My daughter was pulling my shirt one day and refusing to let go.
"Daddy! Daddy! Play with me!" She wailed.
"Cannot la, I gotta study for my exams......" I replied her as the tug of war continued. She was surprisingly strong for a 4-year-old.
She stopped for a moment and asked, "Daddy, why do you need to study?"
She was of course not the only person to be puzzled. Last week I rejected an invitation for supper from a non doctor friend and just yesterday I gave up free tickets to a midnight movie (transformers no less) from another friend. I could almost visualize their bewildered look when I told them I had to study for my exams. The commonest reaction I get is "Huh??" followed by outbursts of laughter.
So why do doctors (and I'm not talking about medical students here) need to study all the time? Why do we need exams even at an advance speciality level? Why can't we be assessed in a formative (and more meaningful) manner?
1) Exams are a major money churning industry. Look at the inexplicable fees we have to pay for each and every exams. The money we pay goes into supporting an entire industry of clerks, adminstrators as well as one dysmorphic looking and weird executive.
2) Have you ever notice that half of the books in Yunnan or Research are How to Do Well or Pearls of This and That Exams preparatory books? Exams help to maintain an entire medical literature industry. Also note that the books are often overpriced! Can you ever find anything less than $30? The authors are often senior doctors banking (and unethically so) on our exams anxiety. The books are often just cut and paste efforts with contents not worth the paper they are printed on.
3) Becoz books are often priced beyond the financial capabilities of junior doctors in general and my hospital MSW flatly refused to subsidise me in any way, we spin off a third industry. I was at a Katong shopping complex and one particular photocopy shop had more medical books than our YLL Library. At least I like the uncle there.....
4) Of course, its not always about money. Our training comm are made up of really nice people and they can never tell a trainee, "Alamak! I think you don't have the aptitude to do what you are doing. Maybe try admin!" Trainees don't ever get chopped, unless they chop themselves. So what better way to let them go than to let them fail their exams? Unfortunately, the weird ones are often self selected to pass exams coz they have no friends, don't do any work at work and spend all their time mugging photocopied versions of exams preparatory books.
Although I was quite pleased that my daughter had achieved an adequate developmental milestone and was asking questions. I thought it was appropriate to prepare her for the sinister world of exams ahead of her.
"Daddy need to study because its my last exam, you also will have lots of exams ahead of you la!"
She ran off crying. Ah, brillant! She is cognitively way ahead of her time!
My daughter was pulling my shirt one day and refusing to let go.
Eighty-nine more cases of novel H1N1 infections were registered today, bringing our national total up to 454. This puts us at number 17 in the world with regards to countries with confirmed cases. There are no deaths in Singapore from this infection as yet, but this is a question of "when" rather than "if" at this point in time.
Trying to get to the MOH website this evening will land one onto "http://www.h1n1.gov.sg/homepage.htm" which is a rather ironic address. The table is a couple of days out of date, and there is a list of countries for which a H1N1 travel advisory has been issued. One is just about as likely to be infected in Singapore as in the majority of these other countries, therefore a travel advisory no longer makes much sense.
Looking at various reports in both the traditional as well as the new media, one gets the sense that the healthcare system is starting to be overwhelmed by the worried well and the mildly ill cases. There now appears to be a considerable backlog in terms of epidemiologic tracing, and hospital emergency department facilities appear to be barely coping at times. Patients are being charged for the influenza A(H1N1) testing, and for the delays in testing, which has rightly been perceived as being unfair.
Moving forward, we should seriously consider doing what Japan (click on the video link on this Channelnewsasia site, just bear with the advert), Australia and US have done:
- Keep the hospitals (and emergency departments) free for the serious cases (and accept that there will be such cases as well as deaths despite the best treatment) and patients with other diseases requiring hospitalization.
- Patients with mild flu-like symptoms and who do not require an MC for work or school (employers and schools should also be more flexible and understanding during this pandemic situation) should stay home rather than go to a GP/polyclinic/hospital.
- Others should go to a primary healthcare clinic, preferably one of the "Pandemic Preparedness Clinics" should these get activated.
Today's ST carried a special report on 'new philanthropy'.
It kinda made me wonder if doctors felt they could do more in this area, or if they were just to busy with their careers and professional work to want to go beyond writing the occasional cheque for the offering bag?
What do you think?
This post is mirrored at Gigamole Diaries..
The President of the Singapore Medical Association was prodded out of the kinda slumbering organization to respond to the 'akan datang' move to appoint non-medical people (chiefly their nemesis, lawyers) to Chair the Singapore Medical Council.
I think it is a rather unconvincing response, almost like he doesn't quite believe it himself. Which really underscores the passivity of the profession at the moment. Same for the Singapore Medical Council.
