A recent case has put the medical profession in the harsh limelight once again.
Understandably, there is much speculation about what could have happened. And this particular incident has more than the usual impact on me personally, as one of the doctors at the centre of the tornado is from my medical school cohort.
Of course, that is completely beside the point. This could've happened to anyone. The big question is: what exactly DID happen?
This entry isn't meant to be a medicolegal commentary. I know nothing about this procedure, but invite those who do to give their opinions, preferably in an unbiased manner.
Pertinent issues at hand:
1) Did the doctor who performed the procedure follow proper protocol?
2) If the patient died as a result of a procedural complication - even if it is an expected one ( i.e. something the patient must be aware of when giving consent ) - could it have been avoided?
3) What is the global safety profile of liposuction performed by doctors who aren't qualified plastic surgeons?
4) Why did this unfortunate patient, who by all accounts appeared wealthy enough to have consulted the best plastic surgeon in Singapore, choose a general practictioner?
5) Should those who carry out invasive procedures of at least moderate risk, and for purely aesthetic reasons, be subjected to more stringent guidelines?
6) It was mentioned that Mr. Heng was not considered overweight by those who knew him, yet fretted over "love handles". However, it is not known whether he consulted only one clinic, or perhaps multiple establishments, before undergoing liposuction.
Is it possible that another doctor may have advised him against having this procedure?
Or perhaps the GP who's currently being investigated also issued similar advice, but later acquiesced to Mr. Heng's wishes, for a variety of reasons?
A GP friend of mine says such a procedure can easily net S$5000 for a single session. Doesn't take a genius to estimate the earnings of a practice which chooses to do this exclusively, even if it's just a handful of cases a day.
Which brings me to Prof. Lee Wei Ling's commentary in the Straits Times today ( apologies that the online link is unavailable ). In it, she mentions this case, and makes the correct observation that contrary to what the Ministry of Health keeps drumming into our heads, Singapore does NOT suffer from an absolute shortage of doctors, but rather, a relative one.
Many of us have known this for ages, and I wrote to The Forum Page in 2009, highlighting this problem in the wake of NTU's plans for a 3rd medical school. Because what is the use of pumping hundreds of local and foreign doctors into the system every year, when most of them eventually leave the public sector?
I reiterated the need for a major revamping of public institutions, from the polyclinics to tertiary hospitals, in order to retain medical staff for the long haul. MOH issued its usual media-friendly reply; who knows whether any actual steps have been taken...
But I digress. The constant efflux of doctors to private practice, in particular General Practice, has resulted in an oversaturated market. And it is absolutely true that when it comes down to nickels and dimes, why would a GP persist in treating chronic illnesses, coughs and colds, when s/he can easily improve profit margins by "specializing" in aesthetics?
The floodgates opened years ago, and we are now witnessing the consequences of those actions.
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10 comments:
I don't subscribe to the ST so I haven't read her article.
But I blogged about this almost 2 years ago.
Maybe it takes a louder voice like Dr Lee's before it's heard...
I did not read the article but I agree that there is a problem with the medical system in Singapore. It used to be that only the creme de la creme get to enter into medical school. Even then, it can sometimes be a squeeze at postings to get to see the patients with the interesting diseases, must see "signs". With the increase in the number of medical students, I can only imagine that it is worse now then ever and will be so in the future with the 3rd medical school.
I agree with Prof Lee Wei Ling- the shortage is not absolute, it is relative. The private sector is getting saturated. The general practioner in Singapore does not functioned like a GP say in UK, Canada where they are true "family" doctor who also will coordinate multidisciplinary, chronic care, advocating for the patient. This results in the slightly more complex patients or chronic patients with a little more symptoms to flood the "tertiary hospitals"- which really may not be true- in certain disciplines. This brings us to the next point.
Why is there such a great efflux of doctors into the private practice? Yes, money is a lure, but believe it or not, push factors are often times much much greater than the pull of money. Specialists are such because the specialty attracts them intellectually, though some do choose certain specialties for the potential earning power. Working in a public institution allows one to be a true specialist or subspecialist, to really do what one loves and not have to do general cases. This is the case in large part in the adult world, but sadly not so in the Pediatric world.
In the Pediatric world, with the public hospitals looking to bottomlines and patient load, most pediatricians who are "sub-specialists" had to do general Pediatrics. General Pediatrics sometimes degenerate into General Practice in the young. If the Pediatrician in the tertiary hospital spend a significant (sometimes the majority of) time doing this, plus having to put up with adminstrative burdens, deal with nasty public relations incidents, where is the time to grow in their area of subspecialty? Experience is very important in Medicine. So, there then comes a point when the love of that subspecialty work is not enough and one leaves. Afterall, one then have more time to spend with family and at least work hard for money that comes into their own pockets.
Looking at the recent efflux of more than 10 pediatricians from the 2 tertiary Pediatric units in the country, which followed an ongoing trend since the mid 2000s, glutting the departments, such that only the very senior and very junior doctors are left in public practice. It is a vicious cycle- there are not enough people to run the bread and butter show, thus the sub-specialist in training has to help, which takes time from truly learning the craft, they get frustrated and then they leave.
The government wants to build a world class biomedical hub- on whose backs? Currently, the most productive researchers are foreign. WHy? They have the time, the exposure abroad and the research training necessary. WHile basic science research is interesting, clinical research is also important. With such a "well- organized" medical facilities (and we do have the infrastructure), why are we not producing more clinical research to inform the world about Asian patients? There is just not enough time or manpower to devote to this.
So, the solution to the maladies of the Singaporean medical system is not to set up more medical schools and train people for the private sector. It is retaining the brains in the public practice to deal with the most perplexing, difficult cases and to make important medical discoveries!
