It was reported last week that Dr Martin Huang - a well known plastic surgeon - was fined $5,000 and censured by the Singapore Medical Council for injecting animal fetal cells into his patients (a dubious and unproven practice). It appears that he was caught only because he was foolish enough to "advertise" this in a health and beauty magazine (therefore who knows how many out there are doing the same). This was further touched upon by no less than the Director of Medical Services in the MOH blog, which fell just short of accusing Dr Huang of not having his patients' interests at heart.
Another reader has submitted a topic for discussion on Singapore MD:
"I received a letter from MOH the other day outlining DMS' vision for transforming postgraduate medical education. It ended with a call for participation in dialogue sessions.
I threw the letter away.
The fact that MOH has decided to hold dialogue sessions only after all the major decisions have been made only goes to show that MOH deals with our professional body in a paternalistic manner. Dialogues inevitably end up becoming monologues. Little wonder why MOH's initiatives rarely gains any support from the ground.
If I may suggest, perhaps, we can have a discussion on what it would take for MOH to gain the confidence and support of the body of physicians that it needs to work with, rather than dictate to."
I tend to agree with our contributor's observation - I just yesterday received a letter from MOH informing me that the planned amendment to the Medical Registration Act will pretty much carry on: SMC will still have "the option" of appointing a legally-trained person to a disciplinary tribunal, except that now that person may be appointed as either the chairperson, or as a voting member.
How this round of "dialogue" will alter the plans for a new training system I do not know, but I am keen to attend one of these sessions just to get a ground feel.
See you all there.
Interesting how a topic about service quality vs cost veered off on a tangent.
So with the raging debate about doctors in general "earning too much", what say you about the salary discrepancy within the medical community, i.e. between the public and private sectors?
Should those in private practice be viewed any less favourably than their counterparts in public institutions?
Is it considered wrong for doctors to treat affluent patients exclusively when so many others belong to the lower income brackets?
I always wonder about those medical school interviews, when candidates are asked, "Why do you want to become a doctor?"
You can expect the usual spiel about "wanting to help my fellow human beings, comfort the sick, ease suffering, etc."
While it's true that you can do all this in a private setting, your clientele would differ quite significantly from those visiting restructured hospitals.
Your comments, please.
NUH nurses play Facebook game at work
What message is the person who posted this photo trying to convey?
1) That healthcare workers aren't entitled to some R&R during downtime, and should instead stare into space and let their minds go blank when there's nothing to do - and probably be accused of slacking off as a result?
2) That certain people like to sneak around counters with the hope of catching HCWs in compromising positions? ( I'm told this picture can only be taken if you walk all the way round to the back, which is not what a normal visitor would do. )
And now it seems the nurse has been disciplined by NUH.
What message does THAT convey?!
Thank you to An Old Friend, who contributed this topic suggestion.
"Hi moderators, wondering if we could have a discussion on The Practice of Medicine (eg Parson's Sick Law) vs Service Quality and Standards (eg ISO) vs cost and the conflicts they present?
Personally I feel that the delivery of medicine is not the same as the delivery of service in other industries, eg hospitality or airlines.
Secondly, the expectations and cost factors.
For example, while there is always this drive towards "service excellence" in every organization, the quality of the service is different depending on the price you pay for that service. However the management do not look at it that way. They look into every complaint in the same way in every organization. It seems to be left to the customer to decide what his expectations will be (sometimes this can be tempered if he is paying a low price). But it seems that in healthcare, free seems to be the price everyone wants to pay so no luck having any pared down expectations subsidized or not.
Case in point. How do the management of SIA and Singhealth weigh their quality standards? I bet they both want "service quality excellence". I don't see SIA rates being cheap though. Same with ShangRi-La Hotels.
It is extremely difficult if the government does not control the expectations of the people when it comes to subsidized healthcare, and yet want to control cost. The system is extremely taxing on the staff who provide the service. They are sandwiched between trying to give "world class service excellence", but keeping costs low."
I will post my reply first. Perhaps the rest of the panel can add their comments by editing this entry.
I fully agree that healthcare in Singapore has a distinct slant towards service provision, and that patient expectations aren't being managed sufficiently.
