The subject of GPs doing aesthetics came up again recently when Dr Woffles Wu wrote a letter to the ST Forum, arguing that liposuction should only be done by specialists.
MOH replied today; while I have no opinion on whether GPs should be allowed to perform liposuction, the final paragraph of the letter disturbs me:The ministry is in the process of strengthening our primary- care sector by enhancing the training of GPs so that more of them could function as family physicians. This will eventually help to improve our primary-care capability, especially in managing chronic diseases in our ageing population.
Now the 'problem' of GPs doing aesthetics has two parts to it: "why don't GPs do primary-care?" and "why do GPs do aesthetics"?
The answers to the two questions are largely related: to the first part it's because GPs do not see doing primary-care work as rewarding to them, and to the second part it's because they see doing aesthetics work as rewarding. However, it would be wrong to think that if we stopped them from doing aesthetics it will automatically mean that they will all turn to primary-care work, specifically to "managing chronic diseases in our ageing population". They can still make a living 'selling' MCs and 'lifestyle' medications (remember this?), or running a high-volume low-quality corporate contract practice, or doing "health screening", where "problems" are "diagnosed" but not treated (that's where the lucrative end of the business is, you see...).
In other words, 'GPs doing aesthetics' is not the root of the problem for 'GPs not doing primary-care', but a symptom. If you stop GPs from doing aesthetics, then they will likely find something else to 'do'. We can only hope that it's not something like Subutex...
So why don't GPs want to do primary-care then? Is it, as Dr Chern seems to suggest, that they don't know how to? That they need more "enhanced" training before they can even "function" as family physicians? Now bear in mind that we are talking about doctors who have invested the time and money into learning how to perform the various treatment modalities that aesthetics encompasses, not to mention the equipment cost. You do not wake up one morning and say to yourself: You know what? I think I'm going to do aesthetics today. Dr Chern tells us that to do liposuction, a GP has to "be accredited by the Accreditation Committee on Liposuction (ACL) and their medical clinics have to comply with specific licensing conditions". Are such people really incapable of functioning as family physicians?
Now even if that was true - let's just assume for argument's sake that a doctor who has gone through housemanship is not capable of functioning as a family physician (and they are not) - we have a situation where a new doctor has the choice between learning how to do aesthetics, and going through the "enhanced training" that allows him to function as a family physician. Which path do you think he will choose and why?
The bottom line here is that primary-care work, specifically the"managing chronic diseases in our ageing population" part, is not financially rewarding. Part of the problem lies with the fact that our healthcare system subsidises primary-care indiscriminately - you may not qualify for full subsidy under means testing in the wards, but you can still get full subsidy at the polyclinics, and be referred to a specialist as such, no questions asked. Such a situation distorts everyone's perception on what primary-care costs and is worth, and the result is what we are seeing today. (Ironically, SMA's effort in trying to encourage GPs to stay away from a high-volume low-quality care with the guidelines of fees was ruled anti-competitive.)
To a hammer, every problem is a nail. To a regulatory group, the solution to the problem is more regulations. The 'authorities', when presented to a problem, will always be tempted to 'do something'. Perhaps it's time MOH took a step back and looked at the economic realities that are present, and asked themselves whether their existing policies have made the practising of primary-care unattractive to GPs. If you can make it rewarding to them, the GPs will train themselves to become good family physicians (MOH don't provide enhanced training for GPs who want to do aesthetics, do they?); if you make it unrewarding to them, then why will they want to train to be a family physician at all?
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19 comments:
I think I've pointed this out to you before: the subsidy *increases* demand for polyclinic services and hence revenue for polyclinics. Without the subsidy, primary-care work will be even less financially rewarding since there would be fewer patients.
Same number of doctor, fewer patients. You think the doctors' wages will go up?
GPs refer to those in private practice, Fox.
Keeping GP fees down has always been politically attractive. One easy way is to flood the market with GPs and effectively peg fees to polyclinic scales. We have seen this supply-side dynamic over the years. And they're still asking why GPs don't fancy the tiring bolts & nuts of primary care? Worse, it looks like more KPI credit hours again.
The simple solution would be to subsidize treatment at private clinics like they do in the UK or Australia.
