Singapore M.D.

True, but neither is it right for RH to omit certa...

2012-05-25T22:56:29.645+08:00

True, but neither is it right for RH to omit certain facts in order to make itself look good in the eyes of the public.

And believe me, even 5 minutes can make a HUGE difference, especially in a heart attack.

The bill issue can be resolved if there're clear policies in place. Even in the US, patients without health insurance can't be turned away at private hospitals, thanks to an act the government implemented not so long ago.

Failure to comply results in a full investigation, and up to US$50,000 fines for both the hospital and the physician/s if found guilty.

What about the fact that if a patient lands up in ...

2012-05-25T08:11:40.244+08:00

What about the fact that if a patient lands up in RH he will have a HUGE bill at the end of the day!

Anyway, if you look at Singapore, being such a small country, the distance spread of the hospitals is not the problem. I mean there are countries with real rural areas where the level 1 trauma centre is hours away.

I don't think this is much of an issue. Golden hour.....as long as ambulances are given way, it is unlikely they will be unable to reach a hospital by the golden hour. You can't save everyone who comes in the Emergency Department even if they all come in within 5 minutes.

You can certainly try.

When do doctors in singapore get into residency pr...

2012-04-28T06:16:21.630+08:00

When do doctors in singapore get into residency programme? i am aware that you could get into it after a year of housemanship. but do most people manage to secure a place?

I do agree. We have done very well with TB but hav...

2012-04-23T23:14:31.345+08:00

I do agree. We have done very well with TB but have failed miserably with regards to HIV management in developed countries.

Accessibity to affordable antiretrovirals is the key to reducing the the HIV viral load in the community and therby reducing the incidence and prevalence of HIV in Singapore. Having worked overseas on HIV, I am appalled at that the lame argument that HIV drugs are not curative and therfore, cannot be subsidised will be disastrous for the prevention of HIV here.

I am Dr.Mayukhmoy Maiti(medical graduate from Indi...

2012-04-19T22:49:50.905+08:00

I am Dr.Mayukhmoy Maiti(medical graduate from India).Currently I have cleared PLAB exam in 2011 and now fully registered with GMC.(GMC registration no-7063411).I am now working as a Senior Clinical Fellow(middle grade) in Royal Blackburn Hospital,UK(East Lancashire Trust) in the department of Accident and Emergency(since 1st February till date.)I am appearing for IMRCS part A in September'2012.

As a junior doctor I am interested in residency programme in General Surgery in Singapore.Can you please help me?
I am not sure about the system and how to apply

Thanks
Dr.Mayukhmoy Maiti

"If I hang out with bad company and keep leav...

2012-04-17T01:01:08.527+08:00

"If I hang out with bad company and keep leaving my door open and getting robbed and I ask you to pay for a police force to keep me safe would you pay?

If it is not my fault and I got robbed and I say I have no money to pay for a private security force, and ask you to pay for me would you pay?"

I would like to say: no, and no actually, but...

The reason why we don't privatise all police and military defence is I suspect partly to do with the practicality of doing so. The other argument as made by slave above is that crime can be seen as an "infectious disease" - broken window and all that stuff, you know? Infectious disease is a reluctant exception I accept in my position on individual liberty, so while I accept that I will pay tax to fund your TB medications, I also expect that you be compelled to take the medication under supervision, on pain of penalty (the same applying to me if I had TB, of course).

The idea of leavng one unit in a block of HDB flat undefended by the army because the owner refused to pay his defence tax is just... well, I don't see how we can do that.

Someone asked if he should be made to pay taxes for the construction of a highway he would never use; well, many places practise the collection of a toll, which would be easy to implement in our context where ERP already exists.

I see your point, but the parallel cannot be drawn...

2012-04-16T23:37:48.456+08:00

I see your point, but the parallel cannot be drawn strictly.

Contrary to what has been discussed here, I feel that the 'service' of the police and armed forces (especially that of the army) is not mainly the tangible service rendered, but the deterrent. (at least that's what I have been brainwashed into thinking by the government lol)

We don't honestly believe that a patrol of three 18 year old NSFs in changi airport with a magazine of 4 live rounds not even loaded can effectively neutralize a terrorist who is intent on blowing something up do we? but the service they render is to deter such events from happening. Same for the police and the law. Singapore has a relatively low crime rate not because our policemen are better shooters or faster runners than those in the US or Europe, but because the law and punishment they represent has been effective in deterring such crime.