Conversations with people from the United States, Canada, Australia and the United Kingdom reveal a very different mentality - they understand the constraints of the public healthcare system based on how much less it costs the consumer.
The ER is a common discussion point - partly because I'm an ER physician. I recall a Canadian couple who recounted an 8-hour wait to consult a doctor about an elderly mother's hip fracture. When I told them an 8-hour wait in our ERs will guarantee a major riot - not to mention a reprimand from MOH, followed by interventional measures - they looked shocked and described this as "grossly unreasonable", especially after I told them we see an average of 400 cases a day, about twice the ER attendances in these countries.
The same goes for Americans and Brits. They know what to expect and usually kick up a fuss only if mismanagement is involved.
One might argue that since the Canadian and UK governments provide free healthcare for its citizens, patients have no cause for complaint.
But Singaporeans also receive substantial subsidies, and have easy access to tertiary hospitals where high-quality medical expertise and technology are readily available ( unlike rural areas in larger nations ).
Even a B2-class patient can be listed for an elective operation within weeks, compared to someone in the UK who waits an average of 12 months for a routine hernia repair or cholecystectomy.
The definition of "service excellence" varies according to the individual. For some, waiting time is a huge factor ( and one of the most important key performance indicators across the board ), while others may pay more attention to, say, the staff's demeanour.
But there's no denying that few subscribe to the idea that "the quality of the service is different depending on the price you pay for that service". In my 10 years within the public sector, I've encountered numerous patients ( and relatives ) who demand a level of service which is better accomodated in a private institution. But when I suggest they seek an opinion at such hospitals, they retort, "Why should I pay more?"
They want immediate scopes, cardiac scans, MRIs, consults with senior specialists. They criticize our "ridiculous policies" of arranging early clinic appointments, even for clearly non-urgent conditions. They start screaming bloody murder when they don't get sent to the ward within 2 hours, even when we explain that the hospital is full and beds can only be emptied when patients are discharged.
Is it because the government isn't controlling the people's expectations? Perhaps, to some extent, this is true, and is reflected by how MOH prioritizes its list of KPIs. After all, waiting times do nothing for a doctor's frazzled psyche, and only serve to pacify and impress the consumer.
The media also plays a part, regularly churning out statistics comparing one hospital / polyclinic with another. Let's not forget the dreaded Forum Page, which every HOD / CEO pores through first thing in the morning, hoping s/he won't see his/her department or institution fingered in a complaint letter which may / may not contain reliable facts.
The evolution of healthcare towards a service industry was probably also accelerated by marketing efforts that trumpet Singapore as THE centre for world-class medical care, including public hospitals in the mix. How much this has affected local perceptions, however, is hard to say.
I wouldn't go so far as to state that "in healthcare, free seems to be the price everyone wants to pay so no luck having any pared down expectations subsidized or not." I do ( occasionally ) meet patients who demonstrate a good understanding of our limitations - and it's no coincidence that many hail from the older age and lower income groups.
Based on personal experience, the majority of those who voice dissatisfaction are the well-educated, more affluent and younger people. I'm especially wary of those who come armed with information from the Internet or "a doctor friend / relative" or "a friend / relative who also has this condition or knows someone who does".
Another contributor to unreasonable expectations? Whether it's deliberate or not, I've had GP referrals asking me to arrange scopes / MRI scans / consults with specialists the very same day the patient comes to the ER.
You can see how this causes problems when the patient thinks I'm trying to pull a fast one, since his/her family physician of XX years, whom s/he trusts whole-heartedly and who can do no wrong, is being contradicted by this idiot of an ER physician.
Anyway, I'm nowhere as good as Angry Doc and Gigamole where in-depth analysis is concerned. Just offering a view from the trenches.
This is not really a 'medical' issue, so I can't claim that my analysis is an accurate one...
There are a few issues being brought up here, from the question of cost and affordability, to quality of "service", and also timeliness of access to care. People want "Better, Faster, Cheaper", and it seems that no one is willing to tell them that they can't have all three.