Well, Singapore has the 6th best healthcare system in the world if you go by the old WHO rankings :-).
But I agree that many of the current problems has to do with how the system was set up. Funding 80% of tertiary care but only 20% of primary care was a deliberate move to reduce costs at the time but it has led to a situation where many GP's would rather do liposuctions rather than manage chronic illnesses (the latter does not really pay very well), partially because the cut-throat competition outside has led to GP's having to slash their consultation fees in order to remain competitive against large HMO's. 30 minutes spent dealing with diabetes, IHD, hypertension for a $15-25 consult fee is just not worth the time.
And many people want to continue being followed up at public hospitals for "trivial" issues like hypertension, hyperlipidemia, etc because they can use the "3M's" and hence reduce out-of-pocket expenditure. The fact that most of the general public perceive GP's to be less capable of handling such conditions than that MO or Registrar in the hospital doesn't really help. And guess what - there is no incentive for the hospital to discharge these patients to the primary healthcare sector either. The remuneration is the same whether it is for a patient with mild hypertension or for a patient with a triple-A. The main incentive for discharging patients to primary care is when the doctors start to feel overloaded from heavy clinic lists (and even so, the hospital doctor has to maintain a significant number of patients on his/her list to show his/her "value" to the institution...).
Recently, the ministry has allowed Medisave and Medishield to be used for chronic illnesses managed by GP's. A move in the right direction, but truly parsimonious as in the nature of the ministry - it is still better to laser away that pigmented patch or give MC's for URTI's where the GP is concerned.
I graduated from australia and currently working in public sector in singapore.
The Gp practice here is significantly different than the australia. During my GP attachment i saw a wide variety of Gp in the private sector. Some do procedure, some manage chronic diseases and some only see managed care patients (tie in with hospital and com hospital)
The Gp there do spend a lot of time with each patient doing health promotion and knows their regular patients quite well. The reason for this is that they are well paid for their effort and have incentives for well managed care. On average the avg GP can see abt 6 cases in 1 hour (paid by goverment + top up from patient - can get avg 50 per patient without resorting to other charges such as selling meds etc)
Here in SG even in the private GP clinics almost everyday is like a mad dash to clear the crowd. There is no incentive to do more as the low consulatation rate - esp the health care card holder or insurance plan care are minimal, with occasional loss if need to prescribed more exp meds)
These are even worse in the public sector here... 100-120 patient in 8 hours. Doesnt take a MBBS to know that something has got to give... and usu patient care suffers. Based on these reasons alone u can see why so many GP are doing aesthesics as the payout is more and workload is manageable.
Singapore need to revamp the healthcare model. There are only so many polyclinic consult rooms. If everyone got pissed and left, hiring non tradisional source of MO for philiipines, india is a poor short term fix to a chronic problem.
As usual all these problem will be ignored until something really bad happens...
While we sit here and debate about what MOH should and should not do, have we addressed what is the true crux of the problem in healthcare today?
I'm not talking about Singapore. I'm talking globally.
There is no such thing as the "best" healthcare model, simply because there are too many variables to consider.
Singapore's system excels because it is efficient and relatively cheap for the level of care it delivers. As a result we pay relatively low income tax rates and still get subsidized health care that is acceptable.
In other countries, income tax rates are high as the healthcare budget is higher.
Will Singaporeans be willing to pay more so that their GP in the polyclinic can see 6 patients an hour?
Well the answer is a flat no. So while some patients talk big about how the government should hire more doctors etc , when asked if they would be willing to pay more eg consult $20 instead of $10, they would say "why should I?"
The money has to come from somewhere.
Having said that, although I am a doctor, I am not entirely biased. If you asked doctors who complain about seeing 120 patients in 8 hours to have a pay cut so that we can hire more doctors to share the load and thus only have to see 60 cases a day, they would also say "no!".
So you see, the real problem with healthcare is that doctors feel they should be remunerated well for their efforts. (well who's to say they shouldn't anyway for doing a good job?) On the other hand patients and governments just want to pay as low as they can get away with.
And then you have the drug companies that dictate quite a lot of healthcare costs but because they can be economic drivers in the form of pharmaceutical manufacturing, governments often are happy to see these companies flourish.
So the easy target is the healthcare workforce as the "culprit" of rising costs.
Over the past 2 decades, the salary of doctors has not kept up with inflation. In reality, doctors earning power has dropped over the years. Unless you aren't practising healthcare.
ie do business eg run a healthcare group, go into beauty/aesthetic business etc etc.
Anyway wanting to be a doctor has to learn that in the future, doctors will earn no more than average middle class incomes. If you are ok with that, then go ahead and study medicine. In Singapore success is often measured by your pay check. No one wants to look like a monkey if they think they are Einsteins.
I think the existence of an aesthetics market is a demonstration of supply-and-demand. It also throws into relief how doctors feel they are being renumerated for their skills and time. While the mass 'conversion' of GPs into aesthetic practitioners may be bad for patients in the short term, on the long term I believe it is good for the profession and subsequently our healthcare system as a whole.
For too long our system has over-worked and underpaid doctors, relying on their sense of "duty", "calling", and "compassion" to keep them compliant. It may have been enough in the past but it is clear now that doctors can command more and that they want to and will. The public's perception on healthcare costs must change - this does not mean that they necessarily will pay more for healthcare, but their attitude towards preventive healthcare, saving for healthcare expenditure, and utilisation of healthcare must change in recognition that healthcare in the future will be expensive.
Solution is to import cheaper drs from overseas so that we can lower healthcare cost and sg citizen will no longer be afraid to fall sick
that's the solution for every problem these days isn't it?
import foreigners. Cheaper, better.
good luck Singapore.
haha :)
It's pretty amazing how a discussion about anything in Singapore nowadays devolves into foreigner-bashing! :P
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