I pay taxes 'to fund' the police and the army not primarily because they might one day come in handy to find the guy who stole my wallet, but because I'm constantly using their 'passive' service. the same way that although I may not directly 'use' public goods such as street lamps, roads, and the port or airport, I am benefiting from them constantly.

Moving back to something more relevant - If i pay taxes for public health initiatives : ensuring clean water, nation wide vaccination, dengue prevention programs, good sanitation, etc etc everyone benefits.

But the benefit to society when the nation pays for an individual to receive specific care in relation to non-infectious diseases is very very small. you may argue that increased illness will lead to decreased productivity in the economy etc., but the solution to that is NOT increased healthcare (as that would be just covering the symptoms), but improved education of what CAUSES these common conditions like heart attack, blocked vessels, diabetes mellitus (which causes SO much loss productivity), and engaging in PRIMARY prevention to well, prevent them.

Providing tertiary healthcare free or heavily, again, IMHO, serves only to win votes.

If I hang out with bad company and keep leaving my...

2012-04-14T20:30:05.553+08:00

If I hang out with bad company and keep leaving my door open and getting robbed and I ask you to pay for a police force to keep me safe would you pay?

If it is not my fault and I got robbed and I say I have no money to pay for a private security force, and ask you to pay for me would you pay?

We should abolish the police and armed forces and just pool to buy insurance in the event people get murdered they can claim insurance. And if they are robbed they claim insurance too. And if a neighbouring country invades, massacres the population and ransacks the country's assets, can also claim insurance.

Insurance is so wonderful

Sigh. @Anon at 06 April, 2012 11:19 So if I am st...

2012-04-14T03:32:23.390+08:00

Sigh.

@Anon at 06 April, 2012 11:19
So if I am standing in front of you and I take a knife and cut my hand and tell you that I have no money to buy plasters or antiseptic cream, will you buy for me? Maybe you're kind enough and do pay for my necessary treatment. But if I do it again, and again and again? Its the same for patients who smoke and binge on alcohol and drink and drive and gorge themselves on fat.

@Prof - What if I did not cause my own injury, but I come and tell you I have cancer (with no modifiable risk factors) and I'll die in 1 year without surgery but I can't pay for it. Will you pay for me? A total stranger?

If you don't, can I blame you being selfish?

You may say, that you will agree to pay for me now, if I agree to pay for you next time if you have any disease. This is risk-pooling. If you think like this, then buy an insurance plan that suits your needs. It's the exact same thing.

IMHO, with regards to medical subsidy, it should be prioritized for those who are really in the bottom 5-10% (in terms of socioeconomic status), NOT based on who's to blame for the disease. Whether you are to blame for the disease you have (e.g. smokers with lung cancer or alcoholics with cirrhosis), or you are just damn suay, it doesn't change the fact that at the end of the day we EACH are responsible for our OWN healthcare. We should set aside money for the unexpected disease, we should buy insurance to try to mitigate costs ourselves. And of course, we should try our best to reduce our own risk of GETTING the diseases.

The role of the government should be to help those who even if they wanted to, cannot possibly even come close to saving for their own healthcare. They did not have a choice to not save enough or to not plan ahead because they were living day to day already. With this in mind, I think if anything increases in health expenditure should be made towards medisave and medifund (especially the latter)

For those of us here commenting on this blog with high speed internet connections, it is likely that if you wanted to, you could pay for comprehensive health insurance. Its just a matter of giving up luxuries that we have gotten used to and now take for granted as necessities.

This is CBM (cover-backside medicine) at its worse...

2012-04-09T10:38:34.957+08:00

This is CBM (cover-backside medicine) at its worse

Even normal people can die when they push their bodies past the limit. A bit of hyperthermia + adrenaline + hyponatremia + hypokalemia can tip the healthiest person into VT / VF and sudden death.

You cannot prevent sudden death just as you cannot prevent rain.

Actually a coronary angiogram is not the gold standard as it only looks at the lumen and it is not able to see unstable cholesterol plaques which are the cause of heart attacks (of course you have a 1:1000 risk of stroke / heart attack caused by the angiogram) - on the other hand looking for cholesterol plaques using CT scans (with risk of contrast allergy, renal impairment and theoretical risk of cancer) will essentially exclude almost everyone above the age of 40 from taking part.

The "gold standard" is as always a normal functional test (e.g. a stress test) even then it is 99% sensitive in excluding a major cardiac event over the next 3 years.

Cardio Doc

Paul ananth I have seen too many cases where heal...

2012-04-07T15:21:02.688+08:00

Paul ananth

I have seen too many cases where healthy colleagues goes to clinics to top up on their supplements or common drugs or in addition, certain hypochrondiacs look for tests after tests.

http://www.straitstimes.com/BreakingNews/Singapore...

