Angry Doctor

Six Years

2011-08-19T08:00:00.002+08:00

Two thousand one hundred and eighty-five days.
Seven hundred and thirty posts.
Thanks for reading.

"London burns: A Singaporean fumes"

2011-08-12T17:00:00.002+08:00

angry doc is not above using other people's misfortune to make a point about his politics, hence the links to this post and this.

In the days ahead politicians, ex-politicians and politician-wannabes will no doubt try to gain popularity by promising to steer this country down a more socialist route. angry doc hopes we will not all be seduced by the vision of a socialist paradise and become blind to its many perils.

Whose voice is it anyway?

2011-08-11T18:00:00.001+08:00

As the Presidential Elections Committee announces the candidates to whom it has issued Certificates of Eligibility, angry doc notes that he has in fact blogged about three out of the four: Mr Tan Kim Lian, Mr Tan Jee Say, and Dr Tan Cheng Bock.

Ironically, while they each claim to be the voice for Sinagporeans, they hold views that angry doc, also a Singaporean, disagrees with. How is that possible?

The truth is, Singaporeans hold a myriad of views over a multitude of subjects, and oftentimes while these views are in direct opposition to each other. In addition, while two Singaporeans may share the same view on one subject, they may disagree over another. There is no "one voice" for all Singaporeans, and anyone who claims that he can be that one voice for all Singaporeans is... well, angry doc disagrees with him.

It is easy to be populist and make the blanket statement that "I will represent you and fight for you", and much more difficult to make a stand and say: "these things I believe in - vote for me if you believe the same".

angry doc certainly won't be voting for any Tan this election...

Donation Economics

2011-08-01T10:00:00.004+08:00

Really, you can't make stuff like this up...

Tax reliefs: Treat all donors equally

WHEN a person makes a donation to an Institution of a Public Character, a government-approved museum or a prescribed educational or research institution, he is entitled to a tax relief equal to 250 per cent of the amount donated.

An approved donation of, say, $1,000 reduces the donor's chargeable income by $2,500.

The impact of this varies for different donors, depending on their chargeable income.

If the donor's chargeable income exceeds $320,000, for which the marginal tax rate is 20 per cent, the net (after-tax) outlay to the donor is $500.

If his chargeable income is between $30,000 and $40,000, for which the marginal tax rate is 3.5 per cent, his net outlay is $912.50.

If his chargeable income is less than $20,000, for which the marginal tax rate is zero, his net outlay is $1,000.

This does not appear right.

First, a donation is a donation. The tax relief results in an inverse relationship between the net outlay of a donation and the donor's marginal tax rate. Why should a donation of any given amount become an outlay that is smaller after tax for a high-income donor than for a low-income donor?

Second, this distortion has been magnified as the tax relief was raised over the years. The tax relief was doubled to 200 per cent of the amount donated in 2002, and to 250 per cent in 2009.

Third, the lower a donor's chargeable income, the donation of any given amount forms a bigger part of his chargeable income and may be a bigger sacrifice for him.

The existing tax relief should be replaced by a tax rebate of a fixed percentage of the amount donated. In addition, individuals who do not pay income tax should receive, in cash from the Government, an amount equal to the tax rebate.

In this way, all donors will be treated equally and equitably.

Such changes should not discourage donations by the wealthy - if the donations are truly from their hearts.

David Boey

angry doc was reminded of the "Barstool Economics" parable when he read this letter; Mr Boey sounds like one of the gentlemen who now pays less for his drink, but is nonetheless unhappy that the richest are enjoying a bigger discount than he is.

Mr Boey ignores the fact that even with the bigger discount, the actual amount of taxes paid by those in the highest bracket remains much higher than that paid by those in the lower brackets. He believes that the a fixed rebate rate treats all donors "equally and equitably", yet has no problem with a progressive income tax regimen.

Ironically, the tax rebate which he proposes that donors who do not pay income tax will come mainly from those in the higher brackets - a man can choose to "donate" $1000, when in truth he donates only part of that, with the remainder being levied from those who pay income tax (with no choice in the matter). In fact, by having a rebate on donations, we are in fact making those in the higher brackets pay for a part of all donations made - we are in effect forcing them to pay for our donations! Is this, in Mr Boey's opinion, fairer than the existing system?

Nationalisation - the cure for all woes?

2011-07-22T17:00:00.001+08:00

Nationalising public transport not fair

MR GERALD Giam states that taxpayers already contribute to the basic infrastructure of the transport system and does not elaborate ("Consider the economic reality of transport here"; Tuesday).

His view suggests that, as we have paid for some of it with our taxes, it should not bother us to continue to subsidise the transport system's operation.

We should draw a clear line between state money, which funds basic infrastructure (which benefits the country as a whole) and state money subsidising transport operations (which benefit only users).

Mr Giam does not differentiate between the two. Using taxpayers' funds to subsidise public transport users is an ongoing, open-ended contribution which is unfair to those who do not use it.

Mr Giam also criticises the profit model which he says benefits only shareholders via dividend payouts.
This may be true but somewhat distorts reality.

Investors did not get a free ride. They coughed up money from their own pockets, which the public transport operator uses for its operation and such.

To the investor, this constitutes some risk and it is not wrong for him to expect a return.

Capital formation markets, be they in stocks or bonds, are basically avenues for enterprises to gain access to vital capital, without which any economy would fail.

It is a willing-buyer, willing-seller system which, one hopes, is a win-win situation.

In a nationalised transport system, the taxpayer who does not use the system is not given the choice whether he wants to ante up this risk money to subsidise its continued operation.

Daniel Yew

angry doc does not think that our public transport system is perfect, or that the public transport market is truly competitive; still, he is not convinced that nationalisation of public transport is the solution, or that it is fair, for reasons that Mr Yew has stated.

The idea that "[u]sing taxpayers' funds to subsidise public transport users is an ongoing, open-ended contribution which is unfair to those who do not use it" seems obvious, but there will always be those who continue to advocate it because they perceive that they stand to gain from it, either for political capital, or because they don't want to pay for what they use.

Not sure if...

2011-07-08T20:21:00.007+08:00

Raise pay of other health-care professionals too

I AM glad the Ministry of Health is reviewing doctors' salaries ('MOH to review doctors' pay'; Wednesday) and hope that the welfare and salaries of the unsung heroes in hospitals will also be looked into.

They include nurses, physiotherapists, speech therapists and nutritionists.

Although public hospitals have a long way to go to catch up with private hospitals, the step to review salaries shows that the ministry is becoming more open to changes.

However, I hope this will not result in an increase in patients' bills.

