Prof. Lee Wei Ling's recent commentary in The Straits Times struck a deep chord with me.
She related her experiences with medical colleagues and, in particular, touched on the topic of character.
There haven't been any follow-up Forum page discussions - yet. I wonder if readers agree with her wholeheartedly?
Integrity - or the lack thereof - is always something one should be concerned about in any profession, but perhaps more so in medicine. Whether we want to admit it or not, doctors wield tremendous power in many ways, whether it's sticking instruments into body cavities or getting a patient to divulge his / her deepest, darkest secrets.
However, honesty deserves to sit at the top of the list because doctors are human, i.e. we make mistakes, and yes, some patients will die as a direct result of our errors.
Such lapses are likely to be more pervasive among junior doctors, but even the most senior consultant is vulnerable, given the right conditions - sleep deprivation, a slip of the hand, an accidental miscalculation of a drug dose.
What comes next is the real test of one's character: will the doctor admit his/her misstep, or will s/he try to ( a) cover it up and hope no-one finds out, or ( b) blame someone else?
Medicine differs from most professions because it relies significantly on the honour system, encompassing everything from history-taking to physical examination to drug administration. Whatever we do is reflected in "medical records", which are predominantly documented by the physician/s attending the patient. Naturally, the accuracy of this documentation is dependent on the doctor, who may opt to omit certain information if s/he chooses to.
While there're many mechanisms / protocols in place to ensure that the patient is protected, no system is foolproof, which is why integrity is key.
One quote rightly states that "Integrity is doing the right thing, even if nobody is watching." Do doctors fulfill the criteria?
Based on my personal experiences in the local context, I would say that most do, but a few black sheep exist.
Here's a gist of 2 of the worst incidents I've ever had the misfortune to be involved with ( obviously, specific details can't be published ).
1) The unexpected death of a young man which resulted in a hospital inquiry.
A medical colleague - A - who took over management after I had started initial treatment, accused me of not following his/her supposedly explicit instructions to send the patient to a certain ward for close monitoring.
The truth: I never received such instructions, and was only told by A that s/he would see the patient urgently, and to please run a fast drip in the meantime.
In the end, the patient was not reviewed by A until 8 hours later, when he began to deteriorate.
My mistake was in not documenting the phone call I received from A, choosing instead to take him/her at his/her word. This resulted in an I-said-A-said confrontation before the inquiry panel, during which I witnessed A's Oscar-worthy portrayal of self-righteousness, and couldn't be sure whether s/he believed his/her own lies or not.
Thankfully, the panel saw through A's performance, and delivered a well-deserved censure.
2) B, a high flyer in the medical community, took it upon him/herself to steal a vial of antibiotic from Hospital X, brought it to Hospital Y, and administered it to his/her boy/girlfriend - C, who was warded for a fever of uncertain origin.
C also happens to have a documented allergy to a drug which is known to have cross-reactivity with the antibiotic that B administered.
When the ward nurse found out about it and filed an incident report ( complicated story ), B consulted a lawyer relative, then told C to "take the fall" - i.e. say that s/he was the one who asked B to bring the antibiotic over to inject it.
In a desperate bid to save B's skin - and the relationship - C agreed to the plan, and B was never disciplined.
I have always felt that doctors are held to a higher standard than other humans, and for good reason. Medical students are gleaned from the cream of the crop, possessing the requisite high IQs and ( hopefully ) equally high moral standards. But with this intelligence comes the ability to manipulate and deceive. And I have noticed firsthand the inverse relationship between academic excellence and guilelessness in many of my fellow doctors.
A simple med school entrance essay and interview can't differentiate the good from the bad, and even the best person can degenerate over time.
All I can tell you is, the medical profession is far from perfect.
The current discussion about healthcare in Singapore dredges up memories of my NUS med school interview, where one panel member grilled me about my opinions regarding patients who contract diseases caused primarily by poor lifestyle choices - do they deserve government subsidies for their treatment?
It was a tough question, and I recall stammering something about Medisave and Medishield helping to offset ( hopefully ) such costs. And thankfully, the interviewer smiled and let me off the hook.
That was in 1994.
Over the past 15 years, I've pondered this scenario intermittently. And now that I have 10 years of clinical experience under my belt, I wonder if such a proposal should be considered?
My line of work involves treating acute cases, a significant number of whom admit to defaulting medications and follow-up, or persisting with habits known to worsen their conditions, despite doctors' clear instructions otherwise.
Real-life examples:
1) A middle-aged man who's had multiple heart attacks and balloon angioplasties, but who recurrently refuses to take his meds, never returns for clinic follow-up, and continues to chain-smoke.
I've seen him at least twice, and each time his family signs consent for angioplasty, because the patient is usually critical to the point of being put on a ventilator.
He is always admitted to a C class ward, which is heavily subsidized.
