Three Years It was fun for a whileThere was no way of knowingLike a dream in the nightWho can say where we're goingNo care in the worldMaybe I'm learningWhy the sea on the tideHas no way of turningMore than this - there is nothingMore than this - tell me one thingMore than this - there is nothing- Bryan Ferry, "More Than This"One thousand and ninety-seven days.Five hundred and eighty-nine posts.One tired doctor.angry doc notices that the volume of his output has decreased over the years - 292 posts in the first year, 192 in the second, and just over a hundred in the past year - and he is not sure that the quality of his posts is making up for the shortfall.Being Angry Doctor is hard work, and ironically being angry alone isn't enough to see angry doc through what is required to sustain this work.angry doc needs a little break from blogging for now. Just in case he doesn't return, he would like to take this opportunity to thank all his readers and fellow-bloggers who have made this a worthwhile experience.Stay angry. Keep asking questions. Subsidy and Other Preoccupations 20 It's not fair, is it? Making angry doc angry on a Sunday morning...(emphasis mine)Means testing on track for implementation in January 2009By May Wong, Channel NewsAsia SINGAPORE : The government is on track to implement means testing in January next year at all public hospitals.Health Minister Khaw Boon Wan said preparations are on-going to link up with agencies like the Central Provident Fund Board and the Inland Revenue Authority.Means testing helps to focus healthcare resources to needy Singaporeans, with low-income citizens receiving higher government subsidies.Mr Khaw was speaking to reporters after launching a campaign on colorectal cancer on Saturday.[snip]Means testing will ensure lower-income Singaporeans have access to subsidised wards like C-class hospital beds.This scheme will also ensure such beds are not overcrowded by those who can afford higher medical bills.Mr Khaw said: "I expect a January implementation which is hassle free and ought to be uneventful. (The) majority will not have a problem with means testing and (for) a small minority of high-income patients, the criteria are very generous, so they'll be expected to pay a little bit more, but not a lot more. (It will be) well within their affordability level. So Singaporeans need not worry."[snip]It doesn't quite add up, does it?Let's look at the statements angry doc highlighted in turn."Means testing helps to focus healthcare resources to needy Singaporeans, with low-income citizens receiving higher government subsidies."While the statement is technically true, it is misleading: "low-income" citizens are not going to enjoy higher subsidies than they already do now; instead, "high-income" citizens are going to enjoy lower subsidies than they already do now.As the minster put it:"a small minority of high-income patients... they'll be expected to pay a little bit more, but not a lot more."How much more is "a little bit more"?A patient with monthly a income of $5,201 and above will receive a 65% subsidy for Class C instead of the usual 80%, while a patient whose income falls between $3,201 and $5,200 will receive a subsidy of between 65-80%.Given that "the scheme will not affect 80 per cent of Singaporeans", this means that (assuming similar bill sizes between the two groups) even if we assume that the 20% of patients who fail means testing all receive only 65% subsidies instead of 80%, we stand to 'save' 6.25% of spendings in terms of subsidies*. angry doc agrees with the minister that this is "not a lot".If we take into account the fact that some of these 20% of patients would not have chosen to stay in a C-class bed to begin with, means testing or no, then the 'savings' will be even less than 6.25%.So let's say means testing allows us to "focus" this 6.25% in "resources" to low-income patients; will it "ensure such [subsidised] beds are not overcrowded by those who can afford higher medical bills"?angry doc doesn't think so, since according to the FAQ on Means Testing on the MOH site:"Patients will still retain their freedom to choose their ward class. Any patient, regardless of whether they are rich or poor, can choose to be admitted to a Class C or B2 ward. They will still be heavily subsidized, but at different rates."So they are free to choose their ward class, they are "heavily subsidized", but the MOH nevertheless expects them to *not* choose a C-class bed. Interesting.And if they are still free to choose a C-class bed (and who wouldn't? It *is* "heavily subsidized"!), will means testing still "ensure lower-income Singaporeans have access to subsidised wards like C-class hospital beds"?angry doc will leave his readers to answer that question for themselves.* - angry doc's maths is poor, so do let him know if he made a error there. Loss Well you may never be or have a husbandYou may never have or hold a childYou will learn to lose everythingWe are temporary arrangements- Alanis Morissette, "No Pressure overCappucinno"angry doc is in pain.All doctors should be in pain - it gives them that concerned look.But seriously, there is nothing like personal pain to put one in a sympathetic mood, and it is in this mood that angry doc would like to look at this article:(emphasis mine)Autism 'cures': Helpful or harmful?Certain studies show alternative therapies may be risky, but some parents say treatments have helped their kidsBy Radha Basu, Senior Correspondent OFTEN, in the dead of night, six-year-old John would wake up squealing. During the day, the boy, who has autism, would be lethargic and surly.Suspicious that his alternative therapy sessions were hurting rather than healing him, his mother, Mrs Sally Lim (names changed), put a stop to it.'I saw no improvement in his condition, and there were rumblings on the Internet that it was not safe,' says the 38-year-old project manager in a bank.Three times a day for six months, she would rub a medicated ointment on John's body as part of a therapy known as 'chelation'.Based upon the medically disputed theory that mercury in vaccines causes autism, the therapy uses drugs to 'chelate' or bind with heavy metals in the blood, which are then purged from the body in urine.It is just one of a bewildering array of more than 20 so-called alternative treatments pitched at anxious parents of autistic children in Singapore.These range from the mundane - such as homeopathy and vitamin treatments - to the bizarre, including one that puts children in high-pressure oxygen chambers, and another that is supposed to map their brainwaves.With mainstream medicine promising no cure, many parents wade through a sea of expensive therapies in the desperate hope of finding something to make their children well.Most of the 15 parents interviewed said they had tried at least three or four different treatments, chalking up large bills in the process.One parent spent $28,000 hoping for a miracle that never happened.Biomedical therapy, which involves vitamins, supplements and wheat- and milk-free diets, for example, can be continued for years, and costs around $350 each month. Parents have been known to