Good healthcare requires considerable resources, and since resources are limited, healthcare must be rationed. Longtime readers of my blog will know that I used to be an advocate for rationing by needs and not means, but over the years I have changed my views on the topic.
My current views on the topic are set out in the comments section of this earlier post.
Put simply, subsidised healthcare not backed by the moral courage to demand accountability from patients distorts the true value of healthcare and is ultimately destructive to the morale of its providers. We are in the state we are in today because the public thinks they can dictate what resources they wish to consume from the system based solely on the fact that they hold a ballot, and no one tells them otherwise.
Many doctors remain within the public system because they have no choice - they are either bonded or under traineeship - and others remain because the public sector offers them things of value which they cannot obtain in the private sector, such as research or teaching opportunities. No one, however, chooses to stay so they can be told how to do their jobs by laymen. Whatever the reason, as long as we choose to remain in a subsidised healthcare system where laymen's "concerns" are allowed to override our clinical opinions, we are helping to perpetuate it.
I will end by repeating the quote I posted in the earlier thread:
"I observed that in all the discussions that preceded the enslavement of medicine, men discussed everything—except the desires of the doctors. Men considered only the 'welfare' of the patients, with no thought for those who were to provide it. That a doctor should have any right, desire or choice in the matter, was regarded as irrelevant selfishness; his is not to choose, they said, only 'to serve.' That a man who's willing to work under compulsion is too dangerous a brute to entrust with a job in the stockyards—never occurred to those who proposed to help the sick by making life impossible for the healthy.
I have often wondered at the smugness with which people assert their right to enslave me, to control my work, to force my will, to violate my conscience, to stifle my mind—yet what is it that they expect to depend on, when they lie on an operating table under my hands? Their moral code has taught them to believe that it is safe to rely on the virtue of their victims. Well, that is the virtue I have withdrawn. Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it—and still less safe, if he is the sort who doesn't."
We've seen a surge in the number of visitors to this blog these past few weeks, mainly the result of lively discussions of hot topics close to readers' hearts.
Thank you for sharing your views with us, and especially with regard to the residency programme issue, I hope all concerns expressed have reached those with the power to do something about them.
Singapore MD was launched only 5 months ago, but thanks to an outspoken panel of contributors, an increasing number of followers, and referrals from other traffic-heavy websites, it appears we're gaining a good momentum.
For me at least, comments from readers motivate me to post more entries. And my fellow writers' choices of current and occasionally controversial subjects keep things very interesting.
On this note, I'd like to make a suggestion to our readers: if you have any topics you'd like to have discussed on this blog, or any burning questions to ask its contributors, feel free to leave a comment or drop us an email. If you choose to contact us via the latter route, please rest assured that your identity will be kept in the strictest confidence.
Bear in mind, of course, the disclaimer posted on the left.
I look forward to seeing what happens. :)
I would like to thank Dr. Chong Yeh Woei and Prof. Goh Lee Gan for their eloquent Forum Page rebuttals to Ms. Salma Khalik's recent editorial in The Straits Times.
This isn't the first time a journalist - usually from ST - has written a piece like this. It seems doctor-slamming rears its ugly head from time to time, especially after an epidemic has died down ( another good example: SARS ).
Lack of other newsworthy topics?
Part of some incomprehensible ST protocol that gets recycled every few months?
Or a certain senior correspondent's compulsive need to assert journalistic power by making sweeping statements about something she knows little about?
An excellent article by Dr. Cuthbert Teo in the September issue of the SMA News.
I'm sure many of us have encountered "special" patients at some point in our career, and that our experiences range from pleasant to downright harrowing.
I personally find the vast differences in how people handle fame and power interesting.
Most recently, I heard how a certain not-that-well-known F1 driver displayed quite the attitude at the ER, causing those who recounted the event to grimace.
Compare this to another driver who ranks much higher on the list of championship contenders, whom I had the pleasure of meeting during his visit to the ER, and who charmed us all with his respectful demeanour and beautiful manners.
Local celebs have also passed through on and off. Again, there're those who want to be treated like normal civilians -- I once treated an elderly man who's related to a very nice actress from the TV series Growing Up -- and those who kick up a major ruckus and make a scene so their demands will be entertained ( a certain TV show host who's a household name in our country ).
