten the skin.

An aesthetics practitioner need not be a doctor or go through medical school. He relies on machines and creams to do the job.

However, there is a big demand for aesthetics because of the growing wealth and expectations to look slim and flawless. This big lifestyle industry, which has developed and spread rapidly in the region, is worth about $200 million.

Aesthetic practitioners used to be beauticians who conducted minor procedures. But with newer and more advanced equipment, the more complicated and difficult procedures were beyond them. Doctors were then roped in to assist in the complications.

However, doctors — both general practitioners (GPs) and specialists — were soon caught up in this wave and started providing such services to meet the demands. In doing so, they shifted their emphasis from healing the sick to undertaking this more lucrative practice where returns were very good.

GPs face hard times with their high rentals and overheads and so some opt for aesthetics practice to supplement their medical practice.

This is a worrying trend. If six out of 10 doctors, according to a Straits Times report, choose aesthetics rather than their usual medical practice, it begs the question: Why train such doctors who end up doing so little medical practice?

This will have an impact on the national healthcare programmes, such as the current chronic disease management of diabetes and high blood pressure.

Which doctor would want to be involved in such healthcare programmes which give him $300 per Medisave account per year, compared to an aesthetics procedure that pays between $150 and $500 per visit?

Moreover, since the Chronic Disease Management Programme requires doctors to follow a strict protocol of management before payment, my concern is that, in time, many GPs will opt out of the programme. The polyclinics will then be even more overloaded if GPs' participation rate is low.

Of greater concern is in the event of an acute infectious disease — such as bird flu or Sars — how are we going to get support from GPs involved in aesthetics care? They are likely to close their clinics to avoid the risks as they are not prepared to manage such a situation.

GPs giving up their medical practice is another likely scenario if the Government comes down too hard on these doctors, especially if they find that offering aesthetics procedures provides them with more than enough income to maintain their lifestyle without struggling with the daily medical practice which pays relatively very little.

I can see why some GPs give up their medical practice. But a doctor is trained to treat patients. What happened to the Hippocratic Oath they took?

All students enter medical school with a noble calling to serve their patients. But as the realities of life hit home when they start practising and have to cope with financial needs to meet the rising cost of living, many doctors will find their calling slowly eroded.

Life was much simpler for my generation of doctors who practise medicine. People were content to lead a lifestyle without a need to change the shape of their nose, have double eyelids or an implant to augment their physical assets.

But with affluence, patients no longer see doctors just as healers but also as practitioners who can improve their physical assets.

Doctors' attitudes also start to change; they now advertise their services, which was not allowed when I became a doctor. Worse, the Government started calling medicine an industry.

I remember protesting against this term "medical industry" because if medicine is an industry, then like any industry, a doctor is just a worker and has to conform to industry norm, working the stipulated hours.

That impinges on the Hippocratic Oath doctors take. The Oath becomes less binding because the "medical industry" shifts the emphasis from practising medicine to being just a worker in an industry. Moreover, the bottom line in an industry is making money while medicine's bottom line is caring for patients.

The Government calls medicine an industry because it wants to promote Singapore as a medical hub. But this drive is so over-emphasised that the cost of medical care has increased as every medical institution, private and public, has to meet the bottom line — an industrial norm especially for those listed on the Singapore Stock Exchange.

How do we manage the situation? We have two pressing issues to be on the lookout for.

One is the management of chronic diseases such as diabetes and hypertension. It is very important to involve the medical community, both private and public, because the debilitating end stage side-effects like stroke, blindness, kidney failure and amputations will deplete the patients' savings as institutional care in hospitals will be very expensive.

Two, if we are not sufficiently prepared, epidemics such as Sars will have serious consequences for the country.

In managing the current trend of aesthetics care, we need to consider:

1) The role of doctors in the aesthetics industry. Identify the procedures that GPs and specialists can or cannot do. Under the Medical Clinics & Hospital Act, which regulates what constitutes a medical clinic, can doctors conduct aesthetics in their clinics? Are doctors who do so complying with the regulations?

2) The role of operators of beauty spas and salons. What are the limits to their work procedures?

3) The role of doctors in our National Health Programmes as the emphasis of medical practice shifts. How can the Ministry of Health encourage GPs to stay on these programmes in the light of the aesthetics factor? One possible consideration is to let the patient carry his subsidy from the public to the private sector for the chronic disease programme.