spend up to $10,000 a year on the treatment, plus frequent blood, hair and urine tests.Transdermal chelation - which Mrs Lim chose for John - requires an ointment to be massaged into the skin. Each tube of ointment costs $100 to $300. The treatment also requires kidney and liver function tests as often as once a month. Each test costs about $270.The trouble is that many of these treatments are clinically unproven and administered by people who are not medically trained. And the results are mixed.In the United States, scientists have dubbed chelation a 'voodoo' treatment. A government-funded trial to test DMSA, the chelation drug Mrs Lim used on John, has been suspended because it was deemed too dangerous.The problem is that the drugs are known to remove essential minerals such as calcium and iron, and there have been reports of at least one botched-up chelation-related death in the US.A recent study on rodents there showed that DMSA, while effective in overcoming lead poisoning, caused 'lasting emotional and cognitive problems'.But such studies have been met with vociferous protests from parents and practitioners in Singapore, who claim chelation and other therapies have helped autistic children.Therapists promoting the various treatments are known to publicise cases of spectacular success - often of their own children.Seduced by such anecdotes, many parents drift from therapy to therapy, only to learn the hard way that the line between miracle and misery is thin.Ms Jacqueline Ang, 38, who has two children with autism and runs an online support group for parents, says the devastation parents face at diagnosis is difficult for others to understand.'How can you live with the fact that your child will never be cured? So we grab whatever little we get by way of hope,' she says.Her support group has about 560 parent members. 'Easily 80 per cent have tried some form of alternative treatment,' she says.To help parents steer clear of dangerous, expensive and ineffective treatments, a 19-member committee of paediatricians and other health professionals is now scrutinising overseas research on the efficacy of the various therapies.MP Denise Phua, who has a 13-year-old son with autism and runs the Autism Resource Centre, sees the new Ministry of Health-supported initiative as timely.'If aesthetic treatments can be regulated, there is an even greater need to regulate intrusive autism treatments such as chelation, which are being administered by practitioners who are not medically trained,' she says.Paediatrician Lim Sok Bee, who heads the committee, says the biggest risk comes from invasive therapies in which a child is made to take pills, syrups or even injections, or is denied food such as milk and wheat, which are essential for growth.She warns: 'Parents should be aware that if not properly monitored, the child could end up being malnourished - this, in turn, may cause convulsions.'Housewife Melinda Chew (name changed) knows exactly how frightening this can be. In 2006, she rushed her son Jeremy, then two, to hospital after he convulsed with fits and foamed at the mouth.Moments earlier, the housewife had fed her son some milk, which a nutritionist had banned from his diet as part of biomedical therapy to 'treat' his autism.The diet-and-supplement regime caused the boy to lose a lot of weight. 'He used to love milk, so I thought I would ditch the diet and give him some milk since he had not been eating much for days,' says Mrs Chew.Doctors at the hospital were able to revive Jeremy. But her doubts lingered. 'If I had not started the diet, this may not have happened at all.'She stopped the therapy. Jeremy is now back to drinking milk and has regained the weight he lost.But as a mother, she says she cannot give up hope. Early last year, she put him on two other therapies - a form of Japanese energy healing and homeopathy.This time, she says the results are 'spectacular'.Little Jeremy talks more, can colour and look his mother in the eye.'I am so happy,' Mrs Chew says, a slow smile spreading across her face. 'Things are finally looking up.'For now, at least.The article is more critical of alternative medicine than angry doc had expected of the Straits Times, so he will not dwell on the scientific aspects of the issue.What angry doc is interested in discussing is what drives the parents to seek unconventional, implausible, and potentially dangerous 'treatment' for their children.Some psychologists (and doctors too, angry doc supposes) believe that parents of a child with disability undergo the process of mourning and grieving for the loss of a "normal" child. This concept is discussed eloquently in this article by psychologist Dr Ken Moses reproduced on the Pediatric Services website.angry doc feels these two paragraphs from the article must describe how parents of children with autism feel:"Parents attach to children through core-level dreams, fantasies, illusions, and projections into the future. Disability dashes these cherished dreams. The impairment, not the child, irreversibly spoils a parent's fundamental, heart-felt yearning... As disability bluntly shatters the dreams, parents face a complicated, draining, challenging, frightening, and consuming task. They must raise the child they have, while letting go of the child they dreamed of. They must go on with their lives, cope with their child as he or she is now, let go of the lost dreams, and generate new dreams. To do all this, the parent must experience the process of grieving."angry doc cannot claim to understand the pain and sense of loss felt by parents of children with autism, but as a medical professional he understands enough about science and evidence to know when the claim of a cure is no more than just a claim. If autism cannot be cured - and there is no evidence that it can be - then perhaps what parents of autistic children should do is not to subject their children to one form of unproven therapy after another, but to accept that their children, different as they may be, are children to be loved, and not disabilities to be cured.As for pain, Dr Moses concludes in his article that "experiencing and sharing the pain is the solution, not the problem." So if it's all right with you, angry doc would like to go savour his pain now.Thank you. Of Shoes and Stethoscopes angry doc's stethoscope broke today.Long-time readers will recall that the last time this happened was more than two years ago. How time flies.Once again, angry doc had to go around begging for a spare one to tide him through the day. Initially he did not meet with much success, receiving instead of relief jokes about his manhood and the friendly advice of 'They sell them at Mustafa' (which incidentally is, as angry doc found out, *the* place to go to get medication on a holiday evening when pharmacies are closed).Eventually his friend M, who was leaving work early, graciously loaned his to angry doc, but not before dispensing more advice.M: They sell them at Mustafa.angry doc: Er, ya - I know now. Thanks.M: Get two.angry doc: Huh? You mean you want one too?M: No, I already have a spare at home. Get two for yourself.angry doc: But why would I