Subsidy and Other Preoccupations 21

Fellow-blogger Dr Huang has a letter to the ST Forum published today:

Get GPs back on track

WE ARE doctors specialising in various fields at Gleneagles Medical Centre and we support Dr Lee Wei Ling's gallant attempts to bring medicine in Singapore back to its noble roots ('Train GPs to be family physicians'; April 21).

We suggest the following:

- Invasive aesthetic procedures should be carried out only by doctors who have had adequate surgical training. Only then will the practitioner be able to recognise the early signs of complications. Complications happen even in the best surgeon's hands, but it is often how soon these are detected and the course of action taken that determine the fate of the patient. Aesthetic medicine is here to stay and the Ministry of Health (MOH) should organise properly sanctioned courses for all doctors who are keen to carry out invasive aesthetic procedures. The bar must not be set too low, and being allowed to carry out such dangerous procedures after attending dubious one- to two-day courses should be a thing of the past.

- General practitioners (GPs) are the vanguards of our health-care system. We want each GP to take his proper place as a 'specialist in taking care of the entire patient'. All of them have undergone training at great expense to the state or their families. MOH should make available rotation positions at various hospital departments for all GPs before they start work and at regular intervals after that, to provide opportunities for 'refreshers' to those who feel they need updates or have gaps in their knowledge of certain specialities. National service 'reservist-style' make-up pay is innovative and workable for this.

- Government subventions for GPs to treat subsidised cases is a win-win for all. GPs get more income and hence will be less likely to go for the more lucrative 'aesthetic medicine' route, and the already overcrowded polyclinics will be able to perform even better. In the same vein, many private specialists are also keen to help by treating subsidised patients who are presently referred to overcrowded specialist clinics at public hospitals.

The medical profession should do regular soul-searching, and if we find that we have deviated from our intended paths, we should have the courage to take remedial actions to rectify this.

Dr Huang Shoou Chyuan


angry doc thinks Dr Huang has correctly identified why many GPs are doing aesthetic medicine - it pays better.

However, angry doc doesn't think that more training is what is required, or that having the government to put more money into subsidising healthcare is a fair thing to do, or that it will reduce the number of GPs doing aesthetic medicine or the number of complications arising from it.

GPs don't go into aesthetic medicine because they don't know how to be "a 'specialist in taking care of the entire patient' "; many already possess post-graduate degrees or diplomas in family medicine, and regardless of whether they do or do not all of them are required to attend a minimum number of hours of Continual Medical Education every two years. The learning opportunities and resources are there, and those who want to be better at their craft will utilise them, while those who do not will perhaps just sign the attendance form and take advantage of the free lunch and check their email on their iPhones while the speaker drones on; you can force doctors to attend training, but you cannot force them to learn, or to practise what they been taught in their daily practice.

Doctors will learn when they perceive that it is to their advantage to do so, and GPs who practise aesthetic medicine regularly take time off their practice to learn about new techniques and new equipment. They don't need MOH to pay them for their time, do they?

Will making the government pay GPs for seeing non-aesthetic cases work?

angry doc thinks it may make GPs give up aesthetic medicine and return to family medicine if (and it's a big and important 'if') the trade-off seems favourable to the GP, and that means that at the end of the day the GP should still make as much if not more money than if he did aesthetic medicine. However, the cost involved makes it unlikely that our Health Minister will likely propose that.

And even if we do subsidise patients who visit a GP for non-aesthetic problems, patients will still visit GPs for aesthetic procedures (they have been doing so, and won't have any reason to stop now), and GPs who have been doing aesthetic medicine will still do aesthetic medicine (again, they have been doing so and won't have any reason to stop now either). In fact, angry doc may even argue that with part of the cost of their non-aesthetic medicine paid for by the government, patients will now have more money to spend on aesthetic medicine. OK, maybe with more money to spare now they will visit a specialist for their aesthetics needs and not a GP.

angry doc thinks that the 'problem' of GPs doing aesthetic medicine is really a reflection of how doctors and patients prioritise their wants and resources. Trying to reverse the trend by asking people to be 'noble' isn't going to work, and throwing more tax money at it isn't always a solution; if good primary care is so important that we can consider forcing doctors to provide them, then why shouldn't we require that those who benefit from it take personal responsibility and pay for it?