I do however agree with Dr Chong's last point: '...what medical ethics really needs is more moral courage and leadership so that public interest can be better served.' How true. But what has the SMC done that can truly be said to have shown moral courage and leadership? So far it's been hiding behind the law, and only taking to task those who have obviously flouted the 'law'.
We saw the biggest local increase (26) in influenza A(H1N1) cases yesterday, raising the national total to 103. There are now 4 cases where H1N1 transmission is believed to have occurred within Singapore itself, including 2 teens who are doubtlessly still schooling. How this happened seems fairly clear-cut for 1 case - his family had dropped by from the Philippines (although reportedly none had been symptomatic) - but not for the rest. The MOH website gives a few more details about the other cases. Perhaps the teens became infected as a consequence of meeting up with friends who had returned from other countries, or perhaps the transmission occurred just because they were in areas where many people congregated (like church functions or shopping malls) and where there were other infected individuals. The 4 cases of local transmission were identified mainly because of the polyclinic influenza surveillance program (where patients with influenza-like illnesses are swabbed regardless of travel history) and alert GP's.
But what this means is clear - the new H1N1 virus is loose in the community. The containment strategy is no longer viable. Whether it has served its purpose is another matter. Community transmission in Singapore has been delayed for a few weeks at the cost of millions of dollars. The time bought with this strategy has enabled us to learn more about how this virus has "behaved" in other countries, and therefore to understand its risks and significance (or lack thereof). Today's news on local transmission and the largest increase in newly diagnosed cases only made Page 6 of the Straits Times (moreover only able to take up a full page because of a very large Robinson's advert), whereas a few weeks ago, it would have been front page with many accompanying stories and expert opinions. There is certainly less public anxiety now.
There was a clear and sufficiently long window for public education, but unfortunately the messages seem to have been rather mixed. Based on ST and MOH press reports alone, most people would probably not have had a clear picture of the severity of this new H1N1 outbreak, nor been able to judge whether official response was appropriate (a rough gauge would be forum postings on the topic of H1N1). If we agree that the virus is not worse than seasonal influenza, why quarantine so many people and hospitalize all with the disease? Why castigate people who travel to affected countries (there are now so many that you could not really leave Singapore without ending up in one of them)? If this is to prevent excess morbidity and mortality, why not do the same for all other influenza cases? If we remain unsure about viral virulence (well, we really should not be too uncertain after so many weeks and so much shared experience from other countries), why step down or talk about mitigation?
Perhaps the containment phase will continue a bit longer. Just so that we can officially convince ourselves that H1N1 is truly in the community (also, the delegates for the Asian Youth Games are in town and it would probably be bad karma to export H1N1 from Singapore via this group of athletes, officials and accompanying persons). Perhaps schools can be closed for a further week after the end of the June holidays. The latter more than anything else will delay the spread of H1N1 in Singapore. But we will have to ask ourselves whether it is now worth such an effort. The other argument for delaying the outbreak is always in the background - that the healthcare system will be overwhelmed by the large surge of cases. Data from other hard hit countries such as US and Australia suggest otherwise. In fact, the number of outpatient visits for influenza-like illness in the US has dropped below the national baseline. But efforts to prevent the system from being overwhelmed may result in an eventual "own goal": as of yesterday, there remain 73 H1N1 patients in our hospitals that would not even have been hospitalized if they had seasonal influenza - these patients do take up beds and significant healthcare workers' time (they have to gown, glove and mask up every time before even entering each individual patient room). Hospitals may have to cut electives and expand on emergency and isolation resources (and these may come with a trade-off in terms of efficiency of care for other medical conditions). If past pandemics are any judge, we are looking at another 1 to 4 years of this virus circulating around before it becomes just another "seasonal influenza".
This is a true story.
Many years ago, when I worked a temp job as a clinic assistant prior to applying for medical school, I met a brilliant consultant surgeon.
He was highly regarded by all and known to have excellent skills. Little wonder that he soon became the head of his department.
When he treated my mother years later when I'd already become a medical officer, we were both extremely happy with the results.
Not long after, something unfortunate occurred, resulting in him stepping down as HOD, then leaving for private practice.
He bumped into a close friend of mine - completely by chance - who happens to be his junior college classmate. Upon hearing about her husband's condition, he offered to treat him at his clinic, which was located at a private hospital.
The procedure was done in the day surgery theatre. Took 30 minutes, under general anaesthesia (GA), after which the patient was discharged.
That very night, my friend's husband complained of severe pain over the surgical site, with recurrent bleeding and a low-grade fever. The next morning, my friend called the surgeon's clinic, only to find out that he'd left for an overseas trip and would not return for another week. When she called his handphone directly, he told her there was nothing to worry about, and for her husband to continue taking the antibiotics he'd described.
