This entry is prompted by a recent question from one of my MOs. I believe we have quite a number of young doctors reading the blog, so I hope you will find this useful.
Administrators, consider yourself warned that you may find the following content 'disturbing'. :)
10. Avoid high-risk patients.
If you're wondering whether I can quote at least 1 randomized controlled trial, preferably triple-blinded, with p value less than 0.0000001, you are sadly mistaken.
Is there a one-size-fits-all high-risk profile? Probably not. Based on personal experience, we tend to develop our own sets of criteria, and with time, through trial and error, you will discover yours.
I know what mine are, but posting them on a public site may be construed by certain 'sensitive personalities' as an example of 'causing societal disharmony', if you catch my drift.
However, the one characteristic I would probably consider a universal precaution is any patient who's 'high-profile', or who has a relative who falls into that category, i.e. celebrities, political figures.
Also, I would be VERY wary of journalists. Don't give them something to write about!
9. Attend risk management workshops and apply what you learn.
This is low on the list for me, for a good reason.
During my rather lengthy career, I have attended a total of ONE such workshop, and I refuse to attend any more.
Why? Because days after learning a wonderful method - complete with a catchy pnemonic - of handling difficult patients / relatives, I managed a guy who couldn't give a rat's ass about my newly acquired skills. He was clearly malingering, blew his top when I refused to issue a medical cert, loudly declared he's 'a lawyer', that he would 'write to the Forum Page' about me, then stormed off to the administrative offices upstairs to lodge a complaint.
He didn't get the MC, and I didn't make any headlines in the newspaper. But don't expect me to bother with any of these workshops ever again, because they obviously don't work on PSYCHOS.
But if you need CME points, be my guest.
8. Spread the shit - oops, I mean blame - around.
What does this mean? Well, if you're still an ikan bilis, so to speak, you will have seniors available to act as buffers, i.e. to review and vet your cases, handle difficult patients / relatives, etc.
While my generation of doctors ( yes, I consider myself a little old ) used to tahan all sorts of nonsense and clinical catastrophes until just before we dropped dead, rather than consult a registrar or consultant, things couldn't be more different now.
My MOs drive me insane with their bizarre updates, which are completely separate from the medical management. I honestly don't care what time the relative is coming to bring the patient home, as long as the patient is fit for discharge, okay?
But this is truly a savvy move on the MO's part. They love to tell me they're discharging a case, after all the tests done are normal and the patient is super-well. Why are you consulting me then, I ask. The reply: Oh, I just wanted to let you know.
Took me a while to fully understand their strategy. If they document having 'consulted a senior', if a complaint materializes, you have to answer it, even if it isn't about you per se.
In fact, some MOs may escape the patient's / relative's wrath completely, if the latter somehow latch onto YOU for whatever reason, even though your interaction with them lasted less than 5 minutes.
Very smart indeed.
7. Look busy, even if you're not.
True story. a patient's email feedback was circulated around my department, in which the patient criticized everything from the waiting time to nursing issues. However, she reserved the highest praise for one of my MOs, for 'working so hard', just because he was observed to be 'running around while everyone else was taking their time'.
This is a direct quote.
Doesn't matter if this particular MO was one of the least productive we had ever had. Yes, he ran around a lot, often with a stressed / harrassed expression on his face, but mostly because he had no clue what he was doing, and failed miserably at multi-tasking.
But the most important lesson to learn here is: the patient / relative rely heavily on APPEARANCES. So make sure you look as busy as possible, because they don't know the difference!
6. Offer freebies.
If you run clinics, check the cabinets for free samples from pharamaceutical companies. Patients LOVE medications and vitamins they don't have to pay a single cent for, and these could come in very handy if you sense a complaint coming your way.
Just present the person with a couple of boxes and wait for the smile.
Never fails. :)
5. Market yourself.
One MO was famous for shamelessly bragging about his venepuncture skills, convincing patients that they had the worst venous access in the universe, and that he was the only doctor who could take their blood / set their IV cannulas on the first try.
As a result, he consistently received compliments from patients and relatives, for his 'exceptional care'.
But make sure you don't come across as obnoxious. This MO managed to pull it off, and I only wish I had learned from him before he finished the rotation, heh!
4. Flirt.
Yes, you read correctly.
Never underestimate the power of pheromones. This tactic can be a powerful tool, but of course, you gotta have skills, and know how to pick the right targets.