David Soh

Sure, why not? Raise service provider's pay, but keep the price to consumers the same. Don't see any problem there...

You CAN put a price on everything...

2011-06-28T11:30:00.001+08:00

(Posted on the Singapore MD blog)

"Getting ill and fat from stuffing our eyes with TV"

2011-06-24T18:00:00.006+08:00

At long last, McDonald’s in Singapore is offering a grilled chicken salad among its menu choices. I gave it a try the other day...

As I was about to tuck into it, a ‘McDonald’s uncle’ (one of the restaurant’s elderly employees) who was tasked with clearing tables, walked past and looked quizzically at my order. He then quietly said to me that I should not bring outside food into a McDonald’s restaurant.

“But I bought this here,” I protested. “Haven’t you seen this item before?”

Apparently not.

Apparently no one else has yet ordered it.

(read the full article here)

GPs not functioning?

2011-06-07T20:30:00.000+08:00

(Posted on the Singapore MD blog)

Obvious News Day

2011-06-05T23:49:00.006+08:00

So... flooding is caused by too much water? That's news to angry doc...

Almost all smokers are aware of the harmful effect of secondhand smoke to others, but still they continued to smoke in front of their families and friends who do not smoke? Well, if they are concerned about the family and friends to begin with, why would they do something that harmed their own health to begin with?

"There is no abuse"

2011-05-31T22:15:00.000+08:00

(Posted on the Singapore MD blog)

"Why Physician Compensation Plans Fail"

2011-05-25T17:00:00.002+08:00

(Posted on the Singapore MD blog)

Subsidy - the cure for all woes?

2011-05-12T20:00:00.000+08:00

(Posted on the Singapore MD blog)

Forget George Yeo...

2011-05-10T21:30:00.001+08:00

angry doc says we make this guy our next president...

Shadowy Health Plan

2011-05-04T18:00:00.000+08:00

(Posted on the Singapore MD blog)

Coming soon to a HDB flat near you...

2011-05-04T00:30:00.002+08:00

Blogger's impression of the James Gomez Wing of Chee Soon Juan Memorial Hospital

Details here...

Small change you can believe in

2011-04-28T23:00:00.004+08:00

angry doc doesn't usually show his politics on his blog, but this news article just has to be brought to his reders' attention, he thinks...

(excerpts)

SDP candidate Tan Jee Say said: "S$10 billion of the $60 billion will be going to promote (and) create industries.

"I think these are industries of the future, where your young, educated population can find traction, do well and excel.

"The kind of industries, services like advertising publishing and all that, these are industries of the future - creative industries.

"Facebook started small, (with a) humble background -- so (did) Google.

"And I'm quite prepared to put aside S$10 billion to promote (this, and) to give a million dollars each to one or two of (the) 'Facebook or Google generation', the young people.

"PMETs like yourselves, (if) you want to start a new industry, ask the government to give you one million dollars each and you do it for the next few years.

"With S$10 billion, divided by S$1m, then you could have how much ... 10,000 firms. 10,000 you multiply by three or five staff per company, (and for a) small company, you could have 50,000 jobs".

Mr Tan was asked how his S$60 billion National Regeneration Plan could be financed, to achieve all the suggestions the SDP wants.

He said the funds can be achieved by selling government assets and drawing from reserves.

"I'm not saying that we take every single dollar from the reserves," Mr Tan said.

"We have, I think the official figure two, three hundred billions, but obviously it's much more than that.

And I'm only asking for S$60 billion -- not much, small change," he said with a chuckle.

Well, angry doc LOL'd...

Happy Easter

2011-04-22T20:30:00.000+08:00

Arrogance of ignorance 2

2011-03-14T22:30:00.001+08:00

(Posted on the Singapore MD blog)

Smile

2011-02-25T22:00:00.001+08:00

A New Low for SMA

2011-02-15T18:30:00.000+08:00

(Posted on the Singapore MD blog)

"Should doctors check the daily horoscopes of their patients?"

2011-02-14T21:30:00.000+08:00

(Posted on the Singgapore MD blog)

Lipstick on a Pig 4

2011-02-07T20:00:00.003+08:00

(Posted on the Singapore MD blog)

Lipstick on a Pig 3

2011-01-27T23:40:00.001+08:00

(Posted on the Singapore MD blog)

Lipstick on a Pig 2

2011-01-09T01:00:00.001+08:00

Reading this letter to the ST Forum...

TCM practitioners not exempted from duty to provide proper medical care

WE REFER to Dr Ong Siew Chey's letter on Thursday ('Certifying TCM practitioners: It opened Pandora's box').

Although Western medicine is the mainstream health-care service in Singapore, traditional medicine services such as traditional Chinese medicine (TCM) remain popular and are increasingly gaining public acceptance.

The Traditional Chinese Medicine Practitioners Act was enacted to safeguard patients' interests and safety, and to ensure an acceptable standard of TCM practice is maintained.

Singapore does not have double standards regarding medical practice. Every professional group has different qualifications, training requirements and scope of practice. TCM practitioners, by virtue of their training and practice, are not the same as Western medical practitioners. In the same way, nurses, pharmacists and other health-care professionals are also different. Therefore, not all health-care professionals could be viewed in the same way.

China's health-care practices and regulatory frameworks are different from Singapore's due to its historical and political development. While we have taken reference from China in the way TCM is regulated here, we are also developing our brand of regulatory framework, as Singapore is one of the first countries outside of China, Hong Kong and Taiwan to regulate TCM.

We have much to learn and a long way to go, as the regulatory framework for TCM is still in the infancy stage compared to the regulatory framework for Western medicine. As a matter of fact, the current Singapore TCM regulatory framework has taken reference from the regulatory framework as set out in the Medical Registration Act and the Dentists Act, in particular, with regard to the disciplinary powers of the TCM Practitioners Board over TCM practitioners.

This is not a case where TCM practitioners enjoy any exemption from their obligation to provide proper and adequate medical care. If any TCM practitioner is found guilty of misconduct or improper behaviour, he will be dealt with by the TCM Practitioners Board.

We thank Dr Ong for his feedback, and welcome feedback and ideas from the TCM community, the health-care family and the public to make our TCM regulatory framework one of the best in the world.

Chuo-Ng Peck Hiang (Mrs)
Executive Secretary for Registrar
TCM Practitioners Board

reminded me of this post I wrote more than a year ago.

Now Mrs Chuo-Ng is factually correct in many of the statements she made: TCM is "popular and... increasingly gaining public acceptance", the TCM Registration Act is largely based on the same framework the Medical Registration Act and the Dentists Act, and TCM practitioners are subject to penalties if they are "found guilty of misconduct or improper behaviour".

