Medicine and Morality

It's been a long week and angry doc lacks the energy to write separate entries for two very interesting articles in the newspaper today, so he decided to lump them together.

The first article is a news article on illegal organ trade in Singapore.

Despite the known benefits of transplant to recipients and the very low risk to donors, the ministry's position on organ donation between unrelated persons is that "organ trading often involves the exploitation of the poor and socially disadvantaged donors who are unable to make an informed choice and suffer potential medical risks".

The second article is an interview with Professor Roy Chan, president of Action for Aids, who had this to say about the fight against HIV/AIDS in Singapore:

"We have to see Aids as a disease. Clouding the issue with the morality aspects only impedes the treatment and prevention of the disease."

Together, these two articles show how much morality affects the ministry's health policies. Whether that is a good thing or not will probably depend on whether you share the same morality.

Real and Apparent Danger

There is a real and apparent danger in Singapore.

(emphasis mine)

Toxins in dish-washing detergent?

I WOULD like to ask why dish-washing liquid detergents do not carry ingredient labels. This is perhaps an oversight since such detergents leave traces on utensils, even after washing.

The danger is even more apparent in foodcourts where mass-washed utensils are coated with unknown ingredients.

Recently, there were reports about the danger of methylisothiazolinone, a neurotoxin that is found increasingly in shampoos, except some old, trusted brands. Methylisothiazolinone is possibly found in dish-washing detergent, especially those that tout 'anti-bacteria' formula since methylisothiazolinone is also a biocide.

Likewise, can the authorities clarify why formaldehyde is found increasingly in shampoos? The dangers of formaldehyde are already known, such as autism, eyesight degeneration and high carcinogenic effect on contact with water molecules. In addition, there are no standards as to how much formaldehyde is added to shampoo since it is considered a non-food item. But the danger is real and apparent.

Michael Yee


angry doc won't address the first part of Mr Yee's letter, since he too does not want detergent in his food. But the second part of the letter gets to him.

Formaldehyde is a widely used form of preservative. No doubt it can be fatal when ingested, and causes irritation of the eyes and skin when in vapour form (angry doc had personal experience of that back in medical school, he does - ah, sweet, gross anatomy!). But is it as dangerous as Mr Yee described?

Does formaldehyde cause eyesight degeneration? Well, yes, if it is splashed into your eye or injected into an eyeball.

Does it have high carcinogenic effect? Well, yes, it has been shown to cause some forms of cancers in mice, but it has not been shown to cause more cancers in people who are exposed to it at work (and who presumably use shampoo when they are off work).

Does it cause autism? angry doc couldn't find any evidence for that.

Mr Yee has given misleading information about the dangers of formaldehyde in the first part of that paragraph, but the penultimate sentence in that paragraph is simply untrure.

Shampoos are classified as cosmetic products, and come under the purview of the Cosmetics Control Unit of the Health Products Regulation Group of the Health Sciences Authority. The amount of formaldehyde permitted in shampoos is regulated by the ASEAN Cosmetic Directive, at the concentration of no more than 0.2%. Shampoos manufactured by Unilever contain formaldehyde of 0.04%. There is no evidence that at that concentration, application of formaldehyde to the skin for short durations causes any of the harmful effects Mr Yee mentioned.

Formaldehyde is a toxin in the commonly used sense of the word, but to say that shampoos can cause cancers, eyesight degeneration and autism, and that the authorities are not doing anything about it is dishonest and irresponsible.

The fact is information about regulations on the amount of formaldehyde permitted in shampoos and the dangers of formaldehyde is available on the internet if one would just search for them. Mr Yee had apparently not done so before sending in his alarmist letter, and the ST Forum editor has in angry doc's opinion lapsed in his duty by publishing it. This lack of editorial rigour is the real and apparent danger.

No labs please, we're homeopaths

While googling about homeopathy in Singapore, angry doc came across a site that advertised as one of homeopathy's benefits the fact that:

"the system does not require expensive tests and reports."

Of course. Why wouldn't that be a benefit? Everybody hates lab tests, X-rays, and biopsies, right?

Patients certainly hate them most of the time.