need two?M:*sigh* Your new one's going to break one day too, right?angry doc: Probably. Yes.M: And you don't plan on changing jobs for a while, right?angry doc: No, no plans to.M: They are not going to become cheaper, or better, right?angry doc: Again, no.M: So if they are going to break, and you are not going to switch jobs, and if you are going to buy the same model again, then you might as well buy a few and save yourself a few trips later, right?angry doc: I see your point...M: It's like your work shoes, right?angry doc: Shoes?M: You wear these nondescript, black, laced-up shoes to work every day. They wear out after a while, and you are going to need a new pair for work. When you get a replacement, you are going to get the same nondescript, black, laced-up shoes because they are not going to go out of fashion. Your feet aren't getting any bigger too, right? So if you find a pair that fits, you might as well get several at one go. Now if you'll excuse me, I have some shopping to do...How can you argue with the man's logic? angry doc is going on a shopping spree this weekend. Here's looking at you, kid. Dumb kids spread AIDS angry doc missed this story in the papers yesterday:Specially for Normal stream New Aids prevention scheme to target ‘high-risk’ studentsALICIA WONGA NEW programme to stop the spread of Aids and other sexually-transmitted infections (STI) among youth here is being drawn up by the authorities — but what is different this time is that the programme is specifically targetted at students in the Normal stream, who have been identified by counsellors working with youth as being at “high risk” of contracting such diseases.According to details in a recent government tender posted on the GeBIZ website, the class-based component of the programme will be customised to meet the needs of students from the Normal Academic and Normal Technical streams. The change, says the tender, is based on feedback from teachers and students. The new scheme is expected to reach schools in November or December.The programme will also equip students with the skills to delay engaging in sexual intercourse, as well as issues related to self-esteem, handling peer pressure, teen pregnancy, abortion and contraception. Currently, the Health Promotion Board (HPB) has a general STI/Aids prevention programme for all Secondary 3 students. Observers say this may be the first time that a major health prevention programme here is being targetted based on an education-linked criteria.Replying to queries, a HPB spokesperson told Today that the health board recognises there is no “one-size-fits-all” approach and this special programme is “part of HPB’s ongoing process to constantly upgrade and improve programmes targetted at youth.”Several groups that work closely with youth support this pro-active approach. In fact, one group even suggested that the HPB design a similarly targetted prevention programme for younger children, extending to those in primary school.Ms Hema Gurnani, the programme director at Wings Counselling Centre, which offers medical and psychiatric consultation to youth here, said that the rising number of youth here contracting HIV show clearly that current prevention programmes “are not as effective as they should have been.” Sexually transmitted infections among teenagers are rising on average by 3 per cent to 5 per cent annually, with more than 800 infected last year, according to the Department of STI Control.“The high risk group are the normal students. I can identify that,” said Ms Sheena Jebal, the chief executive and founder of NuLife Care and Counselling, which according to its website, deals largely with youth-at-risk, school drop outs and ‘late bloomers’. Noting that proper guidance is required for these “academically challenged” students, Ms Jebal warned that they were often unaware of the serious consequences of their sexual conduct as they may lack knowledge about these infections.Hence the need for a customised programme to ensure different students can relate to the dangers of Aids and Stis, said Ms Theresa Soon, assistant manager at the Action for Aids/DSC Clinic. “For instance, in a Special Assistance Plan (SAP) school you can be very academic, very technical, but for normal students you should use simpler terms and language,” she said. By customising lessons, instructors can use different approaches, and relavant case studies to engage the students, she added.While not wanting to generalise or stigmatise, Ms Jebal said that in her experience, normal stream students are at higher risk as many come from dysfunctional families, with little or no support. “Thus (they) tend to go astray,” have low self-esteem and “it is a form of escapism for them when they turn to unprotected sex.” While normal stream students are the “high-risk group”, Ms Jebel said, express stream students are not exempt. She suggested customised programmes for these students too.The AFA/DSC Clinic has seen an increase in youth – across all levels – seeking help, from 775 in 2006 to 820 last year. One factor that some counsellors say has increased the vulnerability of some youth to STI or Aids is family background, said Ms Soon, citing examples those students parents are often busy at work or do not speak to their children on these ‘taboo’ topics.STI is also usually treated as a science subject so most students end up viewing STI as viruses or bacteria, and fail to see how it relates to their everyday life, said project coordinator at the DSC Clinic Mr Tan Ee Han. Some teachers also cover the topic quickly so students learn little. They also have difficulty broaching the topic with their boyfriend or girlfriend, he added.However, beyond customising class-based lessons, Ms Jebal also feels that form teachers or school counsellors should zero in on students most likely to be engaging in sex and pay them greater attention as a mass programme does “not have much impact”.Ms Gurnani from Wings Counselling Centre, one of the first organisations to start a sexuality programme in the primary schools, also suggested that HPB look at a separate preventive programme for these younger students. “It is a concern that younger children below 12 are involved in sex and parents are ignorant of the reality,” she said.angry doc doesn't think this planned programme is discriminating in a bad way. It is, of course, discriminating, but at face value it seems a reasonable thing to do: you want to pitch your programme at a level which your audience can understand. It doesn't mean that a less academic programme will reduce the incidences of STI and HIV/AIDS in Normal Stream pupils, since we can't be sure that a lack of knowledge is what accounts for the rates to begin with, but it sounds like it's worth a try. The problem, as always when we target a specific group in health education, is with unintended stigmatisation of the very group of people we are trying to help.What angry doc finds interesting about the article is the observation made by Ms Jebel:normal stream students are at higher risk as many come fromdysfunctional families, with little or no support. “Thus (they) tend to goastray,” have low