2012-04-07T13:12:13.480+08:00

http://www.straitstimes.com/BreakingNews/Singapore/Story/STIStory_786206.html

Just wondering, but if someone who lives in the North eg Woodlands who never uses this new $4.3 billion undersea expressway.....no need to pay taxes can or not? It's my money what!

"Ask yourself: why does my selfishness offend...

2012-04-07T08:56:18.367+08:00

"Ask yourself: why does my selfishness offend you so much? It is only because you think you are entitled to something I have which you want. Your false sense of entitlement is what offends you."

Actually it is not the case. It is a case where you are enjoying a lot of entitlements in a system that works because WE all pay for it TOGETHER. However you are proposing that YOU do not pay (because the money is your entitlement).

There are many things which our tax dollars are used for besides healthcare. Defence, education, road works, infrastructure etc etc.

The predominant argument of "my money is MINE and no one else should have a right to it" is fair enough. But if everyone worked that way, there will be many more problems.

Point is, Singapore spends around 1% of the GDP on healthcare? So the tax dollars you actually pay for healthcare isn't all that much. How come nobody is complaining about how much they spend in defence? It's still MY money if they take it and spend on defence right?

Yes we should do away with police. People should j...

2012-04-07T00:50:05.029+08:00

Yes we should do away with police. People should just install their own security alarms linked to private security guards etc. As it is some people DO THAT and STILL pay taxes for police services they do not use!

Same for the army. What right do other countries have in trying to take away what is not theirs?

Well at least this seems to be the overriding "no need for justification" as it belongs to me anyway argument.

It's not true that everyone uses services equa...

2012-04-06T21:56:32.996+08:00

It's not true that everyone uses services equally.

Take the police for example. Suppose someone comes to your house, burgles your place and gets caught. He goes through the justice system and is prosecuted, etc.

In a purely pay-for-service system as advocated by angrydoctor, you will be billed by the police (for the number of hours spent on investigation), the court (for the legal process), the attorney-general (for the number of hours the DPP spends on the case), etc.

Why should people not involved in the case pay for the investigator, the DPP's hours, the court session, etc?

Unless there is some kind of risk pooling is desirable but we can't have that, can we?

"The fact is neither the current system nor t...

2012-04-06T14:18:40.739+08:00

"The fact is neither the current system nor the SDP system have the moral courage to hold people responsible for their own health and healthcare cost."

I suppose the ideal system can hold people responsible for their health, which means you will have to pay for the services you consume and not let others pay for you. But who is going to handle the end result if you cannot pay for them? If a chronic smoker who ended up with end stage COPD comes to A&E with an acute exacerbation but cant pay for the treatment/ admission, do you leave them at the doorstep wheezing away? Surely he is responsible for his current state of health by his smoking habit. I would love a system with the "moral courage" to say "NO" to these people who cannot pay for their treatments, to be far to other taxpayers like us who would have to pay on his behalf. Even if it means he ends up dead at the doorstep of A&E.

PS: I also support all citizens paying egual taxes regardless of their income. Afterall, we all share the services equally, why should the rich pay more while the unemployed pay zero? You live in the country, you should pay taxes. ( kinda like entrance to universal studios, without the children and senior citizen discount )

You are right: people who are selfish do not need ...

2012-04-06T13:40:04.831+08:00

You are right: people who are selfish do not need to justify themselves, because they are merely stating their rights over what is theirs; it is people who claim a right over other people's possessions who need to justify themselves.

Ask yourself: why does my selfishness offend you so much? It is only because you think you are entitled to something I have which you want. Your false sense of entitlement is what offends you.

Why not have a system where you assess whether thi...

2012-04-06T11:19:46.558+08:00

Why not have a system where you assess whether this person might have contributed to the cause of his illness. If he has then he has to pay. If cannot pay, then forcefully discharge and leave them to die.

If found not to have contributed then it is subsidized.

This whole argument by angrydoc is flip flopping between the zealous desire not to pay any tax or pay for anyone besides himself and justifying what that is really called ; selfishness.

No need to justify.

SDP's policy is about giving and sharing. Yes it "forces" people to give and share, but we also "force" people not to kill other people or rob and rape too. As I said before if you really DIE DIE WANT TO BE SELFISH then just don't pay your taxes lor.

Thank you, the real Gary. For some reason SDP (an...

2012-04-05T23:37:42.700+08:00

Thank you, the real Gary.