But those points do not change the fundamental fact that TCM is a pseudoscience the theory and practice of which are not based on evidence, and that no amount of legislation or regulation is going to make it so. To want to "regulate" TCM before we can even demonstrate the existence of 'qi' is as ridiculous a notion as that of having a medium registry before we can proof that spirits or deities exist.

A penny for your thoughts? 6

2011-01-06T18:15:00.001+08:00

(via The Singapore Daily)

Lipstick on a Pig

2011-01-06T18:00:00.001+08:00

(Posted on the Singapore MD blog)

A penny for your thoughts? 5

2010-12-24T17:00:00.001+08:00

Just to give an example of how much information may be required in the filling of a medical report, angry doc snapped a picture of a typical medical report request from an insurance company:

So how much do you think a doctor should charge for providing this medical report?

A penny for your thoughts? 4

2010-12-17T18:30:00.003+08:00

At first, it was a case of overcharging.

Then, when it was pointed out that it's in fact a case of undercharging, it became an issue with inefficiency.

Now, it seems that how much it costs isn't really an issue, as long as the "consumer" doesn't have to pay for it.

angry doc buys medical and travel insurance, and he would rather the insurance company "pay" for the medical report than if he paid out of his own pocket. However, even though angry doc is a doctor and not an ex-CEO of an insurance company, he is not naive enough to think that the medical report becomes "free" to him just because it is "paid for" by his insurance company.

The wonderful thing about insurance companies, like casinos, is that they have a whole bunch of people curnching numbers to make sure that the odds are always in their favour, and that their employers' profit margin is always looked after - if the cost of the medical report is absorbed by the insurance company, angry doc is pretty sure that it will be worked back into the equation, either through higher premiums, and lower payouts, such that the company's bottom-line stays where it is.

So at the end of the day, we still have to pay for what we want or need, regardless of how reluctant we are, and regardless of how little we price (note that I say 'price', not 'value') other people's work.

angry doc is pretty sure Mr Tan knows that; he's just confused as to why he would write as if he didn't.

A penny for your thoughts? 3

2010-12-14T20:30:00.004+08:00

Mr Tan defends his $30 price-tag for a medical report on his blog.

angry doc is no longer surprised by how people who cannot and do not produce a goods or a service nevertheless feel they have a right to tell those who do how much to charge for what they produce; but he *is* surprised by how someone with Mr Tan's work experience views the issue of medical report.

What exactly does Mr Tan mean when he refers to a "routine report", which he suggested doctors charge $30 for? If it was simply a case of to "write down what is the problem with me relating to a specific medical condition", then angry doc would say that most doctors will probably not charge a separate fee at all, but consider it as part of the consultation. But is that really all that is required "to support an insurance claim or application for insurance"?

Doctors (and patients) who have been asked to fill up a "routine" insurance claim form will realise that that is not the case; the typical insurance claim form runs to nearly a dozen pages, and oftentimes requires a doctor to report the reason for consultation, diagnosis made, and treatment rendered for *every* visit the patient made to a clinic!

Blogger Cyke also points out that the cost of a medical report do not just go to the doctor's fee, but includes the administrative work required.

Those facts aside, we are still left with the subjective question of when a fee is considered "excessive".

Doctors, and the institutions they work for, charge at the end of the day "what the market will bear", which is to say what they can get away with. So if, as Mr Tan seems to believe, "there is no free market here - but a monopolistic situation", why aren't doctors charging say $800 instead of $80 per medical report? Why do most restructured hospitals charge a fee around that mark?

Well, because there is a market here, despite what Mr Tan claims - a doctor (or hospital) who charges $800 per medical report on a routine basis will find himself off the approved list by insurance companies, and unless he is really that good, find that few patients will go to him.

Mr Tan asks: "The consumer would want a low cost, and the doctor would want a high cost. How can this be resolved in the "free market environment" in Singapore?"

Well, angry doc asks: "What is driving the demand for medical reports?"

If you know why people want medical reports, if you understand why they need medical reports, then perhaps you will begin to have a clue as to how to lower the cost for medical reports (or do the reverse...).

A penny for your thoughts? 2

2010-12-08T08:00:00.002+08:00

Q1: What does it take to claim that doctors charge "excessively" for writing medical report?

A1: A Blogger account.

Q2: What does it take to write a medical report?

A2: Five years of medical school, a year of housemanship, several years of relevant post-graduate training, time to read through a patient's medical records and investigation results, knowledge to understand the significance of each, the ability to synthesise all that information and present it in a format that addresses the relevant issues required by the side requesting the medical report, and finally the balls to stand by and back up what you wrote in a court of law if necessary.

Standing up for the 'godless'

2010-12-04T14:30:00.002+08:00

angry doc wasn't aware this special report (who reads newspapers these days anyway?), but thanks to this letter in the ST Forum, he is clued in:

You don't need faith to be good

THE Saturday Special report last week ('God wants youth') stated that religious groups were determined not to lose a generation to godlessness, especially now with youth gangs in the news.

It also noted that what is at stake is the potential of losing the youth to cynicism, violence and even fanaticism.

These remarks suggest a prejudice against those without any religious affiliation.

The last census in 2000 showed that roughly 15 per cent of Singaporeans did not have any religious affiliation.
The article essentially suggested that this group, 'the godless', are cynical and prone to violence.

As a society for non-believers, the Humanist Society (Singapore) disagrees.

The reality in societies everywhere is that there is no difference between non-believing youth and the religious youth in their propensity towards violence. There are actually higher levels of violence among those who identify themselves as 'religious' or 'faithful'.

As for cynicism, there is certainly no correlation between non-belief and a cynical attitude. Many non-believers are involved in the world around them, trying to make it a more humane, compassionate place.

The two largest charitable donations in the history of the world were by atheists: American investor Warren Buffett and his fellow American Bill Gates of Microsoft donated US$30 billion (S$39 billion) and US$11 billion respectively to the Bill and Melinda Gates foundation, a charitable organisation whose main goals are to enhance health care and reduce poverty worldwide.

I know of many non-believers, people who identify themselves as humanists, atheists and agnostics, who regularly donate to charity. Many also do volunteer work for humanitarian causes.

One does not need to have a religion to lead a good, happy and meaningful life and to have compassion for our fellow human beings.

Paul Tobin
President
Humanist Society (Singapore)

Now angry doc thought the statements:

"The reality in societies everywhere is that there is no difference between non-believing youth and the religious youth in their propensity towards violence. There are actually higher levels of violence among those who identify themselves as 'religious' or 'faithful'."

were contradictory, and so he went to look up the Humanist Society's webpage; sure enough the original letter submitted by Mr Tobin read (emphasis mine):

"The reality in societies around the world is that there is either no difference between non-believing youth and the religious youth in their propensity toward violence or there is actually higher levels of violence among those who identify themselves as "religious" or "faithful." [See, for instance, the studies cited in Michael Shermer’s book “The Science of Good and Evil” 2004 pp. 235-236]"

That made more sense...