self-esteem and “it is a form of escapism for them when theyturn to unprotected sex.” In other words, Ms Jebel recognises the fact that what puts certain young people at "high risk" is not their academic abilities or the lack thereof, but something else which we cannot easily recognise in a glance, something we do not officially label people by. But because we lack the will to classify people by their 'true' risk factor, we turn to convenient labels like what stream a child is in to tailor our health education programmes. Use of such 'surrogate markers' are sometimes necessary in healthcare, but we must always recognise that correlations do not always point to a cause-and-effect relationships. If we fail to remember this fact, we risk ending up believing that dumb kids spread AIDS, or that Malay kids are dumb. Two wrongs make a right A bit of good news to cheer angry doc up at the end of a long week:Stricter guidelines for aesthetic procedureBy Hasnita A Majid, Channel NewsAsiaSINGAPORE: From November 1, doctors will need to seek approval before offering aesthetic procedures like mesotherapy and skin whitening to patients, and they can only do so as clinical trials.These doctors need to get the go ahead from the Singapore Medical Council's newly established Aesthetic Practice Oversight Committee if the procedure is carried out at a clinic, or from the Research Ethics Committee if the procedure is done in a hospital.These guidelines - drawn up by the Academy of Medicine, College of Family Physicians and the Singapore Medical Council - are aimed at enhancing the safety of patients.Currently, there is no formal training for doctors performing such procedures and injuries sustained during such treatments are often unreported.Proper documentation must also be carried out for the purpose of audit. If the outcome of such procedures is poor, then the treatment will be terminated. In addition, such procedures can only be carried out as a last resort, after all other conventional treatments have been tried.Current aesthetic procedures will be grouped into two lists - A and B. List A contains procedures which are generally proven and considered acceptable by experts.This list includes non-invasive procedures such as chemical peels and microdermabrations, and minimally invasive treatment such as Botox and filler injections.Invasive procedures, such as eyelid alteration and breast enhancement or reduction, will have to be performed only by doctors who have the appropriate surgical training.List B reflects aesthetic treatment and procedures that are currently regarded as having low or very low level of evidence and not considered well- established.Mesotherapy - a procedure to burn fats away through injections - and skin whitening injections fall under List B. So are carboxytherapy, stem cell activator protein for skin rejuvenation, negative pressure procedures and mechanised massage.For treatments under List B, doctors are no longer allowed to advertise them and those who wish to perform procedures under List B must register themselves with the Singapore Medical Council.The guidelines also require doctors who wish to perform procedures that do not fall under either list to obtain approval from the Singapore Medical Council.Any doctor who does not comply with the guidelines will be taken to task and liable for any disciplinary action. The guidelines were drawn up after several months of consultation with professionals in the industry.Professor Ho Lai Yun from the Academy of Medicine said: "At the moment, it's a cowboy type of practice... when the guidelines come up, we give the doctors some guidelines."Of course, the patients will know who are the people they can go to, what are the procedures available to them, what they can expect from the procedures. So, to a greater extent, they are protected."It's nice to see that as a result of the aesthetic "turf war", we now have a policy that recognises the importance of evidence when it comes to treatment.For once, truth is not a casualty of war. Cow Dung 8 More news from Ye Olde Country:(emphasis mine)$2.2m for brain injury after detox diet THE family of a British woman who suffered brain damage following a “detox” diet warned on Tuesday of the dangers of such regimes.Ms Dawn Page received more than £800,000 ($2.2 million) in an out-of-court settlement after a diet in which she increased her water intake and decreased the amount of salt she consumed.The 52-year-old mother of two, from Faringdon, southern England, began vomiting severely soon after starting the “hydration diet” in 2001. She was left with epilepsy and a brain injury affecting her memory, concentration and ability to speak normally.She gave up her job as conference organiser and her family says she will not work again.Ms Barbara Nash, the nutritional therapist she consulted, allegedly assured her that the vomiting was part of the detoxification process. Ms Nash, who calls herself a “nutritional therapist and life coach”, denies liability in the case and insists she was not guilty of substandard practice.But Ms Page’s husband, Geoff, 54, yesterday warned of the dangers of “fad-type” diets. He said his wife was not obese but had just wanted to lose some weight.“Just days after she started the hydration diet, she began to feel unwell ... Things went from bad to worse ... Her life has been seriously affected, perhaps ruined,” he said.Geoff said his wife was advised to drink at least four pints of water a day. The therapy was known as the Amazing Hydration Diet. He added: “It’s important people understand how dangerous diets like these are.”Ms Nash has a diploma from the College of Natural Nutrition, based in Tiverton, Devon.Plexus Law, the firm that represented her in court, said all allegations of substandard practice made in the litigation would continue to be “firmly denied” and the settlement agreed was less than half the total claimed. THE GUARDIANDr Crippen blogged about this earlier this month.angry doc is surprised that Ms Page's husband was not 'gagged' as part of the legal settlement. He is not, however, surprised by the fact that he took the settlement - £800,000 is a considerable sum of money, and there was no guarantee that he would have won the case had it gone to trial.As angry doc understands it, in medical malpractice law, a doctor is "not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art". If the same principle applies to practitioners of alternative medicine, then it may not matter how little evidence of efficacy or safety there is behind a mode of therapy - as long as most other practitioners are doing the same thing, it's OK.This legal principle, known as the Bolam Test, has traditionally relied on the opinion of the 'professional body'. It is therefore important for us to look at the body of knowledge and evidence on which each professional body builds it opinion on.Are there any good reasons or evidence to suggest that drinking four pints of water a day while restricting salt intake is a safe and effective way to lose weight? Or that "[w]ater and natural salt, when combined together, give you everything your body and mind need"? Or that homeopathy works? For that matter, how do you know if the treatment your 'western' doctor is giving you is evidence-based?angry doc thinks all 'consumers' of healthcare need become more critical and discerning, and develop the habit of requiring evidence from their healthcare providers. It's not only about making sure that your money is well-spent - it is also about safety. 