Angry Doctor

Thursday, March 27, 2008

Stop using that word!

Not surprisingly, there are a few letters to the press on the recent announcement on aesthetic 'medicine'. What angry doc does find surprising, however, is this letter from the SMA:

SMA lauds ministry's clarification, criticises ST

I REFER to the spate of articles on aesthetic medicine that has been published in The Straits Times since March 19.

The Singapore Medical Association (SMA) welcomes the clarification made by the Minister for Health last Sunday on the position of the Government on this matter, in particular, the emphasis on self-regulation of aesthetic practices by professional bodies.

We are also heartened by the circular issued by the Director of Medical Services to all medical practitioners last Monday which spelt out the principles of safeguarding medical standards in Singapore as well as the press release, 'MOH clarifies position on aesthetic medicine', dated the same day.

The vast majority of doctors in Singapore, including those that provide aesthetic services, are ethical professionals who earn an honest day's living by caring for their patients. Even if some of the mentioned aesthetic practices are not grounded in the most robust body of scientific evidence, the use of the term 'snake oil' is insensitive to many in the medical profession.

Repeated use of this term by The Straits Times, notwithstanding that it was, as we understand it, uttered on a single occasion by a person of authority, is hurtful to doctors and regrettable. It does little to raise the standard of discussions on this difficult issue of regulating aesthetic practices.

Doctors understand that with great powers and trust vested in them by the public, come greater responsibility and accountability. Likewise, we hope that the local media will exercise better discretion going forward so that readers are better served with more constructive reporting.

Dr Raymond Chua
Honorary Secretary
48th SMA Council

EDITOR'S NOTE: We reported accurately the quote in question and used it whenever it was relevant to the stories we ran. We fail to see how being factual in our reporting can lower the level of discussion on this issue. That must depend on the quality of the arguments used by doctors, which is entirely in the hands of the profession.


Dr Chua calls it "aesthetic practices [that] are not grounded in the most robust body of scientific evidence", angry doc calls it unproven therapy. To angry doc's mind, and no doubt to those of many of his readers, unproven therapy that is touted to be able to deliver more than what it can do *is* 'snake oil'.

More importantly, Dr Chua does not challenge the "person of authority" who "uttered [the term] on a single occasion", nor does he provide any justification for why he thinks that the term had been wrongly applied, but expects the press to stop using that term simply because it is "hurtful".

Well, boohoo.

angry doc thinks it's laughable that Dr Chua expects the press to be 'sensitive' to doctors. angry doc thinks that the press doesn't owe it to us to be 'sensitive', but to be honest. angry doc thinks that doctors owe it to their patients to be honest too.

Unless the press had lied about the facts presented in their report, and unless he can provide evidence that that is the case, angry doc thinks it is disingenuous on that part of Dr Chua to try to blame the recent fiasco facing doctors on unconstructive reporting on the part of the press: if you want them to shut up, prove that what you are selling is not snake oil, or just stop selling it.

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Monday, March 24, 2008

Confidence Goods 12

A bit of news that will no doubt bring cheers or jeers from doctors (depending on their 'turf') to start the week with...

When govt's heavy hand isn't best fix
It's 'consumer beware', even as medical profession takes steps to regulate its own over aesthetic services
Tan Hui Leng

ON a black-white spectrum, many aesthetic quick fixes fall in the "gray" area as far as scientific corroboration is concerned. That is why it would not be "practical" for regulators to dictate what procedures doctors should or should not perform.

Instead, said Health Minister Khaw Boon Wan (picture) yesterday, consumers should take responsibility for their own choices, even as the medical profession is taking steps towards self-regulation on such matters.

Mr Khaw was addressing the misconception perpetuated by some recent media reports that said the ministry had banned certain aesthetic treatments deemed "scientifically unsubstantiated".

Making it clear that this was not so, Mr Khaw said: "Tightening up (regulations) means a lot of the treatments would have to be forbidden, which obviously is not practical, so I think our job as health (authorities) is to look at safety."

The challenge of regulating the vanity business, as the Ministry of Health (MOH) put it in a press statement, is that scientific evidence is often missing or inconclusive.

But where the MOH will step in, is when patient's lives may be at stake — particularly in invasive, high-risk procedures such as liposuction, where complications can result in death.

The MOH last month had raised concerns in Parliament about general practitioners (GPs) who perform liposuction procedure at outpatient clinics.

And as Today reported on March 11, plastic surgeons have seen more of such botched jobs by GPs that have resulted in serious complications for the patients.