Over the next few days, the pain, bleeding and fever worsened. One night, my friend's husband developed bleeding which was so severe that he lost consciousness and collapsed in the bathroom. I received a frantic phone call at home at 1am as my usually calm and composed friend sobbed and begged me for advice.
I told her to bring her husband to the nearest public hospital's emergency room immediately, and arranged for a senior colleague to attend to him.
The patient was admitted that very night, and remained warded for a week, during which he received IV antibiotics, underwent exploration under GA and, according to the team caring for him, required a "major clean-up".
Upon returning to Singapore, the private surgeon visited the patient in the ward, coincidentally meeting me as I was flipping through the case-notes. He looked frightened, and asked if he could take a quick look as well. I decided to oblige.
His name was written on the first page of the clerking notes.
My friend's husband recovered fully after his stay in the public hospital, and his symptoms haven't recurred since. Understandably, the couple's opinion of this once-esteemed surgeon has plummeted, and although they considered filing a formal complaint with the Singapore Medical Council, they subsequently changed their minds and the surgeon didn't suffer any consequences.
One may never know why this surgeon behaved the way he did. Was it a result of arrogance, greed, lack of regulation in private practice? It's unfathomable that he would treat an old friend's spouse in such a callous manner. It's even more unfathomable that he got away scot-free.
The reality is, lots of errant doctors escape disciplinary proceedings purely out of luck. Either the patient / relative is the forgiving sort, nobody finds out about the mistake, or the incident gets covered up.
I wonder to what extent doctors nowadays see themselves as having a principal role in being advocates and activists on behalf of patient welfare and well being. Or are they primarily concerned with their own material and professional well being, and see patients as being obstacles in their achieving their ends?
5. "Yes, but that's beside the point..." - when I ask if you're a 1st year medical officer after you miss a glaringly abnormal ECG. Happened very recently.
4. "I've done the x-rays / blood tests but the results aren't out yet." - especially when you know the results will guide your diagnosis and are essential in my decision-making process. I'm not psychic!
3. Indiscriminate use of the word "basically". It serves no purpose whatsoever.
2. "Err, I don't know what I should do." I'd rather you give me a few options and ask my opinion regarding the best path to take.
1. "Err, I don't know what's going on...", especially if it's the opening line. Surely 5 years of medical school ( 6 in certain foreign countries ) and hundreds of thousands of dollars in educational funds have produced someone with more thinking capability.
I wonder how one teaches common sense. I don't know if it's a generation gap or if it reflects a real degeneration of the medical ethos, but it seems like the doctors running around seem to be increasingly devoid of any common sense.
A lady recently went to an A&E because of lower abdominal pain. The usual tests and examinations were done and she was diagnosed as having late stage ovarian cancer. Nothing really wrong here. But what was really screwy was the way the young doctor informed the lady of her diagnosis....pretty much along the lines of ..."The nurse said you were asking what was wrong. Well...you've have extensive cancer of the ovaries. We can't do anything here because we don't have a gynaecology unit here, so we must refer you to KKH." Just like that.
Being alone in the clinic at that time, she freaked out on receiving the news. Understandably so, I think. Surely common sense dictates that if you have such potentially distressing information to convey to the patient, you should try and ensure that the patient has some emotional help nearby,in the form of a relative or next of kin.
So how do you teach common sense?
As promised, an update on the Simon Singh - BCA libel case: Singh has decided to appeal.
Singh continues to receive the support of the scientific and legal community, and a campaign has been launched to "keep libel laws out of science". The website provides more background information on the case, as well as British libel laws.
Do have a read.
I blogged about this topic a few months ago, and a letter to the ST Forum today discusses the results from the feedback exercise:
Medical Act: Did feedback reflect docs' views?
I REFER to last Friday's article, 'Medical Act change: 80% backing for non-doctor to chair discipline panel', which stated that 'nearly eight in 10 people backed this and other changes to disciplinary proceedings and thought it would streamline the process'.
The actual press statement by the Ministry of Health (MOH) last Thursday stated that there were 78 responses received. Of these, 12 were from the public, of which 11 agreed with the proposed amendments under this category. The remaining 66 responses were from 'doctors/health professionals', of which only 18 responses were noted to 'disagree'.
The vast majority of the 8,000 or so doctors in Singapore belong to at least one or more of the following organisations: Academy of Medicine, Singapore (AMS), College of Family Physicians Singapore (CFPS) and Singapore Medical Association (SMA).
All three organisations either expressed reservations or disagreed with the proposed amendment to allow a layman to chair Singapore Medical Council (SMC) disciplinary committees. One can only wonder if the positions of these three large organisations were represented or accounted for adequately in the statistic of almost 80 per cent.
Does the position of one such organisation, which represents anywhere from more than 1,000 to 5,000 members, count as one response and carry the same weight as a response from an individual doctor or an individual member of the public? If so, perhaps the AMS, CFPS and SMA leaderships should organise signature petitions from their thousands of members so MOH can adequately recognise the situation.