2) A male in his 60s who comes to us almost daily for chronic obstructive lung disease. He smokes heavily even though he's fully aware that this precipitates his attacks, recently contracted lobar pneumonia but refuses to take his antibiotics or COPD meds, never keeps his appointments with the specialist, and has begun to give us doctors hell when we refuse to prescribe cough mixtures - which we suspect he peddles on the street.
3) A 20+ year old fellow ( yes, it does seem the recalcitrant ones tend to have XY chromosomes ) who's been consuming large amounts of alcohol since his teens and was diagnosed with liver cirrhosis, comes in one day vomitting massive amounts of blood. Turns out he'd just returned from Thailand, where he'd gone on a drinking binge.
Is it fair to use taxpayers' money for cases where the patients' own irresponsible actions clearly contribute to their healthcare expenditure?
I suppose means testing is one option, but like President Obama's universal healthcare plan, should our government also enforce a policy where some form of personal health insurance ( other than Medishield ) is compulsory for all citizens?
My greatest concern is for the poor and unemployed, who probably can't afford these premiums and are likely to be relatively ignorant about their medical conditions ( which may result in them purchasing packages that don't offer adequate coverage, or insurance companies may challenge their claims citing some obscure clause that wasn't highlighted or explained fully upon signing the policy ).
A few weeks ago, I treated a diabetic with kidney and heart failure. He stopped his meds for 6 months because he lost his job and was in financial difficulty, and a referral to the medical social worker apparently did little good. This middle-aged gentleman began to sob as he told me his sad story, and I recalled another patient I attended to years earlier, who was retrenched soon after a hospital admission for a heart attack, thereby causing him to lose all his healthcare benefits. He didn't have a personal health insurance plan.
Granted, healthcare expenditure is a complicated issue, and I don't profess to be an expert dishing out advice to those who're far more experienced than I could ever hope to be.
But speaking from the perspective of someone who's "on the ground", as opposed to a policymaker ensconced in his/her comfy office staring at charts and graphs, this is a problem which will only escalate as our population ages further, and the younger generation displays an increasing disregard for their own well-being.
All these Wellness campaigns and health promotion events may look impressive, but it's equally vital to clamp down on those who irresponsibly drain our healthcare resources, and increase awareness about the importance of adequate insurance coverage.
A letter by Dr Patrick Kee Chin Wah, in which where he tries to dispel certain "fallacies and misconceptions" which surround our healthcare system, is published in Today today.
As doctors, we no doubt consider ourselves better-informed when it comes to discussion about the healthcare system, and we are probably right - we have a better background knowledge of the healthcare system and of the cost and benefits of medical treatment; we are perhaps better able to identify fallacies and misconceptions regarding the healthcare system.
However, what makes a 'good' healthcare system is not merely a matter of facts and figures, but also one of value judgement - we can arrive at precise figures of how much it costs to separate a pair of conjoined twins, for example, but whether we should do so is not a matter of facts and figures, but of value judgement.
While Dr Kee makes several valid points in his letter, he also presents fallacies and misconceptions of his own and imposes his own value system on what he considers to be a good healthcare system, and that of course goes beyond his stated aim of just addressing fallacies and misconceptions.
I happen to disagree with some of Dr Kee's points, which I will discuss below.
1. "Providing compassionate and competent end of life care is the humane answer to euthanasia which is an evil that we need to be fully aware of."
Here Dr Kee commits the fallacy of 'false dicotomy': the choice is between compassionate end-of-life care and euthanasia, and one is humane and therefore the other is evil.
Well, there really is no reason why we can't have both options available - euthanasia for those who desire it, and quality hospice care for those who do not choose euthanasia. Whether or not euthanasia is evil is not a matter of facts or misconceptions, but one of values.
2. "We need to recognise and prevent the rising incidence of "disease mongering"... Risk factors are portrayed as diseases. An enormous market for drugs are created when healthy people are convinced that they are sick and in need of medicines."
I hate to say this but I think it is Dr Kee who is fear-mongering here by being ambiguous. Which risk factors does Dr Kee think we should not treat? Obesity? High blood pressure? High cholesterol? Dr Kee does not specify any risk factor, yet concludes that those who have risk factors are "healthy" and not in need of treatment.
3. "The cost of medical care to the sick can only be reduced when the running cost of our hospitals and clinics are paid by a common fund through the tax that we pay."
Again Dr Kee is being vague. Is he advocating free healthcare funded solely by tax moneys? Or a subsidy system, which we already have? Is that the *only* way to reduce running costs?
The fact is we can reduce the cost of healthcare overnight by just providing a lower standard of care, so a "common fund" is not the *only* way to reduce costs. In fact, contrary to what Dr Kee stated, a "common fund" may create a moral hazard, encouraging people to consume more healthcare resources than they need.
I would have to say that Dr Kee's claim is in fact itself a fallacy.