For some reason SDP (and Prof) seem to think that just because some people are not directly responsible for their illness, others are therefore obliged to pay for their healthcare needs, and yet others who are somewhat responsible for their own illness should therefore also benefit from subsidy.

They believe that the problem with chronic care management is not cost but non-compliance, yet at the same time argue that reducing cost/payment will result in better health outcomes. Classic example of doublethink where ideology trumps logic.

The fact is neither the current system nor the SDP system have the moral courage to hold people responsible for their own health and healthcare cost. The current system seeks to minimse the unfairness of passing individual healthcare costs to others by imposing a higher copayment than that proposed by SDP's, but they are essentially the same creature.

I hope u are not refering to me. I am not angry do...

2012-04-05T22:53:25.308+08:00

I hope u are not refering to me. I am not angry doc. Anyway, it is the other way around.

There will be people who wants to be screen for all sorts of cancer/congenital anomalies.

Unless screening is not covered and only treatment is covered or there is enough copayment.
But too high a copayment will reduce both appropriate and inappropriate care.
http://www.rand.org/news/press/2009/04/28/copayments_treatment.html

Looking at the behaviour of those with CSC card or private insurance, the behaviour is really different from those who have to pay.
CT head for head injury?
Why not CT whole body?

Do fasting blood glucose and blood lipids for screening? why not check kidney/liver as while?
After I show the patients the list of blood tests (at least 100) and tell them to test everything would take 1 litre of blood?

Anyway, my point remains.
Increasing access without increasing capacity is plain stupidity.

My unpublished letter to strait times :(

I refer to the letter "SDP defends health-care proposal, Friday" and is appreciative of the efforts made by Singapore Democratic Party to come our with their proposed health-care plan. However, I am uncertain about some of their arguments for their proposed health-care plan.

Firstly, they proposed that corporate tax be increased and their rationale is that companies will enjoy savings because they no longer bear the costs of their employee' health care under the plan. This argument is valid if only working employees are covered by the proposed health-care plan as currently companies only cover the medical expenses of their employees (medical expenses up to 2% of total remuneration are tax deductible). However, the proposed health-care plan will cover both working and non working Singaporean which would pose an additional burden on companies especially small and medium enterprises.

Secondly, a single-payer, universal health insurance system may be superior to a multi-player, non-universal health insurance system but whether it is superior to our current system is still debatable. Insurance promote "moral hazard" where those who are insured tend to over-consume health services compared to those that were not insured. Having a copayment that is low will not help to deter this problem while having a high co- payment will reduce both appropriate and inappropriate care. In practice, you end up with more patients straining our public healthcare system.

Thirdly, our 3 M system may not be perfect but neither is the new proposed health-care proposal. Someone once said "Healthcare is a bottomless pit but the resources to meet those literally endless worthy needs are limited, so society must set its priorities and draw the line somewhere. The job of government is to ensure a minimum acceptable level of care for all and beyond that it is for individuals to set their own limits with their resources" Using medisave to fund our healthcare needs or to buy private healthcare insurance should be left to individuals.

Lastly, moving forward, our 3M system needs to evolve to allay the concerns of Singaporeans. Medisave need to grow at a rate higher than medical inflation (2011, 8.4%) or at least inflation (2011, 5.2%) to ensure that there is adequate money to fund future healthcare needs. Medishield may need to expand to cover non catastrophic illnesses but the flipside would be higher premiums. Medifund may want to be less stringent so that more can qualify but the flip side is that more money is needed to ensure it is sustainable. In summary, we need more funding to ensure Singaporeans do not fear growing old and falling sick. The recent move to increase healthcare expenditure is an enlightened move by our government.

The real Gary (I am not angry doc!)

Well, finally the kid with leukaemia gets a break....

2012-04-05T22:34:27.001+08:00

Well, finally the kid with leukaemia gets a break...

As I keep telling Prof, just because someone did not deliberately get a disease does not mean he is entitled to having someone else pay for his healthcare needs.

In any case, there is nothing in SDP's proposal that denies subsidy to people who put themselves at higher risk (non-compliance to advice, smoking, diet, high-risk spors and sexual behaviour), so intent and accountability are not the issue here; unless SDP is saying only those who do not "deliberately" get sick are entitled to subsidy?

(Anyway, Prof, since you are a contriutor to this blog, you can just log in and post your comments without waiting for approval.)

I keep asking Gary to show me people who deliberat...

2012-04-05T22:06:11.146+08:00

I keep asking Gary to show me people who deliberately go and get cancer or congenital diseases so they can enjoy the "free" care he thinks we offer. Has not shown me any examples...still waiting!