Politicians, however, are the true VVIPs.
Every time there's an international meeting for whatever reason, a certain hospital is assigned for emergency medical coverage purposes.
I can understand the need to expedite care for these delegates, but question the prudence of fast-tracking a stable patient and using up a resus panel, when a much sicker case needs more urgent attention.
The number of senior specialists, nursing officers and public relations personnel swarming around the ER when a VIP / VVIP arrives also makes me wonder how much more efficiently the system could function if we cared as much for our many "lower-profile" patients.
Also, let's not forget that in the event of a major disaster, it's very likely that resources will be prioritized such that VIPs / VVIPs will receive medical care in a more timely fashion compared to other mere mortals.
A small price to pay for their invaluable contributions to society? Maybe it's just me, but I think the right thing for a VIP / VVIP to do would be to decline such special treatment at a public hospital, especially when resources are being stretched. Surely being managed at a private hospital would be considered acceptable and perhaps more appropriate?
Last but not least, the fact that a certain ER's staff are on standby 24/7 to make non-urgent house calls to a retired politician's home, even during busy night shifts when manpower is minimal, is something that should be looked into, and preferably stopped.
Lots of hoo-ha has been going around about the residency program ever since the news broke, and it seems like the murmurings are getting louder. Being from the most recent graduating batch, ie the sandwich year, yours truly is keenly interested in the developments, as are her classmates. Many in her class have been straining their ears to find out more, but as of now, there seems to be some gaps in the information being provided to us. Worse still for those in the regional hospitals, because we have had no briefings/roadshows held for us, so all we hear are drips and drabs of info culled from various sources.
So yours truly, being stuck in one corner of the island, has been trying to sniff out information on her own. What she found, however, sounds like fodder for a Saturday Night Live episode. Take for example this:
11. What are the restrictions of duty hours, what do they mean?Cue ripples of laughter.
The ACGME mandates a limitation to duty hours to ensure that there is sufficient rest for the residents. The idea is that if the residents are too tired, they will not be able to learn.
- Residents cannot work for more than 80 hours per week on average.
- After 24 hours of continuous work, they must not see any new patients.
- There should be at least 10 hours of rest in between 2 duty periods.
- In a period of 7 days, one day must be completely devoted to rest.
The ACGME takes all the above very seriously. Failure to comply will result in citation of the program.
Maybe my poor houseman brain is too tired from taking bloods and setting plugs all day, but yours truly honestly can't figure out how an 80-hour work week and a 24 hour day including call can ever be in existence with our current manpower. I mean, I can't even take post calls sometimes (even when postcalls are supposed to be "protected" in a medical posting) so will the 24 hour day ever arrive? And the next thing that comes to mind is even scarier - if residents are truly to be "protected", then it means all scut would have to be borne by people like me - the MOs next year who have not declared their specialty. According to the website, the accreditation visit will be in July 2010, and "we should get most if not all things ready by then", so it sounds to me that I will turn MO next year - and return to doing HO work.
Speaking to seniors (including people who are somewhat involved in this exercise) has not yielded much result. The advantage, I am told, is that a trainee would have the same supervisor for the entire period of training and the supervisor is entirely responsible for the structure and exposure that the trainee gets, which sounds good because the current system does not allow close follow up of trainees. But to do so, the trainee must decide not only on a specialty, but also on a subspecialty, because if, for instance, the trainee is interested in cardiology, he or she would be assigned a cardiologist senior as a mentor right from the start and given opportunities at every turn to develop skills required by the specialty. Deciding on an area of specialisation so early is only possible with the US system, where students are the equivalent of HOs, and are rotated through the work in many departments and hence would have had a pretty good idea of the actual work each specialty does. Most of us here are completely clueless even after HOship, so it is pretty difficult (and unfair) to decide so early on.
But while yours truly is whining about this, she is also thinking of her juniors who, in addition to losing sleep/hair/weight over the upcoming MBBS, now have to concern themselves with portfolios and interviews. I don't envy them at all.
(Just a few cents' worth from a very junior and very tired doctor.)