Practitioners of alternative medicine can often make a diagnosis just by looking at you or feeling your pulse. In fact, some can even feel your energy field without actually having to physically touch you. Who needs tests and reports to know what's wrong with you, or if you are getting better?

Western doctors, with their inability to make decisions without time-consuming and expensive tests which often puts the patient at much inconveniece, discomfort, and not to mention risks, seem by contrast primitive and unsophisticated.

As a medical student, angry doc certainly hated "lab".

Much of the first two years of medical school, the "pre-clinical" years, were spent in stuffy laboratories, where we had to conduct repetitive experiments.

The subject of the week's experiment would vary (this week it would be sugars, the next week proteins, and the week after bilirubin or something), but the physical tasks always consisted of measuring minute quantities of chemicals, diluting them with deionised water from a large plastic vat, then placing the resultant solutions into small glass or plastic containers, which would then be placed inside a spectrometer. The result of each reading would be plotted on a graph, which seemed to be the point of the whole afternoon's labour.

It seemed a sadistic way of wasting our time, making us do the same thing with the same spectrometer week after week just to show something which they already knew was true. Yes, the spectrometer works, the values change with different concentrations of the chemical, in a linear fashion which can be represented graphically. We get it! Can we do something else please?

(OK, we did do something else. Occasionally we were required to supply bodily fluids as raw material for the week's experiment. angry doc will not elaborate further.)

Unlike 'A' level chemistry, lab-work in medical school was not an examinable subject, so angry doc never paid attention and had already forgotten almost all of what happened before the second year ended.

To angry doc's disappointment, "lab" did not end with the end of second year, as Pathology involved hours of eye-straining, vertigo-inducing work in the purple-and-pink topsy-turvy world of light microscopy, where moving a slide left shifted the field of view right, and moving it down shifted the field of view up. angry doc had difficulty using a computer mouse afterwards.

angry doc resolved to not choose a specialty that required any vision-enhancing aid more sophisticated than a pair of spectacles.

angry doc is also vaguely aware of the Radiology module, which he had skipped completely, because they seemed more interested in teaching him about how an X-ray machine worked than how to read an X-ray.

The only bit of lab angry doc didn't mind, and indeed enjoyed, was anatomy. Ah, sweet, gross anatomy!

It was with little regret that angry doc left the sterile world of lab and entered the wards, where finally! he could get his hands on some patients. When he heard that a classmate was interested in pursuing a career in lab medicine, angry doc thought the fellow was mad.

For the next few years angry doc didn't think much about labs. Lab was that mysterious but boring place where he sent his patients, their bodily fluids or some bits of their bodies, in return for which he received reports which allowed him to get on with the business of treating their illness.

But now that he has taken on the task of fighting alternative medicine, angry doc appreciates the purpose of all those lab hours.

Unbeknowst to him, the boring work in those foundation years demonstrated to angry doc that our work is based on real, quantifiable things which can be objectively and independently measured, and not on the postulation of some wise men, or abstract speculation about invisible life energies that seem to be only palpable to those who believe they exist.

Going through the science behind the investigation modalities and performing all those experiments ourselves taught us that we did not have to take anyone's word as authority, but could verify and find out first-hand if something was true, if we understood the scientific principles and had the knowledge.

Lab work was an innoculation against the magical thinking and dogma that characterise some of the more absurd forms of alternative medicine.

angry doc wishes he had paid more attention in medical school.


(If you are a medical student, angry doc is interested in knowing how much lab work you are required to do these days, and also how much exposure to alternative medicine you have in your course. Do share with him in the comments section. Thank you.)

What's wrong with the placebo effect?

Reader sprachen sie singlish, commenting on this previous post, wrote:


Never figured out why the Placebo had such bad rep.

Statistically significant improvement for the patient, no side effects. What more could your ask for when apply the Harm Principal?


What's wrong, indeed, with the placebo effect?

(Or more appropriately, with "placebo effects", since it is an umbrella term that covers a number of mechanisms which might affect a patient's physiology or how he perceives his symptoms.)