'My name is Dr Dabic... ' ... but call me David'. How much is that kidney in the window? 2 They say that one week is a very long time in politics...New hope for kidney patients? Age limit of 60 raised,swap registry to be set up:Tan Hui LengHE HAD said ideas such as organ trading should not be rejected just because they are controversial, and the Health Minister is considering “financial compensation” — but not before pushing altruistic organ donations to their “maximum potential” with two new initiatives.Mr Khaw Boon Wan told Parliament the Ministry of Health (MOH) will first lift the “arbitrary” age limit of 60 years on cadaveric donors and set up a national registry to swap living donors whose tissues do not match the intended recipient with another pair or pairs in a similar situation.More controversially, he said that the MOH is studying whether to encourage third parties to promote altruistic organ donations by providing financial compensation to donors and their families after the transplants have taken place.Mr Khaw revealed that he occasionally receives requests from some charities and religious bodies to compensate donors “in kind and in cash ... to acknowledge their altruistic act”. But these third parties worry that this may be construed as organ-trading.The MOH is studying if the idea, which Mr Khaw would encourage, can be feasibly implemented and if the Human Organ Transplant Act (Hota) needs to be amended.This was a possible example of “good complementary solutions” when the demand for kidneys are not fully met.“By forcing ourselves to think about unconventional approaches, we may be able to find an acceptable way to allow a meaningful compensation for some living, unrelated kidney donors, without breaching ethical principles and hurting the sensitivities of others,” said Mr Khaw.In the meantime, the two new measures, which are expected to be implemented within a year, should boost transplant rates from 50 to 70 per cent in the medium term. This means seven out of 10 on the waiting list will be able to get a donation on a yearly basis.The age limit that had been set under Hota “has unnecessarily put many organs to waste”, said Mr Khaw, who noted that many countries do not have an age limit.“The suitability of the organ depends on its condition, rather than the age of the donor. The condition of the kidney can be determined by the transplant doctor.”On living donor transplants, the MOH will facilitate “pair-matched donations” through the set-up of a live-donor registry. This would require proactive coordination to overcome incompatible donations in order to “meet the altruistic wishes of such living-related donors”.Hota will be amended where required for the two initiatives.In response to questions by MPs Halimah Yacob (Jurong GRC) and Lam Pin Min (Ang Mo Kio GRC) on the current organ trading case, Mr Khaw answered generally that “a black market of illegal transplants flourishes in many countries and not just in Asia”.The result — and the reality — is “poor clinical results for many patients and exploitation of many in poverty”.He added: “We must therefore take a practical approach. Criminalising organ trading does not eliminate it. But it merely breeds a black market with the middleman creaming off the bulk of the compensation which the grateful patient is willing to offer the donor.”The MOH will take a sympathetic approach to the plight of exploited donors and the “basic instinct of kidney failure patients to try to live” even as it takes action against those involved in illicit organ trading.Currently, three Singaporeans are being charged for breaching Hota. The trio appeared in the Subordinate Courts yesterday for a closed-door mention in chambers, and will next appear on Aug 1 for a pre-trial conference.angry doc should be excited about these developments, but he is still suffering from the after-effects of a the rough weekend.He hopes he can contribute to the discussion more actively later this week. Rough Weekend (source: lucid tv)angry doc had a rough weekend. Please excuse him for the lack of commentary in today's post. How much is that doctor in the window? 10 News from Ye Olde Country... The more lives they save, the more they earn But performance-pegged pay means surgeons could spurn high-risk operationsLONDON — :In radical plans being drawn up by hospitals across Britain, National Health Service (NHS) surgeons are to be paid bonuses based on the number of lives they save.For the first time, they will receive performance-related pay according to the results they achieve on the operating table, with levels dependent on how well patients recover.Leading surgeons, critical of the proposals, said that this could deter doctors from taking on higher-risk patients — such as the frail and elderly— and from carrying out complex operations.Patients’ groups said those facing surgery would be “horrified” by the proposals, and questioned why doctors should be paid a premium for fulfilling their basic duty.The Government intends to link doctors’ merit payments to patient mortality and other measures, such as rates of infection, readmission and post-operative mobility.Britain’s largest hospital trust is already preparing a pilot scheme that will link surgical outcomes to bonus payments. Imperial College Healthcare Trust has begun measuring the performance of its doctors, and Prof Stephen Smith, its chief executive, said that it intended to use the data on mortality, infection and the cost-effectiveness of its consultant teams to reward the best-performing doctors.The pilot scheme will concentrate on rewarding surgeons for the degree of mobility that patients enjoy after their operations.The London trust’s own surgeons admitted to risks if the plans were not handled carefully. A consultant, Mr Justin Vale, who is the programme group director for surgery and cancer, said: “We have got to ensure we don’t create a dangerous precedent, that the surgeons doing the big, complex cases aren’t discouraged from taking them on.”Mr Ben Bridgewater, of the Society for Cardiothoracic Surgeons, said that he would be very cautious of using data on a consultant and his team as the basis for bonus payouts.“Surgeons would be quite anxious about using these measures in this way,” he said. “They wouldn’t be confident the data is robust enough, or that it reflects the mix of patients and activity that they deal with. I don’t think surgeons will buy into this.”Ms Katherine Murphy, from the Patients Association, said: “Patients will be horrified. There is a real risk that the most complicated cases, as well as the patients in real need, will be forgotten because they don’t get the best outcomes. Doctors already have a duty to provide high-quality care. I think a good doctor would be insulted by the idea that they will only do their best on the operating table if there is extra money in it.”In the north-west part of Britain, 24 trusts are piloting a scheme that will pay bonuses to the 20 per cent of hospitals with the lowest rates of deaths, complications and other clinical standards linked to five common operations. Managers will be able to pass the bonuses on to doctors and nurses.In December, the Government will publish a set of indicators to measure the quality of treatment at every NHS hospital.THE DAILY TELEGRAPH Cow Dung 7 Ever wonder why Cialis is shaped the way it is?