If the Humanist Society sounds familiar to you (as it did to angry doc), it may be because you've read about them earlier in this news report; a bit of equal air-time, perhaps?

angry doc is ambivalent about the idea of a group that aims to shape our society based on humanist ideals ('ethical' and 'humane' aren't really angry doc's favourite words, you understand...), but he can see why some people feel the need for those without religious affiliation to come together to represent their interests - the fact that "community leaders" believe that the social problems such as gangsterism and dysfunctional families can be solved by making young people believe in the same gods as they do is a scary thought indeed.

angry doc will not be rushing to join the Humanist Society yet, but he certainly thinks it is an organisation to watch.

My Foot!

2010-12-02T18:20:00.001+08:00

(Posted on the Singapore MD blog)

Sense and Sensitivities

2010-12-02T18:10:00.001+08:00

(Posted on the Singapore MD blog)

"Caveat Emptor"

2010-11-28T12:30:00.000+08:00

(Posted on the Singapore MD blog)

Loss 4

2010-10-28T21:30:00.001+08:00

(Posted on the Singapore MD blog)

2010-09-27T08:00:00.001+08:00

It's Paul McCartney - it doesn't have to make sense...

A Taste for Your Own Medicine

2010-09-22T18:00:00.001+08:00

(Posted on the Singapore MD blog)

A Taste of Our Own Medicine

2010-09-18T19:30:00.000+08:00

It's been another rough week.

Thing is, they teach you how to break bad news to patients or their relatives in medical school. People make a lot about it, but angry doc never really believed that how you broke the bad news was important: no matter how you say it, the patient is dying/had a stroke/may have cancer - the fashion in which you put the information across does not alter the fundamental clinical situation; if you don't do it badly and give the patient/relatives a reason to complain about you, they will find some other ways of expressing their anger at the medical system for not being able to stop or reverse the problem. It's all part of the grieving process.

What angry doc wishes they taught him though is how to break bad news to a patient who is a doctor, and one who is a colleague for many years.

When the patient is someone who possesses the same knowledge about the condition as you do, how do you make it sound better than what it actually is?

angry doc needs a drink...

A Taste of My Own Medicine

2010-09-10T08:00:00.002+08:00

angry doc has had a rough week.

It all started with a semi-elective procedure he had to undergo, which was complicated by a medical error at the beginning, adverse effect of a medication following that, and now a possible drug allergy.

The medical error was unexpected but avoidable (and fortunately minor with no longterm consequences), the adverse effect was expected and unavoidable (the benefits of the therapy outweighed the adverse effect), and the drug allergy was of course unexpected and again unavoidable since the medication is part of the treatment.

So three out of four there.

Being a doctor doesn't grant angry doc immunity from adverse medical events, but it does make him see and react to these events differently from the average layman.

He understands how medical errors can occur even under the care of skilled and experienced healthcare workers acting under the best intentions, and he is willing to forgive (as long as the lesson learnt at his expense is not forgotten).

He understands how medications that are good for you can sometimes make you feel uncomfortable, and he is willing to accept that.

What he couldn't stomach though is that fact that it took him so long to self-diagnose the possible drug allergy.

But hey, given the circumstances, perhaps I should cut angry doc some slack, don't you think?

2010-09-01T02:00:00.000+08:00

Just chillin'...

2010-08-23T22:35:00.000+08:00

Five Years

2010-08-19T12:00:00.001+08:00

One thousand eight hundred and twenty-days.
Seven hundred and seventy-three posts.
Thanks for reading.

Whose "health" is it anyway?

2010-07-30T12:40:00.001+08:00

(Posted on the Singapore MD blog)

Confidence Goods 15

2010-07-19T12:15:00.001+08:00

(Posted on the Singapore MD blog)

2010-07-01T23:30:00.000+08:00

Funny thing is, it's got these pictures of horses and all, but Wildfire was a pony...

I'm just sayin'...

Ignoring the Elephant

2010-06-07T23:15:00.001+08:00

(Posted on the Singapore MD blog)

Subsidy and Other Preoccupations 21

2010-05-12T17:00:00.006+08:00

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?

Elite-bashing

2010-04-08T18:00:00.002+08:00

There has been several letters to the ST Forum this week 'bashing' elites, in response to this article by Ms Sandra Leong.

Many of the anecdotes on the cluelessness of the 'elites' are pretty funny - angry doc's favourite is this one:

"A church-mate who lived in a landed property in District 10 - definitely not an RGS girl, and I venture to guess, not even a graduate - once, in all sincerity and innocence, prayed for all those who had to take public transport and live in HDB flats, for God to give them strength to bear these trials. "

Of course, there is no one agreed definition on what makes a person an elite, which makes it hard to discuss the issue intelligently. But what worries angry doc is an assumption that many people hold, exemplified by what Ms Leong wrote:

"... the pursuit of intellectual excellence to the exclusion of character or value excellence breeds an exclusionary attitude to the rest of society. Many of the products of our top schools forget they have to give back to the society that allowed them so many opportunities."

What is implied there is that people who are successful owe a debt to society, and that if they refuse to "give back" to society, there is something faulty with their character or values system.

But angry doc would like to ask: who in society is calling for this debt to be repaid? On whose behalf is Ms Leong calling for elites to "give back"? What makes us think that we are entitled to the time, effort, or the fruits of the labour of those in society who have succeeded?

"Opportunities", you say? Certainly most people could not have succeeded without the infrastructure which 'society' created (schools, roads, utilities, a civil service, industries), but does that entitle us to make demands on them? Did society create all these infrastructure so that these people could succeed, or did we do so because we wanted to utilise these infrastructures ourselves, so that we too could have a chance to succeed? Society may have provided the opportunities, but by claiming that we have a right to the fruits of their labour, we are dismissing the importance of the individual efforts which made the success of these people a reality - we are laying claims to the result of something which we did not give to. The opportunities were open to everyone, but we choose to ignore the 'debts' of those who did not succeed, and present an invoice to those who did and have something to "give back". Makes good economic sense, of course.

angry doc is not against people who feel that they want to contribute to society - certainly there is nothing to prevent them from doing to; society provides many avenues for them to do so. What puzzles angry doc is why some people feel the need to claim that others must do so too.

To conclude, angry doc would like to do some "Ayn Rand spouting", via youtube...

