Pricing, Cognitive Dissonance, & How To Charge More

Something to ponder, especially with the recent publicity surrounding Dr. Susan Lim.

A few choice quotes ( no copyright infringement intended ):

"...I’ve met many, many physicians who under price their services. The primary reason that's given is that they have to have low prices to remain competitive..."

"This can be true — especially around mass consumer treatments like Botox and laser hair removal — but whatever the reason, charging too little for your services is self-sabotage for two primary reasons:

1. When you don’t charge enough you end up resenting your clinic. You do too much work for too little money. It’s not worth it. (Try to tell me this isn't the primary reason that so many physicians would like to leave clinical medicine.)

2. A low price tells patients that you’re not worth it. It may be all smoke and mirrors in the beginning, but if you want to be perceived as the best, you’d better price your services accordingly. Low prices are THE primary indicator of low quality."

Comments, please.

24 Million Dollars

An incident that has been simmering in the background for some time has finally gained prime time in the local newspapers.

Four years ago, local surgeon Susan Lim treated a woman linked to the Bruneian royal household for a period of 7 months and issued a bill of $24.8 million. The Bruneians sought a discount (it does not appear that they had pressed charges from the local press reports) and our MOH lodged a complaint with the Singapore Medical Council. Things have deteriorated to the point where the surgeon has dragged SMC to court, and it appears that she has assembled quite a powerful team of lawyers to press her suit.

Whatever the result, the local medical profession will not come out smelling like roses. On the one hand, there is no escaping the perception that the SMC (especially its disciplinary committee) will appear incompetent. Even the judge had suggested as much. It's very well to slap warnings and penalties on small-time GP's overprescribing sedatives; it's another matter to take on someone with the resources and capability to hit back hard. On the other hand, although we understand that the Bruneian royal family is fabulously rich, and that Dr Susan Lim is not the sole recipient of the 24.8 million dollars (some of it will go towards paying off expenses, as well as other specialists who were undoubtedly called in to assist), it is hard not to believe that she was greedy. Charging as much as the market will bear is an accepted practice in business, but there are limits beyond which virtually all views of such transactions become negative, particularly in healthcare.

And the question that inevitably arises - does she really need that much money? Dr Susan Lim was the first person in Singapore to successfully perform a liver transplant, she is featured on the Monash University website as one of its prominent alumni, and has a wax replica of her hands in Madam Tussaud's. She also has more awards than most and has doubtlessly inspired whole generations of doctors and surgeons. One is left pondering the question: why did it go so wrong?

A New Low for SMA

I am used to SMA's weak stance against alternative medicine, but this letter in the ST Forum today is a new low for the "professional" association.

Unwise to criticise alternative medicine, says SMA

DR ANDY Ho wrote that he was disappointed with the local medical profession for not warning the public about the dangers of chiropractic neck manipulation ("Perils of chiropractic neck manipulation"; Jan 21) and criticised homeopathy ("Indefensible ideas behind homeopathy"; Jan 22).

His scathing commentary on acupuncture criticises the Singapore Medical Association (SMA) for suggesting that the ethical code of the Singapore Medical Council (SMC) be amended to allow medical practitioners to refer to traditional Chinese medicine (TCM) practitioners and acupuncturists ("Pinning down acupuncture: It's a placebo"; Saturday).

While Western-trained doctors do warn their patients about the risk and safety profile of what they prescribe and voice their opinions on various kinds of alternative medicine to their patients, it is another thing to advocate that the local medical profession collectively criticise alternative medicine groups.

This is especially so when doctors and alternative medicine practitioners are seen to be competitors and criticising alternative medicine can be construed as self-serving.

Dr Ho's column on Saturday failed to take SMA's proposal to amend the SMC ethical code in context. When the current code was introduced, TCM practitioners and acupuncturists were not state-registered. They are now.

We do not think doctors will refer widely to TCM practitioners even if the code is amended. However, patients do request from their doctors medical reports and summaries when they seek care from TCM practitioners. The present code disallows such formal communication. Amending the code will facilitate better communication between a patient's various caregivers so that the patient's interest is best served.

The SMA does not encourage its members to refer to alternative medicine practitioners. But we have to be realistic. They exist and are here to stay. Most public hospitals already offer acupuncture services. Several have TCM clinics on their premises.

Continuing this "iron curtain" of no formal communication between doctors and alternative medicine practitioners is impractical and anachronistic.

Finally, many alternative medicine forms are steeped in cultural and religious beliefs, such as TCM and ayurvedic medicine.

From the perspective of safeguarding social cohesion in Singapore, getting the local medical profession to collectively criticise various alternative medicine modalities is unwise.

In Singapore's social context, journalists should not try to pit one group of caregivers against another. It is best for an impartial and respected body such as the Government to step forward
to decide what is safe and unsafe for patients.