(emphasis mine)Almonds, a natural cure for 'half-past six'?THE Mind Your Body supplement on July 9 carried an article 'Natural Viagra?' in which it was speculated that 'watermelons may be a natural Viagra'.This at least is the view expressed by 'a United States researcher' and printed alongside are differing views of others who are labelled as 'sceptics'.I fear scant justice is done to readers, who will surely end up confused by these contradictory opinions.Decades ago, a doctor recommended almond nuts to combat 'erectile dysfunction', as it has come to be known nowadays. The Singlish description of this condition is 'half-past six'.Viagra came to be manufactured many decades later, and is composed of chemicals whose side effects on the body have yet to be properly assessed, whereas almonds are totally 'organic' (the pun is wholly accidental).In fact, it is almost traditional among (East) Indians, of whom the worthy doctor was one, to take a glass of milk daily, in which crushed or powdered almonds and some strands of saffron have been boiled. 'Badaam milk' (almond milkshake), as it is known, is a popular drink among Indians, with reputedly aphrodisiac virtues.Almonds are widely believed to be a key ingredient or supplement to vitality, as well as a wholly natural pick-me-up.Narayana NarayanaPretty standard cow-dung arguments as usual. angry doc is no longer surprised that the ST Forum editor chooses to publish letter promoting unsubstatiated health claims; had the same claims been made by someone actually selling a product, he would have run afoul of the law.But what harm can come from a letter promoting something as innocent as the almond nut?Well, plenty, angry doc thinks.First of all, Mr Narayana tells a blatant lie with his assertion that Viagra is a "chemical" "whose side effects on the body have yet to be properly assessed". Leaving aside the fact that almost everything we put inside our mouths are "chemicals" - from plain water to any active compounds almonds might contain - Viagra had been subjected to rigourous testing prior to its approval by FDA, and continues to be monitored in the post-marketing phase. All that is not to say that there are no known or serious side-effects with taking Viagra, but to say that it has not been "properly assessed" is to tell a plain lie, and undermines the efforts of all those who work to ensure that drugs that doctors prescribe to patients are tested and regulated.Secondly, the publication of such letters promoting remedies based on cow-dung thinking indirectly promotes cow-dung thinking in the public. What the public needs, and deserves from ST Forum, is an editor who is willing and able to apply and require critical thinking in doing his or her job.Finally, beliefs in such unsubstatiated health claims can sometimes be exploited by unscrupulous people to sell supposedly "natural" products which are in reality either useless, or at the very worst hazardous.Belief in the properties of walnut is partly behind the recent fatalities caused by Power 1 Walnut.Will this be the consequence of believing in the virtues of almond? Better, Longer, Cheaper Pick two. (emphasis mine)Playing catch up Issue at hand: How to improve outcomes while containing costs SHERALYN TAYEVEN as medical science progresses — contributing to longer life spans — the ways health outcomes are measured have yet to catch up.Life expectancy has been used as a measure for years, but “there is no quality of life perspective to this, just a number”, said Mr Dean Westcott, a member of the Association of Chartered Certified Accountants (ACCA) governing council at an “ideas forum” yesterday.There is a need for “more sophisticated measures” of healthcare outcomes, said the finance director and deputy chief executive of a healthcare trust in the United Kingdom.This was one of the key issues raised at the ACCA session for academics and industry leaders, including from the public and private hospitals.The roundtable discussion also identified another overarching issue — of how to improve healthcare outcomes while containing costs, which have been rising in recent years, outstripping GDP by two percentage points every year in the Organisation for Economic Co-operation and Development countries.This is not sustainable, Mr Westcott told Today, adding: “Studies have estimated that by 2020, healthcare expenditure will triple.”The question to grapple with is how to decide the most efficient level of expenditure.According to Mr Westcott, the general consensus on efficient resource allocation is a focus on lifestyle and prevention and to have “equity of access”.This means having people enter the healthcare system early, before conditions become chronic and cause complications.But political will, patience and foresight is required for this to happen as results may take years, even generations, to realise.Singapore is one of three cities with different healthcare financing models — alongside London and Washington — sharing its perspective on the issue of healthcare costs versus outcomes, which will shape an ACCA-commissioned study on global healthcare.Mr Westcott, who moderated yesterday’s forum, said: “We anticipate that it will be used to inform healthcare policy decision making.”We've discussed this topic before here, and angry doc's view is this:The fact is people in their last year of life consume a disproportionate percentage of a nation's healthcare spending, ... every life eventually comes (or in this case ends) with a price-tag. In fact, there is also a case to be made that the older this 'last year of life' is, the greater the amount of spending in the last hospitalisation will be....As long as we see longevity and good health as desirable commodities, healthcare spending will continue to rise.The question then is not perhaps on how much to spend, but when to stop spending.Reading between the lines, it seems that Mr Westcott shares a similar view when he said "there is no quality of life perspective to [life expectancy], just a number", and that there is a need for “more sophisticated measures” of healthcare outcomes.Come on now, people.We all know what needs to be done here, don't we? Medicine and Morality 2 It looks like the ministry of health is willing to study the option of "legalising organ trading in Singapore" after all.However, it seems that morality is still a consideration for the health minister when he said:"If you allow trading, currently those who volunteer for the family members or under HOTA, they may then object and say, 'since you can now buy organs, then why should I volunteer