E.g. If you're a young male, the ideal patient who will be susceptible to your charms is a young female, and vice versa. Even those in the middle-aged group appreciate it when a young doctor showers them with attention.
One of my ex-MOs, a strappingly handsome Caucasian dude, was lazy and unpopular among his medical colleagues, but a huge hit with the patients, especially the young ladies.
Remember, a patient who's hot under the collar will never hurt you.
3. Give the patients whatever the hell they want.
See point #9.
Don't be stingy with MCs. Prescribe antibiotics if they demand it, even if it's clearly a viral infection. Why put yourself through hell when they won't listen to reason?
2. Be generous with your time.
This is guaranteed to please any patient / relative, because in Singapore, that is how a doctor's competence is measured.
Never mind if you spend 30 minutes talking about family, kids, travel, food and shopping. As long as they know it's a damn busy clinic / ward / A&E, they will LOVE you for giving them such VIP treatment.
Just ignore your poor colleagues who're working their butts off to clear the changes and patient queues. You see the bigger picture. Service quality awards are 10 times more impressive than actual clinical acumen, conscientiousness and efficiency!
1. Be extra nice! Bedside manner 99%, clinical skills 1%.
Aside from spending loads of time with the patient, always ask whether [ where applicable ] (a) s/he has had his/her breakfast / lunch / dinner yet, (b) you can get him/her a drink of water if s/he's thirsty, (c) you can get him/her some food if s/he's hungry, (d) you can get him/her an extra blanket if s/he's feeling cold... you get the idea.
Sayang the patient - preferably in front of relatives - as much as possible. A reassuring hand on the shoulder or arm. A sympathetic smile. A kind word. Never interrupt. Nod your head repeatedly, even if you're thinking about that nice sports car you want to buy, or that date you have this evening. Unless you're treating a professional magician who's telepathic, you're safe.
Because Harold Shipman, the infamous doctor/serial killer, was so beloved by his patients and their families, that even when his horrific crimes were made public, remained exalted by many.
In fact, one of the victims' sons remarked that were his mother still alive, he would want Dr. Shipman ( her killer ) to remain their family physician!
Let that be a valuable lesson to you all.
Here endeth the tutorial.
The problem with discussing alternative medicine is that oftentimes its proponents do not quote specific studies to back up their claims, so I am in fact quite delighted to see a reply in the ST Forum today that bucks the trend:
Chiropractors have meaningful role to play
I REFER to Dr Andy Ho's commentary ('Perils of chiropractic neck manipulation; last Friday').
To date, there has been no documented case of vertebral artery dissection (stroke) caused and occasioned by chiropractic treatment in Singapore.
Dr Ho did not mention very important facts stated by the Bone Joint Task Force in the journal Spine (2008). The authors concluded that there is no evidence of excess risk of vertebrobasilar artery stroke associated with chiropractic care. The risk - if any - is no different from that associated with a primary care provider such as a general practitioner.
An independent report by the Rand Cooperation concluded that the risk, if any, is estimated at one in a million, lower than that of being struck by lightning (one in 700,000).
The Mercer Report (2008) by two Harvard-trained medical doctors concluded that chiropractic care is more effective than other modalities for treating neck and lower back pain. It is also highly cost-effective. This is supported by the Bronfort Study (2010) from Britain.
The Chiropractic Association (Singapore) has made representations to the Health Ministry to be included in the Allied Health Professions Bill. As a trade association, we adhere to an international code of ethics and we do require our members to upgrade their skills annually with training.
Chiropractic does not have a genesis rooted in mysticism but rather in the biomechanics of the human frame. As in any profession, we have evolved through the years to become a profession that draws its conclusion based on facts and results.
Chiropractors are playing an important role, and being recognised, in hospitals in Canada, the United States, Saudi Arabia and China. Australia is currently in the preliminary stage of utilising chiropractors to serve in hospitals. We believe that sensible national legislation and a proper sense of internal regulations will bring about a higher level of professionalism in Singapore.
Chiropractors have a meaningful role to play in the Singapore health-care system. Although we regret that we are not currently included in the Allied Health Professions Bill, we have been - and will always be - playing a meaningful role all these years.
Terrence Yap
Asian Executive Council
World Federation Chiropractic
Now we are cooking with fire.