4. "Our Ministry of Health is a misnomer - it is more a Ministry of Medical Services. Health is not the absence of disease but the ability to overcome disease. The healthy will not fall sick in the first place and when they do, they will recover. We need a Ministry of Health to focus on helping us to adopt healthy lifestyles, develop healthy families and maintain a healthy environment."
Of all the points Dr Kee made this is the one I found most offensive, because it is simply untrue and an insult to the people who do good work at the Ministry of Health.
The statement "[t]he healthy will not fall sick in the first place and when they do, they will recover" is a meaningless one, since it is but Dr Kee's own definition of what makes an individual "healthy". More importantly, it perpetuates the misconception that everyone can become "healthy" if they "adopt healthy lifestyles, develop healthy families and maintain a healthy environment", and if people are not it is because the Ministry or they themselves who are not doing enough. So is my patient with a congential heart malformation unhealthy because he didn't adopt a healthy lifestyle, Dr Kee? Or did my patient killed in a car accident die because he was not "healthy"?
The Ministry of Health does encourage people to adopt healthy lifestyles - remember the Health Promotion Board, Dr Kee? - and the National Environmental Agency and our public works departments work hard at giving us a healthy environment. To imply that the Ministry of Health only provides medical services and not perform health promotion is disingenuous.
We all have our own value systems and it is not wrong to want to shape how our world operates according to those values; what is wrong is spreading misconceptions and utilising fallacies when we argue our position. Well, according to my values anyway.
Singapore was declared malaria-free in 1982 by the World Health Organization, although up to 270 cases are reported each year since 2000. These are mainly expatriates or residents who have acquired the infection from abroad. For example, one of the largest clusters in recent history occurred in a group of Nigerian students who had been brought into Singapore by a local informatics company for a 2-year training program. Out of the 72 Nigerian youths who came in 2005, 8 were symptomatic for falciparum malaria, but a further 13 were only picked up on screening the cohort. Locally-infected (or "authocthonus") cases do occur sporadically, but are rare.
Since May this year, however, we have had three separate clusters of vivax malaria at Jurong Island (n = 9), Sungei Kadut/Mandai estate (n = 16) and Sembawang (n = 4). It is unclear if these clusters are related, since they occur at different parts of Singapore. Because the infection is caused by Plasmodium vivax - one of two malaria species with a long latent liver ("hypnozoite") phase - it is plausible that some of the cases among the foreign workers may be incidental rather than occurring as a result of local transmission. NEA has not reported the capture of any malaria-infected anopheline mosquitoes during its surveillance of these sites.
These clusters highlight clearly the vulnerability (and resistance) of Singapore to malaria. Plasmodium falciparum and vivax are endemic to the region, including in nearby offshore islands such as Pulau Tekong. No formal malaria eradication campaign had been conducted in Singapore prior to or after 1982 (although there were "antimalarial drainage systems" and "oiling cycles" from the 1910's to 1980's, and vector/case surveillance/control from the 1970's - the last of which is now directed against the Aedes mosquito and dengue/chikungunya), and the Anopheles mosquito can still be found in parts of Singapore.
At the same time, we continue to bring in foreign workers from malaria-endemic countries, some of who will inevitably be carriers of the parasite. The cost of screening each worker routinely is prohibitive at this point, hence cases and small outbreaks will continue to occur.
Singapore's "resistance" to malaria is a result of urban development and the continued failure of the local anopheline mosquitoes to adapt to a more urban environment (unlike the very successful Aedes mosquito). So there will never be a malaria outbreak on the scale of dengue or even chikungunya in Singapore. Because it is a far more dangerous disease, however, it is important to diagnose and institute appropriate treatment early.
And so yours truly is currently on call, but since there's a lull, I would like to pen down some thoughts regarding in an issue that is frankly, pretty disturbing to me.
Just yesterday our esteemed local newspaper published an article about a woman winning her right to die. In this woman's case, it was the right for her caregivers to refuse her sustenence in order to end her life. There have been several such articles in the past few months, and I can't help but notice that they take up quite a bit of space in my newspaper. A while back a senior, non medical person in the healthcare sector raised the issue of euthanasia, and his stance appeared to be in support of having the right to die.
To me, a young 'un in the medical field, this whole issue is upsetting. One could go into a long discourse about the meaning of life and the right to die, but essentially they boil down to one thing - should a doctor, with all his skills and knowledge and experience, help a person die? Are we doing justice to all the work of the ones who came before us by using our abilities to kill someone?
I know my stance in this debate, although I know there will be no end to it. Which is why I wonder about the future of the practice of medicine. Will I end my career in a place completely different from when I started?
The Hobbit writes an insightful commentary on the DMS's 'assurance' to doctors over the proposed amendments to the Medical Registration Act in this month's SMA News.
One of her best works so far, I must say.
Goes to show that when you begin at the end and then try to justify it afterwards, you can sometimes end up looking silly.