MOH should clarify how responses from the AMS, CFPS and SMA representing thousands of doctors were accounted for, so we can better understand how the figure of nearly 80 per cent was obtained.
In addition, I am given to understand that the SMC is a statutory body funded from the annual subscriptions of doctors. If this is so, the least MOH could do is to consider subsidising SMC operations if it really wants a layman to chair SMC disciplinary committees. Not many doctors I know would want to fund a layman to chair such committees.
Dr Adrian Tan Yong Kuan
I share Dr Tan's and indeed the SMA's view that a legal professional may not be sufficiently informed about the complexities of medical cases to be able to make a fair judgement. SMA, I believe, agrued the point very well in its submission the the ministry.
As I have stated before, I see the proposed changes as part of the "democratisation of healthcare" - a belief that laymen (yes, a legal professional or a judge is still a layman when it comes to the field of medicine) have the right and knowledge to understand and make judgements on issues pertaining to a professional field. As a doctor I wouldn't presume to pass judgement on whether a lawyer has conducted the defence of his client with due diligence, or if he had breached the legal profession's code of conduct - why should the reverse be acceptable? Sure, I might comment about it over lunch, but a disciplinary hearing is something that has bearing on a professional's reputation and career, and I believe our lawyers deserve to be judged by someone more qualified than a "tea-room lawyer", just as we deserved to be judged by someone more qualified than a "chambers doctor".
Another undesirable aspect of the "democratisation of healthcare" is exemplified by the feedback to the ministry that a doctor's "communication skills and empathy" were more important than his being on a family practice register (which would indicate that he had undergone training and accreditation in the field of family medicine). The public, not surprisingly, values a "nice" doctor over a competent one; or perhaps (more worryingly) doctors believe that their interpersonal skills can make up for their lack of formal training - are they taking the adage "to comfort always but to heal sometimes" to the extreme?
I see this valuation of empathy over expertise as something that is a threat to family medicine and healthcare in Singapore as a whole as it leads to unhappiness in doctors and their patients due to a mismatch in expectations, and to pressure on GPs to provide non-evidence-based modalities of care based on their "feel-good" factor. Doctors and patients alike need to realise that while a good patient-doctor relationship can lead to better outcomes, it is no substitute for an extensive knowledge base that is required to practise family medicine in this day and age.
The underlying cause of the "democratisation" is probably an erosion in the trust of doctors and the medical establishment as a whole. However, I do not believe that the way to regain this trust is in pandering to the emotional demands of patients, but by changing their expectations of what makes a good medical consultation. As doctors, our duty should be to provide patients with health advice based on the best available evidence at hand, and not to hold their hands and speak comforting words while they die from our outdated and ineffective care.
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.
Was just walking out from the hospital the other day when I saw a small crowd ahead of me. It was next to my bus stop so I took a peep at the commotion. Turns out it was an elderly gentleman who had apparently fainted and fallen down. Some nice folks were sitting him up and gathering up his belongings, but weren't quite sure what to do. Amazingly a car stopped and a couple got out to send him to the emergency department before I could do anything.
The incident got me thinking about how much we are supposed to help in situations like these. We are in a profession that has always been upheld as noble and selfless, and we've got wonderful examples to follow (think Salk and Sabin's free polio vaccines) but we all know that the truth in this day and age is far from that. Profit is now the bottom the line in many institutions, and given the increasingly litigatious atmosphere many doctors are practising defensive medicine.
So it's not hard to understand why some of us, if not all, would hesitate before volunteering help when it is needed. Is it worth it, we will ask. If the victim is bleeding or vomiting, how do -I- protect myself from any unwanted diseases? (We have been told that we should perform CCR not CPR since the former apparently is more effective anyway.) And will I be held responsible should the patient suffer any complications?
Many of us entered medical school with hopes of making a difference. We wanted to help people, and we did our best as medical students, going on overseas trips to far flung places or going door to door giving health checks at the poorer estates here in Singapore. But those two letters in front of our names after we passed the final exams give us not just privilege but also lots of responsibility that we accept if we were to offer our help. That's the reason for the hesitation, and it is an issue that I, as a junior doctor, have yet to come to terms with. I recall noting the surprise of the junior doctors when a senior colleague mentioned that she usually stops to help when there's a traffic accident. Means that it wasn't what they expected to hear, no?
Right after we finished our MBBS a classmate mentioned that he responded to a call for medical personnel while on board a flight during his graduation trip. Would I have done that? A few years ago, before I started clinicals, I would have answered with a resounding yes, but now, especially after one month of work (yours truly is the youngest of the contributors here at singaporemd), I probably would, but with some hesitation.
Anyone has any thoughts on this?