The writer is a GP and former Member of Parliament.

Dr Tan's letter reminds angry doc of another letter by another 'old-timer' published in the ST Forum a week ago:

(emphasis mine)

Over-medicalised, under-analysed industry

THE public is being bombarded daily with so-called health news and tips which have no scientific basis. This includes the use of pseudo-scientific terms which cannot be found in medical dictionaries, promotion of numerous products which have never been subjected to any laboratory toxic tests, or products whereby test results have not been published in any peer-reviewed journal. And yet, we are told these products are completely safe.

Many human conditions are being 'medicalised' so that companies can sell their products or make customers part with their money. These include everyday conditions like ageing, baldness, small breasts, small penis, shyness and acne.

Celebrity endorsements and participants who are paid various sums of money or given free products are commonplace. One example is the issue of weight. Obesity is a serious medical problem and studies in the United States show that obesity will be the No. 1 public health problem and cause of death in five years' time. It is not a cosmetic problem and weight management should be for life and not just for two to four weeks or just to fit into a Versace dress.

Whether someone will take the right actions to stay healthy depends on his health literacy and whether he listens to the right advice and not by reading fancy advertisements. As a prominent health correspondent in a British newspaper, The Independent, said: 'Advice from untrained people is the most dangerous drug on offer today. My advice for you is to take less advice.'

Prof Feng Pao Hsii
Emeritus Consultant
Department of Rheumatology
Tan Tock Seng Hospital Singapore

Adjunct Professor of Medicine
Yong Loo Lin School of Medicine
National University of Singapore

What strikes angry doc is the fact that both writers do not consider acne a real disease nor treatment for acne real medicine.

Acne is so common in adolescents that some people considered it a normal physiological state rather than a pathological one, and aside from the unsightly appearance it doesn't really do those who are afflicted by it any physical harm. In other words, it is an 'aesthetic' condition.

So should we treat acne?

It seems that question was one that the medical profession had to ask itself at one point in time.

angry doc was brought up thinking that acne is a disease - one that we have effective, evidence-based treatment for - and one which he treats because of all the psychological sequelae (as described in the editorial linked to above) that may result from acne and its resultant scarring.

(So does angry doc practise "aesthetic medicine"?)

Admittedly the psychological trauma result not from the acne itself, but the social difficulties faced by the sufferers; yet as society's expectations change, will not those who have "baldness, small breasts, small penis" and other socially-embarrassing conditions encounter the same kind of distress, and suffer from the same psychological trauma? Will these conditions not become diseases, and accordingly require treatment?

angry doc is not sure, but he that believes as long as people suffer, or perceive themselves to be suffering, they will turn to doctors for relief.

Perhaps whether a particular condition should be considered a disease or not should be judged depending on its own set of circumstances, but angry doc feels our guiding principle for whatever treatment we offer to those who come to us, be it "aesthetic procedures" or for silent diseases which patients do not complain of, should be based on good evidence.


More teeth in fight against pseudoscience

angry doc welcomes Vexillum II to the blog.

Friday, April 04, 2008

Rational Rationing? 2

angry doc is not too sure how to react to this latest piece of big news:

(emphasis mine)

New map for patient care
Healthcare to be organised along regional lines: Khaw
Tan Hui Leng

INTERMINABLY long waits to see a specialist. Unnecessary high-level care, leading to bigger medical bills for patients. These problems have dogged Singapore's healthcare system and hogged public debate in recent years.

But while palliative measures have been taken, the symptoms point to a more fundamental flaw in the system: The two-cluster structure, which now sees all hospitals and polyclinics come under either the National Healthcare Group or SingHealth.

Soon, that landscape will be completely redrawn.

Wielding the pen, Health Minister Khaw Boon Wan wants to have the island's north, east, west and central zones served by regional hospitals.

These hospitals would only refer patients to the national centres at the Outram or Kent Ridge campuses — where the Singapore General Hospital (SGH) and the National University Hospital (NUH) are located — if they have complications that require a higher level of care.

Meanwhile, the upcoming Khoo Teck Puat hospital (KTPH) in the north, Changi General Hospital in the East, the hospital planned for Jurong in the West and Tan Tock Seng Hospital (TTSH) in Central Singapore will manage patients' secondary care together with polyclinics, general practitioners and nursing homes in the same locale.