Of course, you're against such state interventions but then again, people in the medical profession benefit immensely from state regulations (for example, certain drugs, and I don't mean narcotics, can be sold with a prescription, only registered doctors from recognized universities can practice, etc). A true free market advocate would support the abolition of the Poisons Act, Medical Registration Act, Medicines Act, etc.
"The simple solution would be to subsidize treatment at private clinics like they do in the UK or Australia."
Yes, that will solve the "GP doing aesthetics" "problem" to a certain extent - some will still want to do aesthetics, of course. The problem then would be one of funding and the inevitable taxation; but we've already gone over that many times. The current government healthcare expenditure is around 9% of the budget, and that accounts for 1/3rd of the total national expenditure. That gives an idea of the sums involved.
"A true free market advocate would support the abolition of the Poisons Act, Medical Registration Act, Medicines Act, etc."
In a "true" free market economy, yes. But there is a difference between intervening in a market with subsidy, and in having the government take a regulatory role in protecting the consumers and providers against fraud and breaches of contract, as well as ensuring safety and quality. Just because we cannot have a true free market economy doesn't mean we must have an economy that has heavy government intervention.
Yes and I've told you repeatedly that the subsidy element is less than 1 percent of the total GDP, less than 5 percent of the government's national budget. The government's healthcare expenditure is 9 percent of the total budget but it includes unsubsidized elements. I've also told you repeatedly that the educational subsidies and defence budgets are an order of magnitude larger than healthcare subsidies.
"But there is a difference between intervening in a market with subsidy, and in having the government take a regulatory role in protecting the consumers and providers against fraud and breaches of contract, as well as ensuring safety and quality."
Conveniently, doctors are positioned to benefit from these regulations.
For example, since the healthcare of its people should no longer be the business of the government, why does it matter that Subutex is regulated? If I abuse it and die, then it is my business. If I go to see a doctor from Vietnam who is not registered with MOH, why should it be the business of the govt. to make it illegal? The govt. doesn't set such regulations for tailors, tuition teachers, car mechanics, etc. You mean to say that there are no fraud/breaches of contract/safety issues in the tailoring industry?
Having experienced GP services downunder, what I can say is that GPs here do spend more and better quality time with each patient as they generally attend to the more complicated cases. I guess this is largely due to the people being "trained" to self-treat common illnesses by getting what they need from pharmacies. Pharmacies here have nurse practitioners available to provide advice and nursing care often at no extra charge when you buy stuff from them (which relieves GPs of run-of-the-mill services).
This culture of self-medicating for simple illnesses inevitably results in GPs having lower patient load per hour and doing more complex and challenging work which is good for morale as well (no need to dabble in aesthetics and the like!). Because of the time spent and level of care, they can also justify charging more per patient (~A$50 per consultation, no medication as patient given scripts to buy meds at pharmacies), thus not affecting their income despite a lower patient load.
"Yes and I've told you repeatedly that the subsidy element is less than 1 percent of the total GDP, less than 5 percent of the government's national budget."
Which is still a lot of money, Fox.
"I've also told you repeatedly that the educational subsidies and defence budgets are an order of magnitude larger than healthcare subsidies."
Which is not the topic of our discussion here, Fox.
"... since the healthcare of its people should no longer be the business of the government, why does it matter that Subutex is regulated? If I abuse it and die, then it is my business. If I go to see a doctor from Vietnam who is not registered with MOH, why should it be the business of the govt. to make it illegal?"
Actually, I agree with you here. If the government no longer subsidises healthcare, then there probably is no need for special laws regulating the medical profession over and above those general laws which protect a tailor's customer. Healthcare professionals will then probably accredit themselves even though not required by law to give a degree of confidence to their customers, as other professions have done.
But it is quite telling that you only fight regulations that don't benefit you. For example, regulations requiring the registration of medical practitioners almost certainly drives up the demand for registered doctors in Singapore. Generally, regulations that you benefit from you hardly question.
Arguing against regulated medical subsidies without arguing with the same vigour against regulations that you are positioned to benefit economically from is not very principled.
"Arguing against regulated medical subsidies without arguing with the same vigour against regulations that you are positioned to benefit economically from is not very principled."
Sure, you are entitled to that opinion.
I can't argue against everything.
angrydoc,
see I had hinted on this.
Basically no need to have any government. No need for any regulations. No need for taxes.
Free for all absolutely.
People are to decide what doctor they see whether quack or not they decide.