That's the problem, people do not recognise t...

2012-04-05T14:07:52.867+08:00

That's the problem, people do not recognise the ideology behind, they just want a free meal.

regards

and there comes the bits of the singaporean patien...

2012-03-30T09:52:48.098+08:00

and there comes the bits of the singaporean patient. If you have a cough and cold in sg, you r always given antibiotics by the GP. Does it work? NO. read pubmed and research will tell you, MOST colds are viral in nature, and antibiotics dont work. Your own body's immune system will fight it off, and so you will usually get better in 1-2 wks time. So most patients come in a few days after getting sick, take their meds,at the end of 1 week, think its working, when actually it did nothing, the body did it's own job. So when you see a dr in the uk/aus, and your chest sounds clear, you dont get any antibiotics. The general public knows not to see a GP for a normal viral cold. The Gp provides just reassurance. except. reassurance is useless in sg. in singapore, if I dont give you any medication, you would say I am a lousy dr. Because I didnt treat u. So doctors give them anyway, even if it's just a placebo effect, because patients end up happier, they feel like the doctor takes them seriously. (I used to be one of these patients as well). so to not a happy pt, just because a doctor doesnt treat you, it doesnt mean they dont take you seriously. maybe you just dont need anything. If you are very doubtful, go down the private route, you will see that private doctors will be very patient and will listen to any complains you have and do any scans you request of them.

To the unhappy pt. Not to be proud, but you cant ...

2012-03-30T09:51:59.913+08:00

To the unhappy pt.

Not to be proud, but you cant compare the job of a dr to a producer. to earn this 2.69k a mth, this jnr dr is working 36 hours shifts 6 times a month. an avg day in a surgical ward begans at 530, finishes at 8 on avg, of which u barely have time to eat or go to the toilet. You are busy doing jobs, and yes u may want to really care for patients, but the lack of doctors, (and MANY good drs are all leaving for e private sector, thus e shortage of drs), means that the workload is too great and you have to stay stuck at it. this dr rarely gets weekends off, gets paid less than most of her peers and classmates. This dr would have had straight As at A levels, and could have gone on to do another course, earn at least 3.3k if they were doing audit, accounting, studying fass at nus. 5k if they were a lawyer. yes long hours are a norm when you just graduate, but these friends who earn better pay or seem to have more life and better hours, at least having a weekend of some sort while we are slogging our weekends away. so for all that we have to go through physically and emotionally, many would choose to leave if they could. Which is why you see so many overseas graduates who have a choice to where they want to work leaving. With a GMC (UK) or AMC (aus) registration, one has alot more job choices , jobs which have better hours, and better support from seniors, better opportunities to learn and better pay. (yes nus mbbs allows you to work elsewhere,but many first world countries wont give you a training post, unless you were trained there or very outstanding, so you are pretty much stuck in sg,)

It doesnt help that the NUS admission process values brains more than passion. one can get in despite saying he is in medicine for the money in the interview. Many singaporeans end up applying for medicine/law, because they managed to get straight As. so why not try? since it's a respected profession. (I have seen many friends who showed zero prior interest in these fields applying and trying their luck) Some do not know what they are truly in for. Honestly, one can never enter medicine for the money. If you want to be rich, go do law, audit,be a banker, any other course. Medicine is too much work and if you stay in the public sector, will not pay off. Yes we get a decent above average pay, but our peers from jc will all be earning the same if not more. To survive in this field, you need to love your patients, or what you study. In med sch, I see people who hate patient contact, but dont mind going home to study everyday and bury themselves in books. Afterall, for the last 18 years, studying is what brought them so far. They dont enjoy clinics, they dont enjoy their job, but they are in it, so they persevere. It's a job that pays, so I might as well go for those that pay well. The government frequently tells us we have a shortage of doctors, but the doctors will tell you it is hard to get into residency to do what they want. wanna know why? Because everyone wants the high paying jobs- Obs and gynae, eyes, ears, plastic, dermatlogy, surgery,paediatrics. And what about the general medics, the geriatrians who works long hours and gets paid little comparatively? There's a great shortage in these fields, the bread and butter of medicine, but nobody wants them, because the pay is not worth it. If I'm stuck in this field, I might as well do what pays well. Unless of course, I try for a few years and still fail to get into the high paying jobs(which usually have few vacancies, coz there's more than enough out there), I end up compromising. I do GP. or I end up doing general medicine. I do geriatrics. anything as long as I end up being a specialist. I dont like it. but it will have to make do. and it shows when drs who do not have a love for their patient or the subject do consults.