(For readers who are unfamiliar with "The Fountainhead", here is a succinct summary...)

'Right' to healthcare

2010-03-19T17:00:00.002+08:00

"One of the misconceptions of rights today is that man has a ‘right to a job’, a ‘right to health care’, a ‘right to education’, a ‘right to a house’ – that man has a ‘right’ to things simply because he claims he needs or wants them.

The sanction of such alleged ‘rights’ is the first step toward the destruction of rights. If man has ‘rights’ to health care, to education, to a house, then the appropriate questions to be asked next are: Who is to provide them? And at whose expense?

Jobs, health care, education and houses are not products of nature, nor can they be products of government – because by the nature of government, it cannot be a corporation and a producer – but the products of the men who produced them.

If a man is entitled by ‘right’ to the products of others, it means that those others are deprived of their rights to earn and keep their own property and their rights to sell to whomever they choose. If a man is entitled by ‘right’ to the products of others, those others are essentially condemned to slave labor. A ‘right’ that violates the rights of others is a contradiction in terms. No such ‘rights’ can exist."

- Ho Say Peng

Sing along

2010-03-05T17:00:00.004+08:00

(click on the picture if you don't have a clue...)

Support Love 7

2010-03-02T22:00:00.000+08:00

Spread the word.

Take our rights... please!

2010-02-18T22:30:00.001+08:00

angry doc is quite disappointed by this piece of news.

Now long-time readers will know which side of the 'religious vs. LGBT' divide angry doc is on, and new readers need only look at the sidebar on the right to know his alignment; it is precisely because of his beliefs in these causes that angry doc feels the making of the police reports represent more of a disservice to the LGBT community than help.

While our laws are currently biased against gay people (S377A) and in favour of people of religion (S298), angry doc does not believe that the solution to this state of inequality lies in appealing to the authorities to gag or punish those who speak against the LGBT community (or for that matter any segment of society).

By appealing to the law to take away the right of a person to express his opinion publicly, even if that opinion is wrong or unjustified, we are effectively supporting the belief that the law has that right. What is needed is not for more of our rights to be taken away, but returned to us. The solution to 'bashing' from religion is not to demand that they be silenced, but for the right to challenge the contents of that 'bashing' to be returned to us.

Regardless of the outcome of the police reports being filed, angry doc cannot see how the LGBT community can stand to win from this situation: if nothing comes out of it, then the police would have effectively given the 'go-ahead' for all other persons of religion to make similar speeches against them. If Pastor Tan is made to apologise and undertake not to repeat his speech, then we have merely reinforced the state's right in shutting people up without subjecting the issue to open discussion and debate. If we as a nation, as a society allow the right to openly discuss and support or condemn a point of view to be taken away from us, if we allow the decision of whether someone has a right to express an opinion to be made not collectively by us but by a few who are not endowed that right by us, then we will all become poorer.

If we say to the police: "shut this man up for what he says offends me," then can we really complain when the police tell us to shut up because what we say offends another man?

Trust

2010-02-03T19:00:00.001+08:00

(Posted on the Singapore MD blog)

When I was a houseman...

2010-01-18T19:30:00.002+08:00

angry doc used to work with a (not much more) senior colleague who used to start every other discussion with the phrase "when I was a houseman...".

Prof Lee now does the same in her latest article in the papers:

(exerpt)

Time to reverse 'narcissism epidemic'
The young today are more self-centred and less driven, possibly due to their upbringing

The principal of a mission school invited me to give a talk to his teachers recently.

'The purpose of inviting guest speakers to the school is to open up my teachers' minds about new possibilities and the demands of the real world,' he told me.

I was unable to give the talk but volunteered one of my doctors, an old boy of the school and a superb and compassionate doctor. I told the principal: 'My perspective on the education of these relatively elite boys is to teach them that they owe society a duty.'

The principal agreed, but observed: 'Unfortunately, given the changes in Singapore... my teachers are increasingly pushed by larger societal forces that worship the relentless pursuit of academic excellence as a means of material gain... While there is nothing wrong with pursuing academic excellence, it cannot be an end in itself.'

I and many other senior doctors have noticed that a significant percentage of newly graduated doctors are more self-centred and less hard-working than we were.

For example, there are more house officers with each passing year, and in some departments, there seem to be too many of them. The total work has not increased much, but this is divided among more house officers. Yet house officers complain that they are stressed out and they cannot cope with the work.

When I was a house officer, there was no payment for being on call. As a medical officer, I was paid $40 for the first four calls in the month, and $100 for each subsequent call. There were no mandatory maximum or minimum number of calls for house officers or medical officers.

But some time after 1990, house officers were not allowed to do more than six calls a month and medical officers were not allowed to do more than four calls. House officers are now paid $110 a call on weekdays and $150 on weekends. Medical officers are paid $210 a call on weekdays and $300 on weekends.

We used to have to do eight to 10 calls a month, and the number of patients I saw each time I was on call was considerably more than the numbers seen by house officers and medical officers today.

But despite having to do less work, junior doctors apparently have less time for self-study today.

Consequently, many training programmes now set aside 'protected time' during working days for them to study. In addition, most departments have structured teaching programmes for young doctors - a far cry from the bad (or good) old days when there was no time during working hours for structured teaching and most of us learnt from patients or senior doctors. And to reinforce our knowledge and ensure we missed no crucial information, we would read a standard textbook from cover to cover.

All of the above would appear to be exceedingly difficult for the present generation of junior doctors. For some years, I wondered whether this was the fault of our medical school or indulgent parents."

angry doc belongs to the generation of doctors who benefitted from the enlightened view that doctors should be paid appropriately for their time on calls ($40 for an overnight call would be way below minimum wage if we had one) and that they should not (in theory) be made to work more than six calls a month. Nevertheless, his personal record was 11 calls in one month, and he can remember a few where he did not catch a single minute's sleep.

Housemanship in his days was tough - angry doc has seen it reduce grown men and women to tears - and even then angry doc heard his share of "when I was a houseman" from his senior doctors. angry doc is willing to bet that as a houseman, Prof Lee too got her fair share of "when I was a houseman" from her senior doctors, who remembered how housemen were better in the days of the Raj.

Do junior doctors have it easier these days? Certainly. But that precisely why the changes Prof Lee mentioned (limiting number of calls, structured training, protected time) were implemented - we want to make learning a less stressful experience than what we went through ourselves, and we want it to be safer for everyone.