Where highly invasive procedures are concerned, draft regulations are being formulated.

But "beyond that, the profession has to regulate themselves", Mr Khaw said on the sidelines of a book launch.

The Academy of Medicine and the College of Family Physicians are formulating guidelines governing the ethical practices of aesthetic procedures. These will draw from other countries with similar guidelines, said the MOH.

Common procedures include skin whitening injections and mesotherapy — an injection of a medicine, vitamins and plant extract cocktail to the layer of fat just below the skin to help get rid of fat.

For now, aesthetic services will be expected to practise with customers' interests in mind "and not allow greed to over-rule ethical considerations", said the MOH.

Doctors, in addition, will be bound by the Singapore Medical Council's ethical code and guidelines. Currently, the council is investigating six doctors following patients' complaints about their aesthetic treatments.

On their part, consumers were urged by Mr Khaw to exercise common sense and not be misled by marketing hype.

"There's no shortcut to things. If you insist on eating a lot yet don't want to exercise and hope that some procedure will instantaneously make you slim, take it with a pinch of salt," he said.

The MOH said customers should "go in with their eyes open, knowing that there will be disappointment and occasionally even accidents, not to mention the loss of money".

If offered treatments that appear to be new or unheard of, they should be "vigilant" and seek a second opinion from their regular family physician.

As for GPs, the ministry said they had been "unfairly represented" by the media recently in reports about aesthetic malpractices.

Singapore's primary healthcare services rank among the world's best, said the MOH, and "a few unethical doctors should not be allowed to taint the good reputation of our medical community".

You can read what the ministry's spokesperson said on aliendoc's post here, and decide for yourself if the ministry had been misrepresented.

You can also read the ministry's full press release here.

It seems to angry doc that the ministry has taken a specific position with regards to aesthetic 'medicine', which in this case translates to: it's OK to us for you to sell any unproven treatment to your clients as long as you don't kill or injure them.

That represents a step backwards for medicine in Singapore, and as noted by aliendoc, is a case of applying 'double standards'.

angry doc believes that the guiding principle when it comes to looking at what we offer our patients should not be how much it costs, whether it's therapeutic or cosmetic, or how much potential harm it can do to the patient, but whether it works. All those other things matter, but if we do not first and foremost know, or have good reason to think, based on evidence, that our treatment work, then we become quacks - professing an ability to heal that we do not in fact possess. A cheap quack who does not kill his patients while claiming to make them pretty is still a quack.

angry doc has said it before, and he thinks it bears repeating again: medicine, including aesthetic 'medicine' is a confidence goods; that we have to put the onus on the 'consumer' to "not be misled by marketing hype" speaks poorly of the medical profession in Singapore.

We do, however, have a chance to redeem ourselves: the minister has effectively left the field of aesthetic 'medicine' to be regulated by doctors ourselves. Self-regulation is a privilege, and whether we can hold ourselves to a higher standard than that which the ministry seems to expect of us on the subject of aesthetic 'medicine' will perhaps influence how much longer we will continue to have that privilege.


Wednesday, March 19, 2008

Take my rights... please! 2

Well, well. Here's a letter to make angry doc stir from his stupor:

Keep S'poreans small, ban char kway teow?
Letter from GOH KIAN HUAT

I REFER to the report "Beware! Super-sized S'poreans on way" (March 17).

My nine-year-old daughter, classified as severely overweight, has been attending counselling sessions with food nutritionists at the Health Promotion Board for the past two years.

However, her attempts at losing weight have not been successful. It is easy to list the types of healthy foods one should eat, but difficult to find and eat only these healthy items.

I applaud the initiative in asking fast-food outlets to put healthier options on their menus. They should also provide healthy choices for adults.

McDonald's could offer vegetables, fruits or desserts with their set meals and Kentucky Fried Chicken could remove the skin before frying the chicken.

Customers should also be able to choose between soft drinks and ones that contain less sugar.

Health Minister Khaw Boon Wan said he eats char kway teow only three to four times a year, and that if we eat this frequently — five to 10 times a month — there will be trouble. I find this is no different from smoking. Should such unhealthy food be allowed to be sold in the first place?

I suggest that the National Environment Agency ensures that its licencees sell healthy, nutritious food.

The fact is every place that sells soft drinks also sell a drink that tastes exactly like a regular soft drink, but contains only half the sugar and therefore only half the calories.

It's called half a soft drink.

angry doc believes that there are no unhealthy food, only unhealthy meals. (Unless you are talking about poisonous food, and some may include food which contain trans-fat in this category...)