It is a commonly posed question and a common defence used by proponents of alternative medicine when evidence shows that their favoured modality of treatment is no better than placebo, and that any beneficial effect observed as a result of that therapy is therefore also likely due to the placebo effect.

Because it is a commonly posed question and a commonly used defence, it is a question that has been answered many times by science and medical writers and bloggers. angry doc does not claim to be able to answer the question comprehensively or in depth, but he will do the best he can, with regards to the study in question.

First of all, the improvement observed in the study is not large enough to be considered clinically significant.

That aside, it is also worth noting that while the parents and clinicians all reported improvement in their scores, scores given by the subjects themselves were a more mixed result - some subjects reported improvement in certain domains but felt they did worse in other domains. In other words, the observers thought that the subjects were functioning better, regardless or whether or not the subjects themselves were feeling better - the placebo effect affects the observers, and not the subjects! This of course has ethical implication when it comes to using a treatment on subjects who cannot communicate how they are feeling - patients such as infants, children, those who are mentally-impaired, and even pets; we can think that we are helping them, when in fact we may be doing nothing, or indeed harm to them.

Also, it is not true that there are no side effects with placebos or biologically non-active agents. Patients given non-active agents can in fact develop adverse effect to them, as was the case with one patient in this study, who had to drop out of the study. This is known as the nocebo effect. Placebos, because we do not always know the precise mechanism by which they work, are often unpredictable in their effect, and can in fact have the reverse effect from that which is desired.

Finally, even if we take the result of this study to mean that placebos are effective for ADHD in children and adolescent, the question of what to give the patients remain: do you give them "a mixture of rice protein powder and a small amount of activated charcoal" or "0.3% hypericin... free of heavy metals, pesticides, and adulterants"? Or something else which has already been proven to be more effective than placebo for ADHD?

If you choose to give a patient a placebo, do you tell him you are giving him a placebo, or do you lie to him and tell him you are giving him "something that works"? Do you want to lie to your patient? Would you want your doctor to lie to you?

The fact is there are practitioners out there who are prescribing treatment to patients which have been shown to be no superior to placebo. If indeed all that they are giving is the placebo effect, then does it justify the cost to the patients? Does it justify the practitioner's time learning all he learnt? Does it not make the whole practice dishonest?

Having said that, all 'healers' use the placebo effect to a degree in his or her practice. The simple ritual of a consultation is sometimes all it takes to make the patient feel better. It is probably impossible to quantify or eliminate such effects from our practice, but angry doc feels that where we know that a treatment is no better than placebo, it is detrimental to the patient-doctor relationship to prescribe it as "something which works", or to not resort to something which has indeed been proven to work.

Where many were, how few remain

Reader sm asks:


Do you happen to know any other public blogs by Singapore healthcare professionals, and could you somehow forward it to me as well?


Ironically, fellow-Clearthought blogger black tag just announced that he will quit blogging, after a run of just less than a year. He did not give a reason for his decision, but angry doc suspects that despite his apparent anonymity, his true identity has been discovered by his employers, and he has had restrictions placed on him.

Certainly that was the main reason why Dr BL Og, a prominent doctor-blogger when angry doc first started blogging 3 years ago, decided to close his popular blog.

Dr Huang, who is in private practice, faces no such restrictions, and can blog without such fear, and does - even if his focus is often not on medicine but on wider social issues.

Dr spacefan, who also works in a 'public' institution, seems to have reached an understanding with her employers regarding blogging, and blogs 'semi-anonymously'. Hers is the oldest surviving Singaporean doctor-blog angry doc knows of.

There have been other short-lived medical blogs which angry doc used to read regularly, like those of his disciple distinguished mediocrity and Dr dth, both sadly closed.

Dr tscd, who angry doc thinks is one of the best bloggers around, seems to be on maternity leave from blogging since the arrival of her first child. angry doc hope she will resume blogging soon, as no doubt her many fans do.

Still blogging, but currently not practising, is proud mother of teenagers aliendoc, whose perspective on the practice of medicine angry doc always appreciates.

Those are the doctor-blogs that angry doc reads or used to read regularly. There must be many that he has not read - certainly some of his colleagues keep blogs on their hobbies, their children, and what they had for dinner, but angry doc has never read any of them.

