Angry Doctor

Thursday, July 30, 2009

Judging doctors 2

(Posted on Singapore MD.)


Thursday, July 23, 2009

Judging doctors

(Posted on Singapore MD)


Wednesday, July 22, 2009

"Good, absolute values"

Because of its innocuous title, angry doc did not bother to read this letter to the ST forum, until he saw two rebuttals to it today (see here and here).

Let's reinforce unity of purpose in fighting terrorism

WE CAN never overemphasise the need to remain vigilant against the threat of terrorism, as warned by Prime Minister Lee Hsien Loong in last Sunday's report, 'PM Lee warns of evolving terror threat'.

He warned that the recent bomb explosions at the Ritz-Carlton and JW Marriott hotels in Jakarta showed that terrorists continue to have 'new ways of doing evil, bad deeds'. Schools, religious organisations and the business community need to make a concerted effort to not only condemn the murderous acts of terrorism, but also set the boundaries that define good and evil in society.

Often, the human spirit needs to be rekindled to distinguish between right and wrong behaviour. Religions with good society and family values must take proactive steps to engage the public and schools by upholding godly values and renouncing the evil that destroys the fabric of society. Our children need to learn from religious leaders who demonstrate how their faith can build strong family bonds and create social stability, harmony and security. Where the fault lines of society are shaken, religious leaders are to super-glue the gaps.

Religious leaders in collaboration with the Government should openly reject socially irresponsible behaviour such as racism, religious intolerance, adultery as well as perverse sexual behaviour in society. Moral relativism has no place in a society that treasures and thrives on good, absolute values.

As part of civil defence, schools must be vigilant to teach children strong traditional family values through the covenant of marriage and fidelity to one's spouse.

Insidious and egregious practices such as abuse of human rights and extreme liberalism must be exposed and rejected for what they are. Drug trafficking, use of abortion as a form of contraceptive, polygamy and serial divorce will remain as wrongdoings. Our police force should be held in high regard as they enforce the rules against criminal behaviour.

Children must be encouraged to speak up against evil and not fear being rebuked for doing the right thing. The heathen attack religious people with the phrase: 'Get down from your high horse for we reject your holier-than-thou attitude.'

Minister Mentor Lee Kuan Yew recently remarked that for 44 years, Singapore still has not yet achieved the ideals of nationhood. Perhaps the next step requires the conviction and partnership of religious and government leaders to take a firm stand against wicked deeds and support those who stand for the truth in nation building. It is time we took serious heed of the axiom: 'Righteousness exalts a nation.'

George Lim

In Mr Lim's opinion, the world would be a better place if governments enforced religious values. Not just any religious values, of course - religions that do not condemn "adultery as well as perverse sexual behaviour", "use of abortion as a form of contraceptive, polygamy and serial divorce" don't really count. In other words, religious values are good insofar as they are the same as those held by Mr Lim's own religion.

The cure for "religiously-informed" terrorism, according to Mr Lim, is more religion. Specifically his.


Saturday, July 18, 2009

Begin at the End...

Begin at the beginning and go on till you come to the end: then stop. - The King

(Posted on the Singapore MD.)

Friday, July 10, 2009

don't need doctors anymore

Concerned patient commented in an earlier post:

I find that doctors do too many tests these days. Can't they just be sure about something without having to do tests? It costs $8+ to consult a doctor at the polyclinic but $10+ for a test. Is the test worth more than the doctor? From where the money goes it seems to be the case.

maybe we don't need doctors anymore.

There are actually a few interesting observations to be made here.

First of all, it tells us that when a service is priced too lowly, it is also valued lowly; something that perhaps the Ministry of Health would do well to consider.

The question of whether doctors do too many tests is also an interesting one. To be more specific, we need to ask: are doctors ordering than they need to be sure of what?

To be sure that they can make the diagnosis?

Or to be sure that they will be able to cover themselves in a court of law?

The reality on the ground is probably a mix of both. To conduct an accurate study of the situation one would theoretically need every case to be audited by one or more doctors - clearly an unrealistic proposition.

But what angry doc is really interested in discussing is the idea conveyed in the last sentence: that tests render doctors obsolete.

Once again, we witness the arrogance of ignorance.

Tests do have their place in the management of patients. They allow doctors access to facts they wouldn't otherwise be able to have using only their senses, and help them come to the diagnosis. But too often patients think that there is a test for every symptom or set of symptoms that would effectively diagnose a condition, and that the process of diagnosis involves simply ordering every test from a 'menu', and the results will give us the diagnosis, which then allows us to institute the treatment. Wrong.

There are literally hundreds of tests you can order from a standard laboratory and imaging ordering form - the doctor's job is to decide which few out of these to order based on the patient's presentation and therefore possible and likely diagnoses. Granted there are 'panels' and 'batteries' of tests which are often 'packaged' together for operational ease, but angry doc bets most doctors would rather do away with these and to tick more boxes on the form than to have to deal with all the incidental mildly-elevated AST that crops up far too often; what tests a doctor orders is sometimes as important as what tests he does not order - we want 'actionable intelligence', not 'noise'.

Similarly, a doctor will be ordering tests to get the positive results he expects, as well as the negative results he expects, because ruling out a diagnosis (or several diagnoses) is also an important part of arriving at a diagnosis.

Once all that thinking had been done and the results are available, the doctor still has to interpret the results and see how they apply to the patient. This involves an understanding of the false positive and false negative rates, as well as pre-test probabilities, all of which will tell us if a positive test really means our patient really has a disease, or if a negative test really means he really does not, and which is very clearly illustrated in this wikipedia entry.