Leave everything to everyone as they are always the wisest.
There will be no end.
Instead of arguing to such extremes it is perhaps a lot more realistic and constructive to suggest things that can be more pragmatic.
For example, instead of saying NO TAX.
Say tax everyone equally. And how much subsidy will be "enough"? And how much would be "too much"?
"Basically no need to have any government. No need for any regulations. No need for taxes."
And I've already stated that I think that is not practical. We begin with the principle that a man has certain rights, amongst which is the right to his own possession, and moving from there on we look at how to deal with the practicalities of living in a society.
I think we need at the minimum a government that makes laws to protect us, and that can enforce those laws.
"Leave everything to everyone as they are always the wisest."
I don't think that's true, but I also don't think anyone else should pay for their decisions.
"For example, instead of saying NO TAX.
Say tax everyone equally."
Do you actually read my posts and comments?
"Which is still a lot of money, Fox."
And public subsidies come out of the common pool of tax money that the subsidized contribute to (income tax, corporate tax, tariffs, GST, licence/fees, other taxes). So, the net wealth transfer, if there is any, may not be 'a lot of money'.
Why don't you produce a case example of wealth transfer through subsidized primary healthcare.
"We begin with the principle that a man has certain rights, amongst which is the right to his own possession, and moving from there on we look at how to deal with the practicalities of living in a society."
I don't think you have ever presented a case of why these 'rights' (e.g. the right to his own possession) are more acceptable and/or inherently superior to 'rights' like the right to minimum medical care. Contrary to what you may believe, the debate over property rights is still well and alive.
"Contrary to what you may believe, the debate over property rights is still well and alive."
I know. So will you hand me your wallet now?
"I don't think you have ever presented a case of why these 'rights' (e.g. the right to his own possession) are more acceptable and/or inherently superior to 'rights' like the right to minimum medical care."
I haven't, Fox; but as for 'right' to healthcare - don't you remember where we first met?
http://newasiarepublic.com/?p=16920
Frankly, I am a little let down...
"Why don't you produce a case example of wealth transfer through subsidized primary healthcare."
Unless you are saying that everyone received as much subsidy as they paid in taxes, I would say some amount of wealth transfer took place...
Well, last year I paid more income tax than I received in primary healthcare subsidy... I know that for sure because I did not utilise subsidised primary healthcare.
But wait! Since I cannot be sure that those dollars I paid in tax went to healthcare instead of defence (I mean, after all, defence sucks up sooo much money!), my statement may be wrong!
Primary care in Singapore is not the same as primary care in Australia. In Australia, people with chest pain will go to the GP, in Singapore, they will pop into the ER at the drop of a hat. And being a GP in Australia is a good career move b/c the earnings is quite substantial and the work quite varied, due to being able to mini-specialize in things like Oby/gyn ( yes, GPs in australia can even do C section for uncomplicated pregnancy), doing procedural work such as colonscopy, skin cancer management, dermatology and even anesthesia. Which unfortunately, the GPs in singapore can't do.
In Singapore, people go to the GP for really minor stuff like cold or cough. The facebook page of a cardiologist in CGH lament that he waste a lot of time having to tend to patient whose condition he had diagnosed but which he felt can be managed by a GP.However, these patients keep fixing up appointment with him.
And you can't really blame GPs for turning to aesthetical practice. After all, with really boring patients, and lower income, aesthetics is really more interesting.
I think the way to go forward is to allow for subsidized visits to GPs, perhaps via means testing. They should develop a class of family physician who must have a M.med in family medicine and maybe 1 more year of training in an area they like, such that they are sub-specialist eg , colonscopy, dermatology management, obg/gyn , pediatrics, pain management etc. Only such physicians can claim medicare for use of such service. Oby/gyn can also be disseminated to GPs for uncomplicated cases....
At the same time, there must be public education on what type of doctors to visit....no point popping into a polyclinic looking for referral everytime for everything.
In this way, earnings of GP will be boosted, work get interesting, some relief will be created in specialists workload...and aesthetics will be less attractive.
sigh..i dread the days i have to come back to Singapore after schooling and end up being a GP only.
angrydoc,
as a matter of fact I do read your comments.
But you keep changing your position and views.
Now your keypoint seems to be "practicality".
Sigh.
cosycactus - you don't have to...?
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