This "pyramidal structure", Mr Khaw explained, would facilitate seamless and integrated primary and secondary care — something the two-cluster system has not been able to achieve.

"If we do it well, the bulk of a patient's needs can be handled at that level – easily 80, 90 per cent of healthcare problems can be resolved at that level," said Mr Khaw, speaking to reporters at the commencement ceremony for the superstructure of KTPH. "That is the most competent level, at the lowest cost, and most accessible to homes."

To illustrate: A simple hernia operation is best done at a secondary care hospital, at a lower cost and with very much the same outcome as in a tertiary hospital, said SingHealth's group chief executive Tan Ser Kiat.

With such secondary-care hospitals playing "a gate-keeping role ", "this will bring about more optimal use of resource and lead to even better, more cost-effective and timely care," Professor Tan added.

With the possible exception of TTSH, each regional hospital would be run by its own board so that "effectively there will be several clusters".

Already, KTPH has an autonomous board. In February, a new board was also formed for the National University Health System – comprising NUH and the National University of Singapore's medical and dental schools. Changi is next in line for its own board.

Meanwhile, in this redrawn landscape, SingHealth will focus on running SGH and the Outram medical research campus, as well as KK Women's and Children's Hospital. The NHG will continue to run TTSH, the Institute of Mental Health and some polyclinics.

But with the Outram and Kent Ridge campuses shedding the load of secondary care patients to the regional hospitals, this means they need to nurture ambitions beyond Singapore.

"The reason is not because they want the money but because they need the patient load in order to practise," Mr Khaw said.

The impending changes were hailed by Lee Kuan Yew School of Public Policy's Phua Kai Hong as the way to go.
"It would encourage right-siting of patients as the Specialist Outpatient Clinics (SOCs) at hospitals now are overcrowded, and many of these patients can be decanted to GPs," said the associate professor of Health Policy & Management.

The current system does not encourage hospital doctors to refer such patients downward.

Conversely, in the new system, integrated care at the primary and secondary levels by geographical cluster means, polyclinics and GPs would have no vested interest in referring patients upwards. This translates into cheaper and more convenient medical care for patients.

Mr Khaw said he was in no rush to push the changes through, especially since setting up a board with suitable members takes time. "If we implement tomorrow, that will cause a lot of heartaches and trauma to everybody."

And while he feels the new system is theoretically sound, its implementation rests upon whether people executive it with a common vision to offer healthcare "of a high standard and yet affordable and easily accessible".

The article is short on details and big on unsubstantiated statements, specifically when the reporter blamed the flaws in the healthcare system on the two-cluster system without explaining how this created the problem, and then stated that the new system will be the solution.

While angry doc welcomes this new emphasis on right-siting, which is a form of rationing by need rather than by means, he is not, given the scant details of the proposed system presented in the article, optimistic that it will solve our problems.

Our current system already have a multi-tier system, or rather a two-tier system where primary care is provided by GPs and polyclinics, and secondary and tertiary care is provided by the hospitals. The proposed system seems to aim to further differentiate the hospitals into secondary-care and tertiary-care facilities - in effect moving from a 2-stepped pyramid to a 3-stepped one.

Will it work?

Well, first of all we must ensure that there is adequate staffing and resources on each tier of the pyramid. This issue is not addressed in the article, but hopefully the ministry has already looked into it.

The other point, and angry doc thinks that this is where the system may fail, is whether we have the political will to enforce the "gate-keeping" function of the primary and secondary-care facilities. Our GPs and polyclinics have traditionally been tasked with this "gate-keeping" role, yet it does not seem to prevent a situation of overcrowding at the hospitals; if we fail to right-site patients who belong on the first tier of the pyramid onto the first tier instead of the second, what is there to say that we will be able to keep these patients off the second or even the third tier under the new system?

(Incidentally, isn't the concept of "gate-keeping" contrary to the minister's pursuit of a "perfect market"?)

angry doc believes that the failure to right-site stems from a lack of incentives to right-site patients, and the fear of disincentives from wrongly-siting a patient onto a lower tier than he will eventually prove to need. At the end of the day, the healthcare professionals making the decision on the ground must feel rewarded and protected in making the right decisions. Unless these specific issues are addressed and tackled, they will likely continue in the new system. From the last paragraph of the article, angry doc suspects that the minister is himself aware of this problem.