Conversely, there is no healthy food that does not become unhealthy if one consumes too much of it.

A calorie from slice of whole-meal bread is the same as a calorie from a slice of patoto chip, and it is not only what you put inside you that matters, but also how much of it you put inside you.

We may legislate against sale of so-called unhealthy food or their advertising, but as long as oil, starch and sugar remain cheap and available, Singaporeans will continue to have access to cheap calories.

At the end of the day, what and how much we eat is a personal choice and thus personal responsibility, except in the case of children, where it becomes the responsibility of the parents ot guardians. angry doc finds it sad that Mr Goh would rather those choices and responsibilities to be taken away.


Thursday, March 06, 2008

Mental Capacity Act 6

An update on the draft MCA:

Draft Mental Capacity Bill to be fine-tuned following feedback
By Asha Popatlal, Channel NewsAsia

SINGAPORE: The draft Mental Capacity Bill will be fine-tuned, following feedback from over 140 people and organisations last year, the Ministry of Community Development, Youth and Sports (MCYS) announced in Parliament on Wednesday.

The changes will address issues such as the definitions of what constitute ill-treatment of those who are mentally incapacitated, and who can be empowered to make decisions on their behalf.

The landmark regulation was first proposed last August, and MCYS has explained that under the Mental Capacity Bill, an individual (or donor) can voluntarily plan in advance for a time when he/she may lose mental capacity to make decisions.

Through a legal document called the Lasting Power of Attorney (LPA), the donor can give another person (or donee) the authority to make decisions on his/her behalf regarding matters related to property, finance, and personal welfare, including healthcare.

The donee can be a family member, a relative, a friend or a professional.

Among the changes proposed, the Law Reform Committee suggested that the ministry define more clearly what constitutes ill-treatment and wilful neglect, which the Act criminalises.

The National Council of Social Services (NCSS) also recommended the original list of disqualifying criteria for donees to be removed.

Originally, the list excluded bankrupts and those convicted of offences involving fraud and dishonesty from acting as proxy decision makers for matters related to property and finance.

It also excluded those convicted of any sexual offence, or offences involving violence or the threat of violence.

NCSS' view was that the donor should be given a choice in who he or she would like to appoint, because sometimes the best person to be the donee is a son or relative who may have committed certain offences.

Taking this feedback into account, MCYS said it will remove the disqualifying criteria for donees, except for bankrupts, from the Bill.

MCYS will also expand the list of excluded decisions which a donee cannot make on behalf of the donor. These are: adopting or renouncing a religion; receiving treatment for change of gender; and making and revoking of any nominations made under the Conveyancing and Law of Property Act where insurance policy proceeds are concerned.

The other exclusions are: consenting to marriage or sexual relations; executing, amending or revoking a will; and making or revoking a CPF nomination.

MCYS will amend the draft Bill based on the feedback, and it will publish a code of practice to provide guidance to caregivers and professionals after the Bill is passed in Parliament.

angry doc finds it interesting that the bill will disallow a bankrupt from acting as a donee, but not someone who has a history of violence or sexual offence. It is as if we expect a criminal to be a friend or family first and a criminal second, and not the other way round, or that we allow people to exercise their judgement when it comes to character, but not if the person being judged is a bankrupt. How odd.

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Tuesday, March 04, 2008

Subsidy and Other Preoccupations 19

After a long period of speculation, we now know how means-testing for inpatients will take:

(emphasis mine)

Healthier coffers, rising costs
MOH gets 19% budget boost to meet subsidy and manpower needs
Tan Hui Leng

AS Singaporeans grapple with medical costs that shot up by 7.4 per cent last year on the back of imported inflation, the Ministry of Health (MOH) is getting a rare 19-per-cent boost to its budget this year — a necessary prescription to meet the need for more manpower, rising expectations and subsidies to help patients cope.

For one, $1.9 billion will be spent over the next five years to grow the pool of doctors, nurses, pharmacists and allied health professionals by 40 per cent.

"Our doctors and healthcare professionals are overworked and at some point, they need a life too," said Health Minister Khaw Boon Wan, noting how director of medical services K Satku was "sleeping less and less", juggling between surgeries and meetings, while younger doctors were "working day and night to meet the needs for increasingly more demanding patients and relatives".

Apart from overseas recruitment — last year, 438 doctors came from abroad, nearly twice the 230 who graduated locally — the bigger budget allows for twice the number of scholarships for allied health professionals this year, plus a new overseas degree-conversion scholarship for Nanyang Polytechnic graduates.