Does it matter that the youths of today are 'less tough' than we were? angry doc doesn't think so. The whole point of training for junior doctors is to produce doctors who can function in their role in an efficient and safe manner. They may not have to do 11 calls a month, or take blood for 40 patients in one morning, but they face a more demanding generation of patients (and relatives), and the volume of new information and evidence they have to assimilate and incorporate into their practice is enormous. The old challenges are not the challenges they *need* to face today, just as we did not have to face the challenges that they face today when we were housemen.

At the end of the day, when angry doc is ill, he doesn't want a tough doctor who has done his 10th call this month, or a humble guy who thinks he owes society a debt - he wants someone who is rested and has had plenty of time to learn about the condition for which angry doc has been admitted for. It matters not to angry doc that the doctor might have a "positive" opinion of himself - as long as he can do what his job grade requires, it is not an "inflated" view.

Look Back In Anger

2010-01-11T20:00:00.001+08:00

It's a little late to post a look-back of the year, but here goes anyway...

The past 18 months have been a time of change for angry doc - some good ones, some bad, but most of which he thinks he has brought upon himself.

angry doc's opinions on many subjects have changed. Not surprisingly, this also meant that people's opinions of angry doc have also changed. Curious thing is, you sometimes don't even know what someone's opinion of you is until he or she tells you that his or her opinion of you have changed. Even more curiously (or curioser), angry doc realised that he doesn't really have an opinion of himself anymore, if he ever had one before.

angry doc doesn't know how often he will be blogging this year. It's not just because he will be busy with work (you are never too busy to blog, really), but because he is not sure he sees the point of putting his opinions down anymore.

Weird?

2009-12-23T20:30:00.000+08:00

Quote of the week

2009-12-03T17:00:00.000+08:00

In Singapore, TCM complements western medicine and this mixed
system is best for consumers. The two operates on very different philosophy and
it is hard and unfair to assess one using the other's benchmark.

For patients, whether it is east or west, so long as it works,
it is the best!

- Mr Khaw Boon Wan, Minister for Health, on TCM

Busy

2009-11-30T22:00:00.001+08:00

angry doc apologises for not posting for almost the whole of this month. The end of the year is usually a slow period for this blog, but he has been busier than with work, fighting against racism and stupidity in real life, and the general mechanics of daily living.

It will probably be another two or three weeks before he gets his groove back.

Thanks for stopping by.

Wednesday

2009-11-04T22:00:00.000+08:00

Monday

2009-10-26T08:00:00.000+08:00

Dr Tan, I presume?

2009-10-22T17:00:00.000+08:00

Google is a wonderful thing.

This letter on the ST Forum today did not come as a surprise to angry doc:

Dispel concerns about complications after vaccinating kids

I REFER to Tuesday's report, 'Immunise infants early, specialists urge'.

I would like to ask child specialists how much adjuvants are given to children in the form of aluminium and mercury salts in vaccines, besides preservatives, over a two-year period, under the Ministry of Health (MOH) childhood immunisation programme.

Scientists have shown that aluminium and mercury are foreign to our biological system and do more harm than good. Does MOH have a register of all complications related to childhood vaccines given in Singapore? According to vaccine package inserts, these complications range from mild fever to severe convulsions and delayed eczema.

In a 2007 clinical study of 300 babies aged between nine and 12 months at five SingHealth polyclinics, what was the adverse complication rate and the severity, in terms of morbidity and mortality? Are these babies followed up long-term and for how long?

Mothers' concerns about autism and vaccination are real. The incidence of autism is reported to be rising in Singapore. This issue has not been thoroughly addressed as to its causation.

Tan Soon Kiam

Sounds familiar?

On a whim angry doc decided to google Mr Tan's name, and it turns out that 'Mr' Tan may in fact be 'Dr' Tan.

In fact, judging from the topic of his 'concern', he may be the same Dr Tan we encountered on this blog more than two years ago.

Dr Tan, as we can see from his letters, is no heavy metal fan. Readers may wish to google his name to find out for themselves why this is so.

What's in a name?

2009-10-16T17:30:00.001+08:00

Fellow skeptic-blogger Singaporean Skeptic's post draws angry doc's attention to a study on Traditional Chinese Medicine (TCM) on ADHD being conducted at IMH.

angry doc is one of those people who routinely calls modern medicine 'western' medicine. He does so because he thinks it is a convention that reduces confusion; but Skeptic does make a good point - calling things by their proper name is important in promoting public understanding of science.

The fact is, even if "yi shen ke li" is shown to improve the behaviour of children with ADHD, it doesn't mean that TCM 'works', because giving a fixed formulation to all patients with a diagnosis that is made by 'western' doctors and which does not exist in TCM canon is not TCM.

Rather, it would mean that the active components in 'yi shen ke li' works. If we go on to identify that active component like Skeptic suggested, then it will mean that that active component works. If we continue to give children 'yi shen ke li' in its current form to children, then it would mean that this particular *herbal* medicine works. Either way, it would mean that modern or scientific medicine works, but not that TCM works.

Being conducted by IMH, angry doc is pretty sure the trial will be vigorous and have proper control group/s and be properly double or triple-blinded, although he suspects that the results will be like this one he looked at a while ago. He eagerly awaits them , and hopes that a 'negative' trial will also be reported with the same fanfare in the local media.

Medium Register

2009-10-12T19:00:00.001+08:00

An interesting piece of news here:

Mediums to be regulated
Taoist Federation aims to weed out unskilled tang ki
By Yen Feng

THE Taoist Federation is taking steps to regulate spirit mediums here.

As early as next month, it will issue registration forms to the roughly 300 temples affiliated to it, so a register of mediums, or tang ki in Hokkien, can be set up.

Federation president Tan Thiam Lye told The Straits Times last week that this was the first in a series of steps to set apart those trained in channelling Chinese deities.

Registration is, however, voluntary for now. Down the road, licences may be issued.

More immediately, the federation will also produce a free manual to help devotees discern between skilled and unskilled mediums.

Saying the federation will take things 'one step at a time', he added: 'It is time for us to regulate them. We must not let the actions of a few bad apples lead to a misunderstanding of mediums and Taoism.'

angry doc will be very interested in finding our how to "discern between skilled and unskilled mediums". Maybe they can give a copy of the manual to Father Simon so he doesn't hold a "prayer session" for the wrong person in the future...

Discussion

2009-10-11T22:00:00.000+08:00

(Posted on the Singapore MD blog)

WWSKW?

2009-10-06T23:30:00.001+08:00

angry doc is a little disturbed by two letters that were published in the ST Forum in response to Salma Khalik's article.

Fellow bloggers spacefan and Gigamole have blogged about them, and angry doc thought he might venture an opinion too.

While angry doc had always had respect for Prof Goh and more recently Dr Chong, he found their letters too defensive in tone; rather than to just stop at admitting that our profession has some way to go to policing our own, both men found it necessary to strike back at Ms Khalik.