to save my family members?'Why should they indeed? After all, the aim of the transplant is to improve the patient's health, and not to give his relatives a chance to demonstrate their selflessness.While the chances of finding a matching donor amongst relatives are higher, with the proper selection process and follow-up, transplants from living unrelated donor (whether a spouse or a 'seller') have good long-term results. Patients whose relatives are unable or unwilling to donate their kidneys must look to unrelated donors, living or dead.More resistant to the idea, however, is the Singapore Medical Association:SMA against legalising human organ tradeBy Valarie Tan, Channel NewsAsiaSINGAPORE: Doctors in Singapore are split over whether human organ trading should be legalised in the country. A medical ethics debate over the issue has been re-ignited in recent weeks after five persons were prosecuted over illegal kidney-for-sale deals.For the Singapore Medical Association (SMA), after much internal discussion, it has come to a collective stand that it does not support legalised organ trading.In response to queries by Channel NewsAsia, the SMA said that besides the medical risks to the organ seller, there is too much potential for abuse of disadvantaged individuals. It is also difficult to make the process transparent and equitable.The SMA represents two-thirds of doctors and specialists from the private and public hospitals in Singapore. It said emails and discussions were exchanged over the past two weeks, and its 16-member council held an emergency meeting on Saturday to deliberate.Dr Tan Sze Wee, a spokesperson for the SMA, said: "Within the council itself, we had a debate and the views were split down the middle as well, between those who felt that there could be a possibility of legalising it because of the good it can bring to the recipients - the quality of life, saving a life."However, the other point that we still felt was very important is - how are you able to administer it? The devil is in the details."But with the number of kidney patients growing in Singapore, the SMA said the call to legalise organ trade may grow stronger in the future.Dr Tan said: "It may, but the voice for legalising organ trade is not something that's a current topic. It has been around since the beginning of time. But we recognise the fact that the human body itself cannot be treated like a commercial property that it can be traded with a value."There are medical complications, short-term and long-term. The short-term risks are... the operation itself, anaesthesia for both the recipient and the donor in the surgery."Long-term risks are: if you have two kidneys and you donated one... what do you do when something happens to you? Some accident or some illness, then you've got no back-up plan. And, it's well documented that organ donors do suffer from, what we call, donor remorse."The SMA was not able to comment on the implications on the growing number of patients getting transplants from non-related donors in Singapore. In 2007, 33 patients received kidneys from non-related living donors compared to 19 in 2006 and six in 2005.However, the SMA does support the suggestion to have transplant patients screened at the Health Ministry level, instead of just leaving it to a hospital ethics committee.Dr Tan said: "I think that's definitely better. I think that is something for the ministry to work out to ensure that such cases do not repeat again."There are so many things that can possibly happen that even if you want to think about ways to put safeguards in to prevent illegal activities from happening, there are a lot of details that have to be worked out."(snip)angry doc wonders how the SMA, with it's membership "split down the middle", could choose to make a stand on the issue; essentially, SMA is making the stand of one-third of doctors in Singapore its official stand.What is worse are the reasons SMA had given for opposing the legalisation of organ trading.Had the SMA stuck to the moral argument of "the human body itself cannot be treated like a commercial property that it can be traded with a value", angry doc would have respected that, even if he did not agree with it.However, Dr Tan showed that the SMA's position may stem more from a lack of moral courage than moral conviction when he argued:"There are so many things that can possibly happen that even if you want to think about ways to put safeguards in to prevent illegal activities from happening, there are a lot of details that have to be worked out," and when he asked "how are you able to administer it? The devil is in the details.".In other word, faced with the complexity of the task of regulating organ trading, SMA has chosen to object to it than to participate in looking at whether we can create a system that will minimise unfairness to parties concerned. How noble.Dr Tan also could not help throwing in some flawed arguments against organ trading:"There are medical complications... The short-term risks are... the operation itself, anaesthesia for both the recipient and the donor in the surgery."This is not a valid argument because all surgeries which are performed under anaesthesia carry anaesthetic risks. More importantly, risks to donor and recipient are similar whether they are related or unrelated. If the SMA's position is (as angry doc's is) that it is unethical to subject a person (the donor) to anaesthetic risks for a surgery that does not benefit him physically, then should it not similarly object to living-related transplant?"...if you have two kidneys and you donated one... what do you do when something happens to you? Some accident or some illness, then you've got no back-up plan."Here Dr Tan chose to appeal to fear, instead of providing the public with actual risks to donors in the form of statistics to allow them to make their own decisions on whether or not donation constitutes an unacceptable risk.How many donors actually require renal replacement therapy due to trauma to their single remianing kidneys? How many donors go into chronic renal failure due to diseases which would not have affected both kidneys equally had he not donated one anyway?If Dr Tan is concerned with the lack of a "back-up plan" for donors, will it not be better to provide for their interests by having a regulated system that covers their medical follow-up and costs, and which makes more organs available?angry doc feels that Dr Tan had not represented the position of the half of its membership which do not oppose legalisation of organ trading adequately or fairly; by making a moral stand on the issue and backing it up with flawed arguments, Dr Tan gives the impression that the SMA is willing to impose the morality of some doctors over the public, and that its members either think that the public are too dumb to see through the flawed arguments, or that its members themselves are, when in reality it may be more a case of SMA being unwilling to tackle the issues of organ trading head-on.The fast pace of progress in medical science means that we are now often faced with treatment options which are not available a generation ago - options