More competitive salaries, too, are needed to retain those enticed by competitive posts abroad and even from the booming local hospitality sector.

But the bulk of the $421-million increase in the MOH's coffers will go towards subsidised patients. Indeed, direct subsidies for class B2 and C ward patients will likely exceed $1.7 billion this year, said Mr Khaw, who unveiled the finalised details of the means-testing scheme to kick in next January at public hospitals.

Sporting "more generous" criteria following feedback from public dialogue sessions and Members of Parliament (MPs), the scheme will not affect 80 per cent of Singaporeans — including all housewives, retirees and children living in HDB flats as well as lower-annual value private properties.

Patients with a personal monthly income of $3,200 or less will continue to enjoy the full subsidy of 80 per cent in class C and 65 per cent in class B2 wards. The higher up the salary scale one is, the smaller the subsidy entitlement.

"We will be flexible at the margins to help those who may appear to be of high income, but who have exceptional financial liabilities," said Mr Khaw.

Similarly, at the other end of the income scale, many of the people in need "end up paying nothing" after some help from Medifund, he said to Nominated MP Siew Kum Hong's suggestion to give an even bigger subsidy to such patients.

And while the minister acknowledged that — as some MPs pointed out — per capita household income was a better gauge of financial ability than personal income, this would be costly to implement and "intrusive to every patient". Should one feel unfairly treated, a thorough means-test can be done upon appeal.

Rising costs will continue to be a worry as health spending goes up from 4 per cent of GDP to as much as 6 per cent in the medium term, said Mr Khaw.

"Last week, (MP) Dr Ahmad Magad related a personal experience during which his daughter was hospitalised in a private hospital. He said he almost fainted when he saw the bill of $2,300 for a two-day stay."

But what is contributing partly to cost increases are Singaporeans' higher expectations. Take the 11-per-cent jump in attendance at emergency departments last year, said Mr Khaw, which creates the need for prices to be adjusted to deter non-emergency patients.

Likewise for subsidised wards, the continual upgrading of services is drawing more higher-income patients — hence, the need for means-testing.

But while the MOH's bigger budget will result in improved clinical care and hopefully shorter waits for medical services, Mr Khaw had some words of caution. Don't expect "on-demand service" like that in five-star hotels. And beware that it does not lead to a vicious cycle of even higher expectations and more cost spikes.

Non-constituency MP Sylvia Lim asked if the MOH shouldn't in fact moderate such expectations. Mr Khaw responded that even as he would be "the last one to be fanning expectations", he could not ignore the growing demands for better public healthcare standards.

For instance, one such improvement will see the bed-to-patient ratio, which stands at 1.6 per 1,000 population now, improve to 1.8 by 2015.

The news article on the CNA site gives more details, and tells us that:

"Higher income earners will get subsidies on a sliding scale of one percentage point, depending on their income range. This is capped at 65 per cent for Class C wards and 50 per cent for Class B2 wards for those earning more than S$5,200.

Economically inactive patients will also receive full subsidies unless they live in a property with an Annual Value exceeding S$11,000.


As for those who feel the simplified approach has treated them unfairly, a thorough means-test will be conducted upon their appeal and will be based on the approach that is currently used by nursing homes."

angry doc must say that he is impressed by this new scheme. It leaves a large proportion of patients unaffected, and still gives those who earn more than $3200 a month a substantial amount of subsidy (essentially they may pay B2 prices for a C class bed, or B1 prices for a B2 bed).

There are still a quirk or two in the system, like say how a family with the father as the sole bread-winner earning more than $3200 may be better off if the mother or a child fell sick since they will enjoy full subsidy, than if the father fell sick, since he will not pass the means-test and it will at the same time leave the family without income.

The actual savings in terms of subsidy not given out will probably not amount to much, especially if those who find themselves faced with a large bill and failing the means test can appeal for a 'thorough means-test'. angry doc also notes that the actual amount of money the ministry expects to save is never mentioned in any of the news articles on the subject.

At the end of the day, angry doc suspects, this scheme is probably not aimed so much at reducing government healthcare expenditure by subsidy saved alone but - despite what the minister said - a way to 'moderate expectations'; if this step in introducing the concept that one's inpatient subsidy entitlement is tied to one's wealth is accepted, then it may in the future be easier to implement it in other levels of healthcare, as it has been for nursing homes.

Whether that is a good thing or not will depend on your point of view.

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