Finally, angry doc hopes that access to the third tier of care will not be rationed by means, since it is reported that cost will be one of the differences between the tiers.


Thursday, April 03, 2008

Based on a true story...

The recent discussion on unproven forms of therapy reminded angry doc of this little clinical episode that occurred a while ago ...

Patient: So doc, how's my condition?

angry doc: Actually, your control is worse compared to the last visit. Are you still taking your medicines?

Patient: To be honest, doc, I stopped taking the medicine you gave me and I'm now taking some traditional medicine.

angry doc: I appreciate you being honest with me, but it doesn't seem like this traditional medicine is effective in controlling your condition. Where did you get this medicine from?

Patient: Well, it's from a guy my friend recommended me...

angry doc: Does he operate out of a clinic, or his home?

Patient: He sold them to me during a talk at a hotel function room; says it's a secret formula passed down for generations in his family, and that it's 100% effective for this condition. He said he wasn't selling it for the money, but because he wanted to help patients.

angry doc: I see... and how much did this medicine cost?

Patient: A month's medicine cost $100. You think I've been conned, don't you, doctor?

angry doc: Well, let's just say that if I was out to help as many patients as I could I wouldn't be keeping the formula a family secret.

Patient: So you think he's just doing this for the money?

angry doc: Well, if I had a medicine that is 100% effective for this condition, I certainly wouldn't be selling them out of a hotel function room at $100 a bottle - I'll just sell the formula to some big drug company for $10-million and call it a day.

Patient: I see your point, doc. I guess I'm just too gullible. So what shall we do about my condition?

angry doc: Well, first you can put all your money and jewellery into this plastic bag with these apples here, and don't open the bag until you get home.

Patient: Huh? How's that supposed to help with my blood pressure?

angry doc: Blood pressure? Sorry, I thought you were talking about your gullibility.


Tuesday, April 01, 2008

An April Fools' Day advice

"I think you should be open-minded to any scientific test. There are still lots of things to prove and disprove. If something sounds too good to be true, it probably is."

(Yes, it's been ten years!)

Labels: ,

Science and how we know we are right 2

Mr Wang comments on the issue of aesthetic 'medicine' in his post today, and once again angry doc finds himself disagreeing with his take on science.

Specifically, angry doc takes issue with the following passages:

"I am quite confident that most, if not all, the aesthetic treatments offered by your neighbourhood HDB beautician are also "scientifically unsubstantiated". This does not mean that all these aesthetic treatments do not work.

It merely means that the treatment either does not work, or the treatment works, but has not been "scientifically" proven to work. And most of the time, the latter simply means that scientists have not bothered to do research on that particular treatment."

It is quite common to see supporters of unproven therapy argue for their pet therapy this way, but in reality those passages actually contain a few separate flawed arguments.

First of all, by saying that an unproven therapy may actually work but "scientists have not bothered to do research on that particular treatment", one is trying to shift the burden of proof from those who propose and support such treatment. The logical way is of course to require those who propose and support the claims of such treatment to offer evidence for its efficacy, and not the other way round - otherwise anyone can make unfounded claims and there will not be enough scientists to go around debunking these claims. The legal equivalent would be to put the onus on the defence to prove the innocence of the accused, instead of requiring the prosecution to prove its case of guilt.

Also, for some forms of unproven therapy there is not only an absence of evidence of efficacy, but there is in fact evidence of a lack of efficacy. angry doc is unable to find any study on the efficacy of facials (OK, he didn't bother to look), but a quick search on "mesotherapy" on PubMed revealed more articles on the complications of that mode of therapy than articles on efficacy, and the latter do not support the claims of efficacy in body contouring.

Of course, it is true that scientists "have not bothered to do research" on certain modes on unproven therapy. The burden of proof aside, this is also due to consideration on the prior probability of a claim, or the lack of any plausible physiological or known physical mechanism by which these therapy claim to work. If angry doc claimed that he could shoot invisible bolts of energy from his hands to calm your pet cat, he would not be surprised that scientists will not bother to research his claims; that doesn't mean his claim is true, it just means that scientists may have more important things to do, like finding a cure for AIDS or cancers.