Fellow-Clearthought blogger Edgar, a dental student, keeps his blog here, and angry doc has come across a few blogs kept by nurses too, although he doesn't have the links right now.

Those are the ones angry doc can remember... did I miss anyone out?

Blogging is a tricky business for healthcare professionals, as we are expected to safeguard patients' confidentiality. For those who are not their own bosses, there is also the rule of 'not blogging about work'. Over the years angry doc has shifted from blogging about his work to discussing medico-social issues and fighting quackery, so hopefully this blog will survive to its third birthday.

If you are a healthcare professional and you keep a blog, do leave a comment and let sm know about it.

Thank you.

A £10,000 challenge

Via Orac, news about a professor of homeopathy who has offered a £10,000 prize to anyone who can "demonstrate that homeopathy is effective by showing that the Cochrane Collaboration has published a review that is strongly and conclusively positive about high dilution homeopathic remedies for any human condition".

As far as angry doc knows, no one has taken up the challenge, but Le Canard Noir at Quackometer tells us that "excuses for ignoring the challenge are already being discussed on homeopathic sites and message boards". angry doc believes that the Professor Ernst is familiar with most of them.

While not as well-known as acupuncture and TCM, two forms of alternative medicine which we discuss regularly on this blog, homeopathy nonetheless has its presence in Singapore, and from angry doc's personal observation it is growing. While herbal medicine and acupuncture have shown efficacy for certain conditions and have plausible or known mechanisms of action, the same cannot be said of homeopathy.

angry doc thinks all healthcare workers should be aware of this relatively new form of alternative medicine, so we can educate our patients about it. Homeopathy simply does not hold water*.

* - Sorry, I just couldn't resist.

Science and how we know we are wrong 3

This study made it into several newspapers when it was published last week. Science-blogger Orac gives a detailed look at the study, and points out the flaws in the arguments in the accompanying editorial, which tried to defend alternative medicine in the face of evidence of absence of efficacy.

In the meantime, angry doc finds the study interesting for a different reason.

The study looked at the subjects' performance on the ADHD Rating Scale-IV and Clinical Global Impression Improvement Scale (which are assessed and scored by clinicians) as primary end points, and also analysed the Parent-Reported Child Behavior Checklist or Youth Self Report Form (for subjects 11 years and older), Conners Parent Rating Scale, and parent-report and child-report forms of the Pediatric Quality of Life Inventory (which are scored by the subjects or their parents), and found that there were no statistically-significant differences in the scores before and after treatment between the group receiving St. John's Wort and the group receiving placebo.

But that's not all.

If you look at the scores (you'll need to register to read the full paper on JAMA), you will find that except for the Youth Self Report Form, scores for both groups improved at follow-up.

In other words, the clinicians involved in the trial and the parents of the subjects all *thought* that the children were improving.

What's more, children in the placebo group 'improved' more than children in the treatment group, even if the differences in the scores were not statistically-significant.

To angry doc, this trial demonstrates the power of the placebo effect, where just the fact that the children are being given a pill three times a day, regardless of whether it contains "a mixture of rice protein powder and a small amount of activated charcoal" or "0.3% hypericin... free of heavy metals, pesticides, and adulterants" can affect a clinician or parent's assessement of their behaviour.

So the next time you are tempted to say "I know it works because he got better after taking it", stop and think of this study, won't you?

Singapore's Healthcare System

angry doc would like to draw his readers' attention to two informative articles on Singapore's healthcare system.

The first, via The Singapore Daily, compares the different funding models in the US and the Singaporean system, as well as their respective successes.

The second, via Dr Crippen, is an interview with the director of Healthcare Services at the Singapore Tourism Board which describes Singapore's healthcare system in a way that is easy to understand; angry doc must say he learnt a fact or two from the interview himself.

Do have a read.

OK, I'll be good

A reader had this to say about angry doc's posts:

"You seem almost reluctant to take a firm stance on any issue without engaging in an overdrawn rationalization with yourself. Playing "devil's advocate" on a topic is fine if done once or twice, but to do it at every post is, frankly, quite irksome."