One wonders of course why despite all the evidence that Mr Yap quoted, chiropractors are nevertheless not included in the Allied Health Professions Bill. If we are going to put lipstick on TCM, why not chiropractic too, right?
Now you can read the Bronfort Study in its entirety here. It will take me a few days to read through the thing and track down the individual papers reviewed (if I can find them), but let's for argument's sake say that its conclusions are true; the question then is: if, as Mr Yap claimed, chiropractors are "a profession that draws its conclusion based on facts and results", does that mean that the World Federation Chiropractic are committed to censure all its members who claim that chiropractic is "effective" for neck pain of any duration, mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults, asthma and dysmenorrhea, Stage 1 Hypertension, otitis media and enuresis in children, infantile colic, knee osteoarthritis, fibromyalgia, myofascial pain syndrome, migraine headache, and premenstrual syndrome?
Added: Out of curiosity I googled "Singapore chiropractor" and looked at the first few sites that came up. Do try the same and see how many of them advertise a cure for those conditions that the Bronfort Study had found chiropractic to be ineffective for.
I believe this is what the young people these days call self-pwnage?
I trust many of Singapore MD's readers came across this articletoday.
To be frank, I was taken aback by the number of foreign doctors being recruited - approximately 800 out of 1300 newly registered physicians.
I guess the MOH ( or MOHH as it's called these days ) deserves some credit for taking steps to ease the shortage ( though relative and far from absolute ).
But yet again, numbers aren't everything. Sticking your finger in a hole can plug a leak, but you still need to fix that damn hole.
And who oversees the quality of these foreign doctors? There used to be strict regulations on recognized universities / degrees, but it seems just about anyone can get their feet through the door these days.
Do they need to take a theory or clinical test before being accepted into the local workforce? I'm guessing no, since quite a few of the foreign MOs I work with can't take proper histories, do simple physical exams, read ECGs or x-rays, or interprete basic blood test results.
They're also not very productive, so you need approximately 2-3 of them to cover the workload of 1 competent junior doctor.
And there've been many near misses, so the supervising senior doctors also have their hands full.
With the recent implementation of the residency programme, the overall patient workload will become even more unequal, as residents have clearly stipulated patient numbers which MUST NOT be exceeded, leaving the extra cases to be distributed among the non-residents ( many of whom are now - say it with me - foreign-trained ).
I see a vicious cycle starting.
p.s. KTPH is now hitting full bed capacity in terms of admissions. I wonder if MOHH can get JGH's contractors to speed things up.
To me, the question on whether or not TCM "specialists" should be allowed to call themselves specialists is as meaningless as a discussion on whether an astrologer should be allowed to call himself a "specialist astrologer" (in maybe the sign Aquarius?); you can legislate to regulate something, you can have Bills and Gazettes to stipulate who can or cannot call themselves by what terms, but at the end of the day, it doesn't change the fact that if the body of knowledge behind something is not based on reality, a "specialist" in that field is as much a charlatan as a "non-specialist".
Dr Ong gives us a summary of the problem with the status of TCM in Singapore in his letter to the ST Forum today:
It opened Pandora's box
WHEN the Health Ministry followed China's example by registering and certifying practitioners of traditional Chinese medicine (TCM), it opened a Pandora's box by not defining the limits of practice and putting in place clear regulations to safeguard patients' welfare ('Health Ministry to probe TCM 'specialists'; Monday).
Singapore has a double standard regarding medical practice. For practitioners of Western medicine, mistakes such as omission of a test, missed diagnosis, failure to inform the patient of possible treatment complications and well-intentioned misjudgment would land doctors in legal trouble.
But TCM practitioners seem to enjoy an exemption from such obligations. Strict oversight of medical practice is highly desirable and it should apply equally and consistently to all healers of diseases.
It is not right that one school requires scientific proof and evidence for its practice and is held responsible for possible errors, while the other is exempt from the need for scientific scrutiny and is free of legal responsibility of the outcome.
China has its reasons for promoting TCM. We appear to have followed suit for reasons of affordability, medical tourism and the muddled belief that freely allowing all schools and methods of medical practice will lead to progress and innovations.
Based on my 50 years of medical practice, including teaching in medical schools, and my knowledge as a person primarily educated in Chinese, I can categorically declare that if TCM follows a scientific path, it will eventually become Western medicine as we know it.
But the reinvention of the wheel has a long way to go.
Dr Ong Siew Chey
Not much more needs to be said besides that, is there?
