A letter to the ST Forum today allows me to illustrate a point about judging doctors:
H1N1: Family doctor did what hospital did not
ON JULY 21 at 11pm, we sent our 10-year-old son to KK Women's and Children's Hospital (KKH) with symptoms typical of a flu. He had a high fever of 38.6 deg C, sore throat and persistent cough.
He had seen a GP that evening and the day before and was prescribed antibiotics and a cough mixture. It was his worsening condition that prompted us to take him to KKH.
The doctor did a chest and throat X-ray and confirmed that it was not H1N1 as she claimed that the symptoms were not typical of the illness. The X-ray showed a narrowing of the trachea.
Note that my child is asthmatic and therefore belongs to the "high-risk" group for H1N1 infections.
She prescribed a cough mixture and fever medicine and advised that he be referred to an Ear, Nose and Throat specialist for follow-up at a later date.
The next afternoon, we took him to our family physician and after reviewing his case, he immediately ordered a swab and sent it to the lab to test for H1N1.
The next day, the results came through positive for H1N1.
I don't understand why the doctor at KKH did not order that same test.
The lack of initiative by the doctor might have led to unnecessary risk of exposure to the disease for a whole lot of people if we had accepted her diagnosis and carried on with life as normal without taking any precautions.
After receiving the test results from our GP, we stopped work and immediately returned home for quarantine.
How many people could we have infected during the two days?
I thank my GP, Dr Fadzil from Al Barakah Clinic and Surgery in Hougang, for his professionalism and foresight.
I strongly urge the Health Ministry to implement a policy that all doctors order compulsory
H1N1 tests for all patients displaying flu symptoms.
I agree we should not panic but we should all learn to be responsible - doctors and patients alike.
Steven Seow
Now Mr Seow, presumably a layman, obviously thinks his assessment of the situation is correct - in fact he is so sure of it he wrote a letter to the newspaper to admonish the doctor at KKH, to praise his GP, and to urge the Ministry of Health to implement a policy on his recommendation.
In Mr Seow's point of view, the first doctor was obviously wrong, the second one a paragon of "professionalism", and he, a layman who had been aggrieved, is qualified to tell us what the correct policy should be, never mind all those people who examine data and evidence and work all day on our policies to combat the epidemic. He presumes to judge doctors and policy makers based on his personal experience of three clinical episodes.
Is it any wonder why doctors resist the inclusion of laymen on the disciplinary committee?
Here's the article one of my fellow bloggers was looking for.
Whether this can be extrapolated to other countries, including Singapore, is of course questionable.
But speaking as an ER physician, burning out at least once a year probably indicates a significant amount of work stress.
My department saw 540 patients over a 24-hour period a few days ago.
You do the math.
A rather bold statement to make, especially in light of the current limelight on self-regulation of the medical profession, but surely a factual one, given the fact that it is based on a study by doctors?
Well, not quite.
While one may conclude that there is a difference between repsonses from local grads and overseas grads (IMG is such an awkward term, isn't it?), the title could easily have been "Foreign-trained docs more willing to condemn colleagues", couldn't it?
I read through the vignettes given in the paper, and frankly I would only have recommended one of the three HOs to be struck off - guess which one.
I'll give you a clue: in only one of the three scenarios given was it implied that patient-care was compromised; the other two were not about clinical care, or medical ethics, but *work* ethics.
The survey was not really about "ethics", but about "professionalism". In fact, these scenarios are not the typical types brought to the attention of the SMC Disciplinary Committee - those are predominantly about inappropriate prescriptions.
The authors of the paper probably chose the scenarios they did based on the subjects of their survey, which of course limited their choices.
Nevertheless, I am rather disturbed by the fact that the HOs involved in the survey are so quick to strike off one of their own based on a brief vignette, but perhaps it is easy when you reduce the questions down to their bare minimum, and ask yourself:
1. Should a doctor be struck off for being a jerk?
2. Should a doctor be struck off for being irresponsible and dishonest?
3. Should a doctor be struck off for being a sex offender?
But surely when the DC is considering a case, the question they ask is:
Should *this doctor* be struck off?
Perhaps that's why HOs are not put on the SMC DC...
I was asked to give a psy opinion on the fact that a Canadian study found that stress levels were the highest in A&E doctors.
I tried to search for the above mentioned article but to no avail. Don't get me wrong, I have no intention of doing a journal critique. I just wanted to scare my MO out of her A&E traineeship so that she will join us in psy.
Back to the issue at hand.