Prof Goh tried to shift part of the blame for the problem to the media ("including the newspapers"), and in effect called Ms Khalik's article "unfair reporting" which hurt the feelings of ethical doctors.

Dr Chong brought in the red herring of the H1N1 pandemic, and accused Ms Khalik of being "callous and unpatriotic".

Ironically, the first sentence of Ms Khalik's article reads:

"There is no doubt that the majority of the 8,000 doctors in Singapore are ethical professionals."

angry doc has no love for Ms Khalik, but over the years he had come to realise that sometimes an 'unfriendly' journalist can in fact be the profession's and patients' best friend, and that the best question to ask when looking at a question on policy or ethics is sometimes: "What would Salma Khalik write if she knew about this?".

angry doc had never had his feelings hurt by expose of unethical doctors, because he knew very well how *he* practised; he is responsible for his professional actions as an individual, just as the errant doctors are - he feels no shame for other doctors' actions, just as he does not expect other doctors to feel shame for his actions.

Yet the letters from the two presidents have managed to make him feel embarrassed to be a doctor today. Had angry doc belonged to either of the societies, he might have felt ashamed.

Chowder is just Chowder

2009-09-30T23:10:00.002+08:00

Once in a while angry doc learns important things about life from children and cartoons.

Yesterday, while watching an episode of Chowder with his young nephew, angry doc asked: "What sort of animal is Chowder?"

Rather impatiently, his nephew answered: "Chowder is not some sort of animal; Chowder is just Chowder."

Then, seeing the embarrassment on his uncle's face, he added: "Chowder is a kid."

He obviously gets it.

We should all spend more time watching cartoons with children.

Still around

2009-09-30T23:00:00.000+08:00

angry doc is still around, but he is too busy following up on his small victories to post anything substantial.

Still, you can join him in the discussion on the new residency programme over at Singapore MD, where he still drops by occasionally to moderate the comments.

Small victories

2009-09-18T23:00:00.001+08:00

It's been a long day, but angry doc is in a good mood.

Important decisions affecting the lives of thousands are often made by one person, but that one person's decision can often be affected by the words and action of a few.

angry doc thinks he made a difference today. In fact, he counts three little victories today.

It's the little victories that keep us fighting.

2009-09-15T17:30:00.001+08:00

Most things can be explained.

Some things are harder to explain.

Some things are better left unexplained...

From somewhere else

2009-09-14T18:00:00.002+08:00

Something better than what angry doc can come up with all by himself here.

Oh my God, the sued Simon!

2009-09-13T11:15:00.001+08:00

You bastards!

Somewhere else

2009-09-12T22:00:00.003+08:00

angry doc apologises for not posting for more than a week now.

He is not being lazy, and is in fact continuing the fight to promote scientific thinking over at Mr Wang's blog. Do drop by and have a read (here and here).

Any rumours of angry doc hoping to gain a cut from Mr Wang's advertising income are just vicious lies.

Big World

2009-09-04T22:00:00.001+08:00

It seems whenever you attend a gathering where there are a sizeable number of doctors and lawyers people will find that they have common friends or ex-classmates or colleagues.

Invariably someone will exclaim:"What a small world!"

angry doc always laughs to himself when he hears that; the fact is it is a very big world, and no matter where our business, studies or leisure takes us, we will have only seen a small portion of it, and have met only a tiny percentage of the six billion people who live on it.

It's a big world - we just move in small circles.

Nope... I got nothing

2009-09-01T20:00:00.002+08:00

Fallacies and Misconceptions

2009-08-20T19:00:00.001+08:00

(Posted on Singapore MD.)

Four Years

2009-08-19T08:00:00.004+08:00

One thousand four hundred and sixty-two days.

Seven hundred and thirty-eight posts.

To celebrate this blog's fourth birthday, angry doc would like to share a bit of trivia with his readers: Angry Doctor was started on the same day The 40-Year-Old Virgin was released in the US.

This was of course just a coincidence - angry doc was not 40 years-old then.

Quote of the Week 4

2009-08-18T17:00:00.000+08:00

"... we are concerned about the public perception of persons with mental illness (PMIs) that may be generated from this report, or other similar reports.

We would like to add that anti-social personality disorder is not a mental illness, but a problem with personality traits that result in persistent anti-social acts (they are also sometimes called sociopaths or psychopaths)."

- Ms Rajeswari K., Executive Director of Singapore Association for Mental Health, on why it is okay to stigmatise people with anti-social personality disorder.

Quote of the Week 3

2009-08-05T17:00:00.002+08:00

"We don't talk about clinical trials. We're not reducing people to digits and statistics. We treat people as a whole. I don't think like most doctors do. I'm different."

- Dr Y. M. Wong, on stem cell "anti-aging" treatment

Begin at the end 2

2009-08-01T22:50:00.003+08:00

(Posted on Singapore MD.)

Judging doctors 2

2009-07-30T17:15:00.001+08:00

(Posted on Singapore MD.)

Judging doctors

2009-07-23T20:30:00.001+08:00

(Posted on Singapore MD)

"Good, absolute values"

2009-07-22T12:00:00.000+08:00

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.

Begin at the End...

2009-07-18T19:00:00.002+08:00

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

(Posted on the Singapore MD.)

don't need doctors anymore

2009-07-10T22:00:00.002+08:00

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?

Probably.

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.

The Doctor and the Virus

2009-07-08T23:00:00.004+08:00

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?

WTF?

2009-07-07T21:30:00.002+08:00

No, seriously: WTF?

angry doc needs to go lie down now...

Showing his politics

2009-07-05T12:00:00.002+08:00

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.

Arrogance of ignorance

2009-07-03T23:30:00.005+08:00

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?

2009-07-03T22:10:00.003+08:00

Tired

2009-07-02T21:00:00.001+08:00

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...

Because it's okay to just post a video?

2009-06-29T20:30:00.000+08:00

Compressions by an Australian Opium Eater

2009-06-25T22:30:00.002+08:00

angry doc has always wondered where drug companies that manufacture opiate-containing drugs got their 'legitimate' opium from - now he knows.

Opium-eating wallabies get high, make crop circles

SYDNEY (AFP) - - Wallabies are getting "as high as a kite" on opium in Australian poppy fields and flattening crops as they hop round in circles, according to a report.

The marsupials, which look like small kangaroos, have been getting into medical opium crops in the southern island state of Tasmania and chewing on the plant's intoxicating heads, state officials said.

"We have a problem with wallabies entering poppy fields, getting as high as a kite and going around in circles," state attorney-general Lara Giddings told a parliamentary estimates hearing.