Will they come up with a computer programme someday that can elicit a history and perform the required physical examination to arrive at a list of differential diagnoses, and which can determine which tests to order to eliminate and ultimately confirm diagnoses from that list, and subsequently come up with the recommended management?


But they haven't. And until then angry doc thinks he deserves more than $8+ to do all that thinking. Don't you?

To end, angry doc would like to share a video with his readers, not because it has anything to do with what we are discussing here, but because he thinks this song doesn't played as often as it should. Have a good weekend.


Wednesday, July 08, 2009

The Doctor and the Virus

This letter to the ST Forum today got angry doc thinking.

H1N1 flu: Doctors' moral obligation overrides the law

LAST Saturday's report by Mr Andy Ho ('Flu: Docs need not swallow bitter pill') makes me feel that doctors are nothing but cowards. They have no compassion, moral obligations and certainly no passion in their profession.

Mr Ho indicates that doctors are not obliged to treat patients during a flu pandemic because 'under common law, no one is legally obliged to rescue another from danger'.

Fortunately, this is not the case. People choose to be doctors because it is their calling. They are passionate in wanting to heal the sick. There is a Chinese saying that goes, 'to heal the sick, one has the heart of a parent', so they are definitely compassionate and high in moral obligations.

The law spells out a lot of things, but moral obligation overrides the law.

Take this example. In a major road accident, the first to stop and help the injured before an ambulance arrives would be other motorcyclists. Parking their vehicles along a highway or expressway is breaking the law, but it is still done. Why? Because it is a humane act, a moral obligation...not because the law says so.

Ronald Lee

How generous of Mr Lee to risk lives that are not his own.

Fellow-blogger Gigamole seems to agree with Mr Lee's view, and frankly angry doc too thinks that risking his life to fight a disease is part of his job description.

But angry doc doesn't do it because the thinks it's a humane act or a moral obligation. His motivation comes from a... a different ethos, reflected here in the novel "The Neverending Story":

Only a Greenskin would have dared to hunt these beasts, and moreover they used no other weapons than bows and arrows. The Greenskins were believers in chivalrous combat, and often it was not the hunted but the hunter who lost his life. The Greenskins loved and honored the purple buffaloes and held that only those willing to be killed by them had the right to kill them.

The Greenskin and the purple buffalo, the doctor and the virus, the Old Man and the Sea.

It's only fair, don't you think?


Tuesday, July 07, 2009


No, seriously: WTF?

angry doc needs to go lie down now...


Sunday, July 05, 2009

Showing his politics

angry doc has added another 'cause' under the 'angry doc supports...' section in the sidebar.

He is fully aware of the hypocrisy being displayed here - it wasn't that long ago that he argued that doctors should advocate for causes based primarily on scientific merit, and now here he is supporting something that is not strictly medical (yes, he is also aware that practically *anything* can be made to be 'medical').

Still, he hopes that doesn't stop his readers from clicking on the link and examining the issue at hand.

Have a good week ahead.

Friday, July 03, 2009

Arrogance of ignorance

Once in a while angry doc comes across a blog post or comment that makes him get personal - a post on Emerald Hills today managed to do that to him. angry doc reproduces his comment on that post below:

Your post contains many unfounded accusations directed at health professionals, policy makers, and some segments of the population, and ignores some of the facts we already know about the virus.

I think the latest direction from MOH is in fact a reasonable one based on what we know about the virus so far.

The DORSCON system was designed with a deadlier virus in mind. Current evidence is that the virus we are dealing with is not as deadly as previously thought, so it is reasonable to modify it than to stick to what is ‘on paper’. This shows that the policy makers are monitoring the situation and adapting, rather than blinding adhering to protocols.

Given that patients can be asymptomatic and still be infectious, I fail to see how raising the alert level will help contain the spread.

Given that the disease is mild in the majority of the cases, and that Tamiflu can have adverse effects, it makes sense to reserve its use in patients in whom the benefits will outweigh the risk. Doctors are trained to identify patients who are at higher risks – just because you are ignorant doesn’t mean that health professionals are too.

Also, the fact that the disease is mild in the majority of the cases means that an accurate diagnosis is not helpful in the treatment of the patient most of the time – a patient with H1N1 but is not severly ill will not require Tamiflu or supportive treatment, while a patient who is ill will require supportive treatment regardless of whether it is from H1N1 or seasonal flu.

You display the arrogance of ignorance with your post, thinking that your knowledge of the virus and medical science allows you to criticise the efforts of our policy and healthcare workers, when in fact you have merely displayed your ignorance on the subject, and have not come up with any solution (except to raise the alert level, although you have not explained how that will help make things better).

As a healthcare worker in the frontline fighting against the virus, I am offended by your insult to the competence and professionalism of my colleagues and myself. You are like a panicked airplane passenger who demands to have a say in how the plane is piloted when it hits a turbulence, thinking that you have the training and experience to tell the pilot how to do his job, when he is vastly more qualified than you are, and fully aware of the responsibilities he bears, because if the plane goes down, he goes down too.

Added Jul 04 2009: See this post on the Singapore MD site and decide for yourselves if doctors "make conclusions and decisions blindly, without the necessary facts to back them up".

It's not exactly brain surgery, is it?


Thursday, July 02, 2009


angry doc apologises for not posting anything of substance for... for more than a month now, in fact.

Everything seems to be a bit of a struggle these days, even blogging - somehow Blogger wouldn't let angry doc add a comic which he felt described his mood rather aptly to his post, which is a pity because it had hamsters in it...