Dr Abdul Razakjr Omar
Honorary Secretary
Singapore Medical Association (SMA)


Notice how Dr Razak had not addressed Dr Ho's main focus, which were on the lack of evidence behind alternative medicine.

Instead of accusing Dr Ho of failing to "take SMA's proposal to amend the SMC ethical code in context", Dr Razak should perhaps ask himself why SMC's ethical code specifically makes that distinction between medicine and "complementary medicine" - as I have argued in my previous posts, just because practitioners of a certain mode of alternative medicine are registered does not mean that there is any evidence backing their claims; reality does not alter itself because of cultural beliefs, political decrees, economic conveniences, or public opinion. Hopefully, as a professional society representing (about) half of all doctors in Singapore, SMA understands that.

There are many forms of alternative medicine out there which are being sold to unsuspecting patients. Just because they are a part of our "cultural beliefs" or that they are renting shop spaces in our hospitals does not mean that doctors as a profession must accept them or not speak up against them. If you know that certain forms of alternative medicine are ineffective or indeed potentially harmful, but choose not to advocate against it because you do not want to be seen as "self-serving", what does that say about your strength of character? Will we rather our patients be harmed by such therapy than we be falsely accused of being self-serving?

If we claim to be a profession that is built upon science, if we claim to be advocates for our patients, then we must speak up even when we know it will not be well-received, even when we know it will offend.

Thus, that line about "safeguarding social cohesion" is really a betrayal of what this profession and SMA should be about. If you go through the SMA's constitution, you will find nothing that states that it is its aim to safeguard social cohesion. In fact, this cowardly defence of alternative medicine can be said to go against a few of the stated aims.

SMA needs to ask itself whether it will choose what is expedient over what is right, and whether it is more important to be popular or to be intellectually honest.

Should doctors check the daily horoscopes of their patients?

Good question indeed, Dr Ho.

Lipstick on a Pig 4

It seems that Mr Yap is not only a member of the Asian Executive Council of the World Federation Chiropractic, but also the Correspondence Officer for The Chiropractic Association (Singapore).


Chiropractors' body all for regulation

DR CHARLES Siow's allusion to the alleged unreported cases of stroke caused and occasioned by chiropractic treatment is moot ('Concerns over titles, X-rays, treatment packages'; Jan 31).

Let us not go down this slippery slope as the same question is equally relevant to any profession, including the medical profession.

A significant portion of the chiropractic curriculum in accredited chiropractic colleges includes radiology. Chiropractors are taught in detail to operate, process and interpret radiological films.
The Chiropractic Association (Singapore), TCAS, has a radiology protocol as part of its ethics, rules and regulations based on international standards. Unfortunately, chiropractors outside our association may not follow the protocol.

As part of our ongoing effort to self-regulate as mandated by the Ministry of Health, TCAS has made a clear stand against unnecessary and large treatment packages. As membership to any professional association is voluntary, we do not have jurisdiction over non- members.
TCAS has maintained that all chiropractors must be graduates of an accredited international college. They also have to show good standing with their previous chiropractic association and they should not have criminal records.

This is the reason TCAS hopes chiropractors will be included in the Allied Health Professions Act to uphold the integrity of practice in Singapore.

We are not against meaningful regulation. Thus, we agree with Dr Yik Keng Yeong's opinion ('Regulate chiropractors'; Forum Online, Jan 31).

The latest studies - The Mercer Report and The Bronfort Study - support chiropractic treatment for its efficacy as well as its cost-effectiveness in neck and lower back pain management.

No professional system can hold a monopoly on health care - we should leave it to the public to decide. Patients' welfare is paramount.

Terrence Yap
Correspondence Officer
The Chiropractic Association (Singapore)


A busy man, Mr Yap must be, and no doubt made busier by the spotlight on chiropractic and the incidence of stroke.

Mr Yap would of course want us to not go down "the slippery slope" of questioning the association between neck manipulation and stroke, seeing as it is other mainstream medical therapy does sometimes cause harm instead of good. But the question is not whether or not other forms of therapy cause strokes, but whether or not neck manipulation, for whatever therapeutic benefits it purports to have, justifies the risk of stroke. If, as Mr Yap once again points out to us, chiropractic has only been found to be effective only for neck and lower back pain, and not the myriad of ailments many chiropracters claim it is good for (and which the Brontford Study has shown it is not), then we need to ask ourselves: is stroke an acceptable risk for neck or lower back pain?

The rest of the arguments for creating a register for chiropracters miss the main issue at hand: chiropratic is a pseudoscience. It does not matter whether a chiropracter is "trained" or "accredited", or indeed eventually "registered" - an astrologer can similarly be "trained", "accredited" and "registered" with a professional body if the law so recognises one, but that says nothing about whether or not astrology actually works.

Faced with such a situation, Mr Yap takes refuge in that same cry that those with no evidence to back their claims do: "leave it to the public to decide".

Of course. Why bother with science when there is such a thing as public opinion, right?