Excerpts from a colleague's recent tongue-in-cheek email, before the A&E lodger issue made the Straits Times earlier this week.
"Lodger Medicine is a promising new branch that allows effective medical firefighting skills to be nurtured and used.
The trainees will benefit from the endless number of lodgers littered in the Emergency Department (ED).
Our unique monitored bed shortage allows trainees to get hands-on experience in handling p1L cases— [ stable ] cases that become priority 1 [ i.e. collapse or deteriorate ] while they are lodgers.
Other training highlights:
- How to prevent patients from dying in the ED before they get a bed
- Keeping patients alive on a diet of Milo and biscuits
- Coaxing zombified nurses to carry out orders
- Facing family members with sore butts and deep vein thrombosis from sitting out for >12 hrs
- Fine art of converting Intensive Care Unit-grade patients to General Ward to get a bed"
It remains to be seen whether adding 2 new hospitals will ease the bed crunch, but ED overcrowding is a completely separate entity, not merely governed by ward capacity, but by Singaporeans' abuse of already overstretched resources.
Our government is obsessed with numbers, and the Ministry of Health persists in its mistaken hypothesis that creating more beds is the best solution, the same way it maintains that pumping more doctors into the public sector is a magical elixir which will cure all our manpower shortage problems.
It was announced on Thursday that MOH is looking into buying a stockpile of pre-pandemic H5N1 vaccine. One million doses - or around SGD15-20 million if one assumes the price is similar to current influenza vaccines.
In November last year, the US Preventive Services Task Force stunned many cancer groups and experts by doing a U-turn and publishing a new set of guidelines that advised against routine mammography in women aged 40-49 years who did not have any known risk factors for breast cancer. In women aged 50-74 years, annual mammograms were of little benefit (the Task Force recommended biennial mammograms instead for maximal benefit vs. risk). At no age was breast self-examination found to be useful.
Consumerist Healthcare
Sunday, January 24, 2010 | Labels: consumerism, experimental therapy, healthcareThis question was floated at a yakking session at the lounge the other day: should a doctor (or medical group) provide any treatment that a patient requests, as long as he/she is willing to pay for it?
We are not talking about the situation where a doctor offers "unproven" or experimental therapy (although this is probably still the more common situation here - I even know several patients that traveled to Shenzhen for their p53 gene therapy), or the well known but yet controversial healthcare inequities that arise when patients who can pay more get better care. Rather, internet-savvy and/or well-educated patients nowadays may request for medications or therapy that they believe might help with their conditions/illnesses.
This may be particularly difficult when patients have a terminal disease. What do you do when you know that whatever you provide (especially if it is the therapy requested by the patient), the patient will (99%) die without necessarily having meaningfully extended his life?
Some doctors go ahead with the requested therapy, reasoning that the patient knows what he/she is getting into, and anyway, the therapy will only be provided elsewhere (by rival doctors) if said doctor rejected the request. A rare few try to talk the patient out of it, and refuse to provide that therapy when counseling fails. In the private sector, I suppose the equation is more straightforward. There is a chance for a miracle (always good for one's conscience) and anyway, there is revenue to be considered. In the public sector, this is more troubling because resources (doctor's and other healthcare professionals' time, hospital bed and other services) that might be better utilized elsewhere are taken up by such cases - even if this was an A1-class patient. But then the public sector might well be accused of NHS-style practices...so where does one look for an ethical compass in such a situation?
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And of course, nothing will be done.
- More regulation of the healthcare industry, particularly doctors - lawyers chairing the SMC Disciplinary Committee, doctors getting fined 10 times more than they currently do now. The $1 (or several) million dollar question - can the 'wild wild west' of the private sector be reined in? Will there be more prominent doctors investigated rather than the usual 'uncle-type' GPs who have prescribed excessive sleeping pills?
- H1N1 hype - we will end up with a huge stockpile of unsold vaccines.
- Chaos when the Residency program starts in May, as the public hospitals struggle to cope with increased teaching requirements while the junior doctors try to deal with the 'express' vs 'normal' stream divide that will arise.
- Nurses and nurse-clinicians taking over more of the responsibilities of doctors.
- A boom in compulsive behavior studies as the casinos (sorry, integrated resorts!) open.
- Even greater congestion at hospitals and emergency departments, even with the welcome opening of (part of) the KTPH.
- More money poured into cancer and infectious diseases research (especially basic science) - will we see anything useful for the common folk coming out this year rather than just claims of breakthroughs in the ST??
- Big GP chains and conglomerates squeezing out more and more single GP establishments. A reprise of Sheng Shiong vs wet markets?!
- More complaints about junior doctors on this blog....
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.
There's been some discussion about this within my professional and social circles recently.
Are we becoming too soft with our juniors, and is this turning out to be a bad thing?
When I was a medical student, houseman and medical officer, stern seniors were pretty much the norm. Oftentimes it was something subtle, like a raised eyebrow or a frown, maybe a pause or a cryptic "Really?" in response to your statement.
Of course, there were a handful of explosive characters - surgeons who throw instruments, internists who pass sarcastic remarks, the occasional screaming session ( all of which I haven't personally experienced ).
The general impression I get is that such behaviour was tolerated in the past, but not anymore. I'm not saying it should be tolerated as a rule, but worry that being too nice is having a detrimental effect on our juniors.
It isn't my imagination that I'm encountering an increasing number of MOs, HOs and even med students who give me attitude even though I far outrank them. It seems no amount of telling off works unless you send an email directly to his/her Head of Department and threaten his/her chances of a) getting a good performance appraisal grade, b) securing a traineeship, or c) becoming a registrar.
I recall my first MO posting with a medical specialty notorious for its no-nonsense, obsessive-compulsive consultants and demanding work ethics. It was a rotation that was nowhere on my list of requests, and I started my first day with great trepidation.
It took me a month to get into the swing of things, but found myself adopting my seniors' attention to detail and constant sense of urgency. The consultants were extremely strict but also reasonable. Laziness and disrespect were considered cardinal sins.
Perhaps this paved the way for my current work ethos. I'm willing to grant an adjustment period, and always start off believing the best of my juniors. But if you demonstrate no interest in learning, slack off every chance you get, take advantage of your colleagues or show no remorse after making a mistake that jeopardizes a patient's life, I guarantee a severe reprimand.
Over the years, I've noticed a shift from simple rebukes to milder admonishments, even for cases where a junior doctor was clearly reckless. Peers who used to fry MOs for sloppy work now opt for gentle counselling, while some take the easy way out, i.e. act oblivious.
I have also toned things down somewhat, though I'm still considered one of the most sharp-tongued among my colleagues. However, that first MO posting I did 10 years ago taught me that:
a) if you're not performing up to a certain standard, it's only natural that your senior won't be happy;
b) you can choose to mope / curse / swear and stay in a rut, or you can evaluate your own shortcomings and rectify them;
c) earning the respect of a senior who is almost impossible to please is an extremely rewarding experience.
My bosses subscribe to the soft approach - or what I like to call the "New Age style of teaching" - and encourage me to do the same.
I try to humour them, but still have a reputation for being "a little too fierce" for my juniors' liking.
Doesn't bother me one bit. :)