If my limited interactions with A&E physicians were anything to go by, the plasma cortisol levels in our dear A&E colleagues must be sky high. I base this not on the degree of hirsutism but on several observations I have made:
1) the facebook status of a friend working in A&E reeks of fear before his shift starts.
2) the female A&E MO who attended to me when I sprained my ankle did not smile back!
3) a certain A&E has a protocol for medical HOs/MOs to accompany patients for CT scan even if the A&E was empty and the A&E MO then had to accompany the medical MO who was accompanying the patient to the CT scan as the A&E MO had nothing to do and felt paiseh that her classmate was accompanying her patient.
My own gripes aside :P, there are several reasons why the A&E is likely to cause more stress in their doctors than other speciality:
1) Shift work.
Shift work affects sleep and is a precipitating and perpetuating factor for insomnia. This can lead to a vicious cycle of poor sleep, anxiety, even poorer sleep and even more anxiety. A&E doctors also tend to have unstable meal times as well.
2) Uncertainty.
The work of most other speciality are more circumscribed while the A&E doctors can never predict what will come through their doors. Indeed, patients with psy complaints are often the most feared ones. Although A&E training probably equips their physicians in dealing with medical emergencies, they are not trained to deal with emotional disturbances and psy emergencies that may turn up at their door steps.
3) Identifying.
In the course of trauma work, clinicians often identify themselves with the victims. There is no doubt that some A&E doctors may identify themselves with RTA, burns, suicide patients. If not properly dealt with, the doctors may suffer emotional consequences.
4) Load.
As with all other specialities in Singapore, our load is ridiculous.
5) Care and Welfare.
Little or no formal programmes are in place to address the stress faced by A&E physicians and these are often substituted by camaraderie amongst colleagues and incessant rantings on blogs.
Of course, this does not answer the question of whether the A&E speciality is indeed the most stressful of them all.
If a teacher came to me telling me that her job was the most stressful one in the world, I would agree. If a prata seller came to me telling me that flipping prata was the most stressful job in the world, I would agree.
After all, stress is unquantifiable and up to an individual's own perception. If one chooses to perceive his or her work as being the most stress inducing, he or she is probably right.
There is still some confusion on the ground (in healthcare and other institutions, such as schools), but this is to be expected given the relatively swift switch to mitigation after many signals (some mixed) and cautionary messages about the risks of complacency and the need to be safe. Most hospitals have stopped admitting “well” H1N1-infected patients and even those that are hospitalized get discharged rapidly once doctors are certain that the risk of complications developing are minimal.
In the coming weeks, another phase of the outbreak in Singapore will be apparent. Mathematical modelers in NUS and TTSH have already detected (and predicted) an increase in flu cases in Singapore above the baseline. As the numbers increase, we will see the truly ill patients come in. There were three H1N1-infected patients in ICU’s all over Singapore as of yesterday, and this number will grow over time. Given the record in other countries, we should expect deaths to occur as well, despite the best medical care. It does not mean the virus has suddenly become more virulent, but this is just the natural course of events. Earlier detection and treatment of the severe cases may ameliorate the morbidity and mortality that will arise. Less “clogging” of the healthcare services (such as emergency departments) will help.
There has been news of a H1N1 vaccine on the horizon. Realistically, this will not come in time for most of us. All is not gloom and doom, of course. It is after all the most wimpy pandemic virus to date and the vast majority of people infected will suffer nothing more than a cold.
I came home from a long day at work to a pleasant surprise - a letter from the Ministry of Health giving more details on the proposed amendments to the Medical Registration Act - specifically on the appointment of a legal professional as a chairperson to a SMC Disciplinary Tribunal - and seeking further feedback from doctors.
As usual I read the letter from the end to the beginning - it helps to know early who approved it, and what they really want - and as usual it helped me notice a little irregularity in the argument.
In section 8. of Annex A (the FAQ), we learn that one of the reason for the proposed amendment is the fact that the DC occasionally committed errors when in comes to the issue of legalities.
So why can't we solve that problem by having legal professionals assist the DC?
Section 4. tells us that the DC is indeed assisted by Legal Assessors, lawyers of at least 10 years of experience.
However, since DCs commit errors of legalities despite being assisted by experienced lawyers, it tells us that even experienced lawyers make mistakes and therefore in some more legally complicated cases, the DC should be chaired by an experienced lawyer or an ex-judge. Makes perfect sense, doesn't it?
