Anecdotes From The Past Decade

Last month marked the 10th anniversary of my graduation from the National University of Singapore.

I haven't had the chance to pick any of my fellow classmates' minds about their feelings regarding this important milestone, so I'll just offer mine for now. :)

While there're many issues worth raising, 3 deserve special mention.

I speak from an emergency physician's perspective, but views from other specialties are welcome.


1) The difficulties ( and perils ) of the doctor-patient relationship

My biggest peeve where clinical practice is concerned is Singaporeans' almost pathological lack of interest in their personal medical histories. Educational level plays no significant role, as I've had more than my fair share of English-speaking yuppies who are completely clueless about their own conditions.

Ever since medical records became easily accessible through integrated hospital computer systems ( only in the public sector, that is ), patients routinely instruct me to "check your computer lah, it's all there", which is a breeze until the system crashes or gets shut down for maintenance work.

I often wonder how valid "informed consent" for procedures and operations really is, when I come face to face with someone who tells me "I had surgery, but don't know what it was for. I think maybe it was a tumour in the large intestine?"

Which brings me to another huge concern: patients not being informed that they have cancer, just because their relatives ( usually their offspring ) request it.
The usual reason being: I'm afraid my mother / father won't be able to take the news and may sink into depression / do something rash, etc.

Most of the time, I choose to play along with the charade - hey, if the oncologist is doing it, who am I rebel? But once in a while, a patient will push me for an answer, and I will feel like a piece of crap for lying.

Medical law experts assure us we can't be sued for revealing a diagnosis to a patient, because s/he has the right to know. So why do we still allow this farce to continue?

My third complaint is about patients' expectations. Certain public figures and even medical colleagues need to share the blame on this one.

Emergency Department (ED) annual patient attendances rise steadily with each passing year, and manpower distribution never seems to catch up. I turned registrar in 2005, and within just 3 years, it got so busy that we couldn't cope with the usual 2 senior ED physicians on morning / afternoon shifts and 1 senior on night. Now, we often need 4 in the morning, at least 3 in the evening, and 2 overnight.

I will never comprehend what goes through some of our patients' minds when they make the conscious decision to come to the ED. Excluding referrals and valid presenting complaints ( e.g. chest and abdominal pain, shortness of breath, suspected stroke, bleeding, etc ), we encounter a significant number of common colds ( even pre-H1N1 ) and requests for "full body checkup" / scans / scopes / appointment with a specialist that very same day.

My annoyance often prompts me to ask the latter group where they got the idea that the ED is capable of organizing all these tests and appointments with such astounding efficiency. The commonest answer: My GP told me so.

Wow, I don't know whether to be flattered or to perform a vivisection on myself.

Other vexations: people who scream and shout demanding instant service when we're already swamped with much sicker cases, and here's a good one - those who require immediate admission wanting to be discharged for personal reasons, then asking that we "hold the bed" for them until they return a few days later.

Are they getting this from TV shows? Something on Channel 8 or Channel U, which I never watch?


2) Patients and the media

I don't keep track of statistics, but the Forum Page - for a certain period, at least - seemed to target medical institutions until it started toning things down recently. Change of editor, perhaps? ( I suspect this because my emails got rejected for years before getting published regularly starting from 2008. )

The worst examples occurred in 2003, when an Infectious Disease specialist and a surgical registrar were blasted by the press for acting irresponsibly and spreading the SARS virus to others.
That year also produced quite a few complaint letters from patients ( or their relatives / friends ), one of whom got all her facts wrong and should've been sued for defamation for implicating the Singapore National Eye Centre in a complication that was caused by a private eye surgeon.

I'm all for Forum letters which are factually correct. But when the editor chooses to believe one side of the story without bothering to get any form of corroboration - such as checking with the hospital in question - this is just plain negligence of the highest order.

There've been occasions where the complaint is printed together with the hospital's reply, but this is rare. So unless you pore through the section on a daily basis, you're probably going to miss the all-important response.

Little wonder an ED chief once remarked to me that "The Forum Page is the first thing I read every morning, because I worry that there'll be a complaint against my department in there - whether it's justified or not."

And let's not forget all the patients who've threatened to write to The Straits Times when they don't get their way. One lawyer from a few years back used to frequent our ED for MCs, always presenting with chest pain then refusing to complete the full 8-hour observation protocol so he can leave after 2 hours and default whatever follow-up appointment we arrange.
Smelling a rat, I decided not to issue him medical leave, only to witness his transformation from Dr. Jekyll to Mr. Hyde, as he berated me in public and said he'd write to the Forum Page about my behaviour.

It's a sad, sad day when the power of the press is abused to such a degree.


3) The evolution of emergency medicine practice

Those of us in this field share the impression that emergency medicine just never seems to garner the respect it deserves.

I blame a lot of this on ignorance. Most of those who belittle ED physicians have never worked in the trenches before and/or don't know us personally and/or have no inkling of what emergency medicine involves.

A couple of years ago, an inquiry into a dengue mortality resulted in a medical colleague's disparaging email being forwarded to me by friends in the ward. Her critical comments about ED physicians being nothing more than glorified "postmen" isn't new, but having rotated through multiple EDs since my med school days, it's clear to anyone who bothers to look that patient care in the ED setting has improved tremendously over the years.

I remember how, as a house officer, I often clerked ED admissions who came up without an IV plug, bloods, ECGs, x-rays or medications of any form. Now, we do as much as we can before sending patients up, including taking blood cultures and starting IV antibiotics.

CT brains in the ED have become the norm for anyone with a suspected stroke, and for cases of possible intracranial bleed, certain seizure patterns and altered mental state.

Emergency ultrasound is gaining a lot of momentum as well ( I'm one of its strongest proponents, even though we're still struggling to get money for a new machine ), and we see a difference in how other specialties treat us when we're able to diagnose pericardial effusions, aortic aneurysms / dissections, intravascular volume status ( measuring inferior vena cava diameter ) and hepatobiliary pathologies.

The ED is instrumental in co-ordinating time-sensitive interventions for ST-elevation myocardial infarctions ( ED physicians activate the cath lab directly instead of waiting for the cardiologist to see the patient first ) and acute stroke ( we expedite urgent CT scans and thrombolysis in special cases ).

Last but not least, in this day and age of specialties and sub-specialties, ED physicians are part of a dying breed of "all-rounders", diagnosing and managing a wide range of medical and surgical conditions - both adult and paediatric - and staying up-to-date with the latest guidelines.

And if I may offer a closing statement to this entry - if I'm ever in need of medical attention in an out-of-hospital setting, I'd trust an ED physician over anyone else, anytime.