In response angry doc would like to mention this news article from Today last weekend:


Take it easy, We have the 3cs
Richard Hartung

ON A recent Sunday morning, a sick young boy stopped at the private clinic near his home with his parents. Less than $30 and 30 minutes later, he was on his way home with a diagnosis, medicine and the reassurance that his illness wasn’t serious.

On a weekday, however, the cost at a polyclinic would have been even lower.

Amid recent complaints in Singapore about high prices and low standards of medical care, this commonplace scene presents a distinct contrast with that of other countries and shows how fortunate we are with healthcare.

Both anecdotes and statistics bear out the high quality overall. If we look at three of the more important factors in healthcare, which one might call the 3Cs — care quality, convenience and cost — we in Singapore should feel good, rather than complain.

There can be little doubt that care quality in Singapore is high. Singapore is ranked sixth globally by the World Health Organisation (WHO), well above developed countries like the United States or the United Kingdom. This high ranking reflects good care in many areas, from paediatrics to geriatrics.

To some, quality of care might also mean spending more time with the doctor. Not in Singapore, though, where faster speed of consultation seems more important. Doctors spending an average of 18 minutes with patients, as they do in the US, might be far too long. If anything, Singaporeans want faster turnaround time for patient-doctor consultations, says a Ministry of Health study.

Healthcare in Singapore is also convenient and available seven days a week. Polyclinics are scattered around the island and private clinics are found in most areas. While some clinics here are open on Sundays or in the evenings so that you can see a doctor almost anytime, just try to find a doctor on a weekend in most other countries. Unless it’s an emergency, it can be difficult at best.

The waiting time to see a doctor here is also comparatively short. In Singapore, the average waiting time at a polyclinic, even without an appointment, is 20 to 40 minutes, according to the MOH survey. This compares favourably with that of other countries.

In the UK, Canada and the US, Commonwealth Fund-supported research shows that most patients can’t even get an appointment on the same day they’re sick and have to wait one to six days to see a doctor. The average waiting time to see a doctor in the US, even with an appointment, is 20 minutes, according to the American Medical Association.

Emergency care is also readily available here. While recent data showing a nine-minute response time for ambulances reflects a longer wait than the best practice of less than seven minutes, the speed has still improved from 11 minutes in the early ’90s and it’s below the average target of 12 minutes in Hong Kong.

Along with the speed of arrival, ready availability of medical care at hospitals means that cases like the widely-publicised story where a woman in an ambulance in Japan died after 30 hospitals refused to accept her seem unlikely to happen here.

Cost is another important component of healthcare, yet it is among the most difficult to measure. With differences in the cost of public and private care, as well as in insurance or government reimbursements, international comparisons are challenging at best.

Still, Singapore appears to fare well on this measure, too. The US remains one of the most costly places to see a doctor, with a visit averaging $84 and a visit to the emergency room at $536, according to health insurer Blue Cross. Even if insurance pays 80 per cent, the cost is high.

Compare that with Singapore, where the average polyclinic visit costs the patient $8.80. This cost is similar to visiting a doctor in Australia, where direct expenses average the equivalent of $8 to $10, or in Hong Kong, where the cost of visiting a clinic is about $10 in Singapore currency.

On a broader national basis, Singapore achieved these levels of carewhile spending about 3.8 per cent of its gross domestic product on healthcare, compared to an average of 8.9 percent in all Organisation for Economic Cooperation and Development countries.

Singapore thus has a good combination of high care quality, high convenience and relatively low cost. Rarely does a country excel in all the 3Cs. Japan may have high quality, being at No 10 in the WHO study, but the cost is also higher. Costs in Australia are similar to Singapore, but on care quality, it is ranked 32nd by the WHO and 46 per cent of Australians said they waited at least a day to see a doctor when they were sick. Other comparisons show similar results.

Despite their complaints, Singaporeans should feel fortunate to have such easy access to affordable, high-quality healthcare. If you need to see a doctor, Singapore hits all 3Cs.

The writer is a consultant who has lived in Singapore since 1992.


angry doc would like to state (without engaging in overdrawn rationalization) that he agrees firmly with the writer's opinion.

We hope this post has been informative.