It also tells us that a lawyer or a legal professional acting as the chairperson actually displaces the layperson from the DC, so that instead of 3 doctors and a layperson, assisted by a lawyer, we now have 3 doctors and a lawyer. Furthermore, the decision to appoint a legal professional as the chairperson of a DC lies with the council, so that instead of a DC made up of three doctors and one layperson not of the council's choosing, we have a DC of three doctors and one legal professional of the council's choice.
And the reason why we are doing that?
Because it makes it look like we are being less partial.
See? It always makes sense when you begin at the end, and work your way up...
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?
Why don't we have one like these countries?
If we did have one in Singapore, which date would be suitable? Hmm...
Any Johnny Hates Jazz fans out there? :)
I'm going to be frank - there're times when I really, really, REALLY hate practising medicine.
And I wish, to the core of my very being, that I could hurl verbal curve balls at a patient or his/her relative/s without any fear of repercussions.
Like Dr. Gregory House ( right, love the slogan by the way :)).
Although there're no formal statistics available, I sometimes wonder if the "rule of three's" applies to the medical profession - where 1/3 almost invariably love what they do ( don't ever want to retire ), 1/3 tolerate it because they still want to make a difference and there's no viable alternative ( can't wait to retire ), and 1/3 are in it purely for the money ( aim to retire before the age of 40 ).
Me? I used to think I'd never want to retire, but now, I can't wait to do so.
And I'm only in my 30s.
While my parents would have me believe that the decision to join medicine was entirely mine, I do recall a conversation where, if I wasn't accepted at the local university, I expressed my wish to switch to journalism.
Not that they would've let me have my way at any cost. But it does leave me wondering about what could've - or perhaps should've - been.
And I do find it troubling when I live a little too vicariously through Dr. House.
In the not too distant past, a line from the pilot episode of House caught my attention.
Medical resident Dr. Eric Foreman asked, "Isn't treating patients why we became doctors?", to which House retorted, "No, treating illnesses is why we became doctors. Treating patients is what makes most doctors miserable."
People like to wax lyrical about the "art" of medicine and its "holistic" nature, but isn't that sort of missing the point? If you got sick, wouldn't you want a doctor who'd help you get well as quickly as possible with the least amount of fuss?
Or as Dr. House once asked, "What would you prefer - a doctor who holds your hand while you die or one who ignores you while you get better?"
The reality is, people want their hands held. And while I don't fault this intrinsic human need, especially in the setting of an acute or chronic illness, I do find it hard to accept when an incompetent doctor with good bedside manners makes a serious mistake and gets off scot-free, while a careful and accomplished one who doesn't smile or chat much gets slapped with a complaint for being "rude".
To quote the most extreme example I know, the relative of a patient who died at the hands of convicted serial killer Dr. Harold Shipman told a reporter that, despite Shipman's hideous track record, she still considered him a "wonderful doctor".
There are, of course, no easy answers to the predicament I face. Switching careers at this juncture isn't a viable option, and I don't expect workplace conditions to change anytime soon.
I think I share House's behavioural traits to a certain degree, though I keep things toned down to stay off the administration's radar. Doesn't get me any service awards or letters of commendation, but at least I haven't compromised a patient's welfare - or my own code of ethics.
If you have time, I recommend this terrific site.
...do doctors ( especially those in the primary care sectors ) put all their faith in the crummy ECG printout analyses, which invariably detect "ST depression, possible infarct" even when no such changes exist?
...do I keep seeing GP referral letters which have no documented physical findings? "Giddiness, ?stroke. Please see."
...doesn't anyone bother to check computerized medical records for past histories? The MO should be the one telling me a patient has ischemic heart disease post coronary bypass instead of me digging this up by tracing all the way back to 1999.
So yours truly has finally gotten her slaves, ahem, student interns, today. Reminds me of a time not too long ago when I was enthusiastic, when being allowed to catheterise, set plugs, take bloods made my day.
There's a saying in medicine - see one, do one, teach one. when I first read it early in medical school, I didn't quite believe that such a thing could happen. But it does - you watch one or two, get an offer to try one or two, and then go ahead and start teaching others. (Should I be saying this on a public blog? Heh) But it is kinda nice to be able to teach, although my skills are limited for now.
I'm looking forward to my first lumbar puncture!
For the benefit of those who don't subscribe to the Singapore Medical Journal.
And for those who routinely put their copies in the recycling bin - myself included. :)
Click here.
The Medical School is 104 years old today, but does anybody care?
An heritage forgotten, an heritage forsaken.
So sad.