"Then they crash. We see crop circles in the poppy industry from wallabies that are high," local media reported Ms Giddings as saying.

Tasmania is the world's largest producer of legally-grown opium for the pharmaceutical market, with about 500 farms supplying approximately 50 percent of the raw material for morphine and other opiate drugs.

Livestock and other animals, such as deer and sheep, which eat the plants had also been seen acting "weird," industry spokesman Rick Rockliff said.

"There have been many stories about sheep that have eaten some of the poppies after harvesting and they all walk around in circles," he said.

Tasmania is beginning to sound like a nice holiday destination...

Because it's okay to cry

2009-06-22T22:35:00.001+08:00

Confidence Goods 14

2009-06-18T17:45:00.001+08:00

Does this sound familiar?

Website to put up hospital ‘scoreboard’
Cancer support website to collect public feedback on patient services
by Lin Yanqin

FROM time to time, medical professionals may need gentle reminders to show more empathy and care when dealing with patients.

And the founder of a cancer support website hopes to do just that, by helping members of the public send notes to doctors and nurses from public hospitals whom they feel have not carried out their duties well.

So that such feedback does not go unnoticed, the number of such notes - called “Smart Chips” - received by each hospital will be tallied on a “scoreboard” on the website www.cancerstory.com.

Said website founder Lee Soh Hong, 47: “By having members of the public come together to express their concern, I think it will draw the public hospitals’ attention and help them realise that they need to do something about their shortcomings.”

But the idea has drawn criticism from some medical professionals, who doubt the effectiveness of such a feedback mechanism.

Ms Lee, a freelance accountant, started this initiative following the feedback she received on the book she wrote last year about her father’s death and her negative experience with the care he received in a public hospital.

Changi General Hospital chief executive officer T K Udairam felt that the scoreboard created an unfair basis for comparison.

“Some of the public hospitals are large and see a huge volume of patients, so it’s likely they will gather more notes and feedback than other hospitals,” he said. Hence, it would be unfair to draw conclusions based on numbers alone.

The hospital has five different feedback mechanisms, all of which are actively used. “We get emails and calls every day,” said Mr Udairam.

“It’s a complex balance between the patient’s expectations and whether we can meet them as a public hospital, and I don’t know if this (initiative) can address (the complexities).”

A nurse from a public hospital said she did not understand the need for the initiative, since patients can send their feedback to the hospital or the medical personnel themselves.

“I think it’s more sensible to encourage communication between the public and us,” said the 34-year-old nurse, who declined to be named. “This seems roundabout.”

Ms Lee acknowledged that the initiative was not a perfect solution. “I have spoken to doctors and nurses I know, and while they were encouraging, they also said that it’s up to (individuals) whether they take the message to heart,” she said.

“There is no quick fix to influence others, and it will take time for Smart Chips to be successful in reminding doctors and nurses to play their roles professionally. But I think it’s worth a try.”

Ms Dorothy Tan, 46, an accounts and admin manager and a supporter of the initiative, felt it was a good move.

“It’s another outlet for people to make their feelings known and I think it creates a bigger sense of accountability for improvement for the hospitals,” said Ms Tan.

If it does, maybe it's because you read about a similar idea here almost three years ago?

It is difficult to predict how Ms Lee's project will turn out, but angry doc is not optimistic that such a scheme will improve the quality of care delivered by the hospitals. angry doc doesn't care if his patients feel good after seeing him - he just wants them to get better. He eagerly awaits his first "chip".

2009-06-14T21:30:00.001+08:00

1.6 billion viewers can't be wrong

2009-06-12T20:15:00.000+08:00

How about that?

Libel Laws and Blogging Against Quackery 2

2009-06-05T17:50:00.000+08:00

(Posted on the Singapore MD blog.)

Changes 2

2009-06-04T17:30:00.002+08:00

(Posted on the Singapore MD blog.)

Family Values

2009-06-02T18:00:00.003+08:00

"just being strong for all of us the way Papa was..."

While the world frets over North Korea's nuclear ambitions, angry doc actually find the whole episode rather heart-warming in the light of this news story:

North Korea's Kim picks third son as successor

SEOUL : South Korea's main spy agency believes North Korean leader Kim Jong-Il has designated his third and youngest son, Jong-un, as his successor, a lawmaker said.

The South's National Intelligence Service (NIS) informed a closed parliamentary hearing on Monday of the development, Park Jie-Won of the main opposition Democratic Party said in an SBS radio interview.

"I was notified by the government (Monday) that there are such movements, and that (North Koreans) are making pledges of loyalty to Kim Jong-Un," he said.

According to South Korean media reports, Kim is understood to have informed his military, parliament and diplomats abroad of the nomination shortly after the communist North's second nuclear test on May 25.

The NIS and other officials declined to confirm the reports.

"Our ministry has yet to confirm the nomination of Kim Jung-Un as successor," Chun Hae-Sung, spokesman for the unification ministry in charge of inter-Korean affairs, told reporters.

The succession is a subject of intense interest, notably after South Korean and US officials said Kim Jong-Il, 67, suffered a stroke in August last year. He is thought to have since recovered and resumed most of his duties.

Quoting well-informed sources, the Dong-a daily said North Koreans were being taught new songs apparently aimed at instilling loyalty to the next leader, addressing Jong-Un as "General Kim."

Yonhap first reported in January that Kim Jong-Il had nominated Jong-Un as his successor and informed the ruling communist party leadership of his choice but there has been no official announcement from the North.

Jong-Un was born to the leader's third wife, Ko Yong-Hi, who reportedly died of breast cancer in 2004. He was educated at an international school in Switzerland. It is not known whether he holds any official post.

Kim's eldest son -- Jong-Nam, 37, who was born to a different mother -- apparently spoiled his prospects as leader after being deported from Japan in 2001 for trying to enter the country with a forged passport.

Some analysts have seen his second son, 27-year-old Kim Jong-Chul, as the favourite to take over.

But Kenji Fujimoto, a former Japanese sushi chef for the North Korean leader, has said in a memoir that Kim thought of Jong-Chul as too feminine and unfit for leadership.

He described Jong-Un as a "chip off the old block, a spitting image of his father in terms of face, body shape and personality."

- AFP

angry doc believes that if you look beyond all the communist ideology (who believes in that these days anyway?) and the realpolitiks, the whole nuclear thing is just about, to paraphrase Connie Corleone, "papa being strong for all of us" and Kim Jong Il wanting his son to have the power to protect the family, just as his father had wanted his son to. How can anyone fault someone who values family so much?

Once again, "The Godfather" answers all of life's questions...