which morality we, as a society, have yet to come to an agreement on. angry doc feels that while doctors are individually entitled to their own moral viewpoints, and as a profession our ethics allow us to choose whether to participate or refrain from participation in a certain type of treatment, as advocates for our patients our role when it comes to a medical issue should be one of active participation through education and provision of information. We must not try to abdicate our responsibilty while using the morality of a portion of doctors as an excuse. "The History of Creationist Thought" It's just a THEORY, stupid 2 Reader zhanzhao made the comment in the previous post that evolution "cannot be observed under lab conditions, vaildated [sic] nor replicated".He is partly correct.Evolution has been observed and validated in a lab condition, but curiously, it could not be replicated*.Leng Hiong covered this interesting experiment briefly earlier. If you want a more detailed account but do not want to read the original paper, Bad Science has a post on an exchange between the investigator and a critic which covers some of the details of the experiment.Both are well-worth a read.* - Edit: On closer reading of the posts I realise that the citrate+ trait does "re-evolve" in the 'ancestors' of the populations of E. coli that evolved the trait, but not in the other 11 populations in the study, so in a sense evolution has been observed to be replicated. I apologise for the error. It's just a THEORY, stupid Rather unexpectedly, the discussion on the "exorcism" trial has spilled over to the topic of evolution.Since angry doc is no expert in evolution, he has decided to seek help from fellow Clearthought blogger Leng Hiong to tell us why the theory of evolution is a "theory", and not a "fact".Do have a read. It still isn't an exorcism, stupid More on the "exorcism" trial.(emphasis mine)Lawyer questions priest’s logicPlaintiff’s lawyer accuses priest in Novena trial of evading questionAnsley NgIF A political party held a rally without a police permit and were quizzed about it, would the party be right to argue no rally had taken place because no permit was issued?That was the analogy lawyer R S Bajwa made to explain that a “prayer session” two Catholic priests had carried out for his client Amutha Valli Krishnan four years ago was a violent exorcism rite that lacked authorisation from the archbishop and the church.Calling the hypothetical reasoning “stupid”, the lawyer added: “I said you did all these acts; you said no. I asked why; you said you did not get permission from the bishop.”Father Jacob Ong, the priest in the witness box on Friday, reiterated what another priest, Father Simon Tan, had said earlier — that no exorcism was carried out on Madam Amutha Valli. “The whole package must be followed. It cannot be set as an exorcism,” Father Ong said.For an exorcism to be performed, the archbishop — the faith’s head in Singapore — has to give permission and appoint a priest to carry out the rites. An investigation also has to be carried out before the ritual.Father Ong is among nine parties being sued by Mdm Amutha Valli over an alleged botched exorcism attempt at the Novena hurch in 2004. She claims the incident left her traumatised and unable to work.“It doesn’t help you,” Mr Bajwa said in reply to Father Ong. “The substance is what we are interested in, not the form.”As Mdm Amutha Valli — who at times spoke in a voice that sounded like a low male voice — struggled harder during the alleged exorcism, the group prayed harder, the lawyer said. At one “momentous” point in time, Father Tan “engaged” the spirit by talking to it, said Mr Bajwa.Using the same line of questioning he served on Father Tan, the lawyer asserted that Father Ong and his co-defendants had pinned Mdm Amutha Valli onto the floor in a room at the church and strangled her, thinking she had been possessed.Father Ong disagreed, saying the group merely held a “gentle” prayer session to “protect” her even as the 52-year-old woman was screaming and writhing on the floor.Mr Bajwa also asked the priest if he had seen people who had been possessed. The priest said he had seen instances where people displayed signs of possession and cited four examples, including people who spoke in voices that don’t sound like their own while trembling.“Would you agree that the signs displayed by the plaintiff were more severe than these examples?” asked Mr Bajwa.The priest replied he could not tell, prompting the lawyer to accuse him of avoiding the question.The hearing continues on MondayAt least now someone has stated the obvious: it doesn't matter whether it was an exorcism or a "prayer of deliverance" - what matters is what happened and whether what happened caused the plaintiff to become ill. (Then again, maybe even that will not matter if the defendants can prove that the plaintiff is not actually ill.)angry doc wonders if the persons involved in the trial would have spent so much time over terminology if one of the parties involved was not a religious organisation with an organised belief system on the existence of spirits and demons, possession by such entities, and on how to cast them out. Had the trial involved alleged alien mind-control and an attempt to break the control, the judge would perhaps not have been so indulgent.The priests seem to be caught in a no-win situaion. To prove that they did nothing wrong, they need to show that what they did for the plaintiff was appropriate, and that means proving possession by spirit or demon, something which they cannot do. On the other hand, their argument is that the plaintiff is actually faking her illness, which if they manage to prove, will mean admission that their assessment of her condition on that day was wrong, and that the subsequent intervention (be it an exorcism or a "prayer of deliverance") was also wrong. It's not an exorcism, stupid‏ More on the court case which we first looked at almost a year ago:Was it exorcism? Priest denies accusation, says it was salvationLeong Wee KeatIN THE witness box, he sang hymns and showed how she had apparently slithered like a snake.Yesterday, one of the two priests accused of performing a forced exorcism at the Novena Church about four years ago — gave his version of what transpired — the first time the High Court was hearing the defence’s story.Father Simon Tan denied that the incident on Aug 10, 2004, was an exorcism. Instead, he called it a prayer of deliverance for plaintiff Amutha Valli Krishnan.Cross-examined by her lawyer, Mr R S Bajwa, Father Tan also said the archbishop’s permission must be sought and a thorough investigation conducted before any exorcism could be carried out.While he did not think she was crazy, what this Catholic priest saw that night was definitely “not usual behaviour”. Father Tan, 44, claimed it “never occurred to him” that Madam Amutha Valli was possessed or was a mental patient, and that he was “just answering the family’s request to pray over her”.Father Tan is among nine parties — including the church, Father Jacob Ong and six church helpers — being sued by Mdm Amutha Valli over an alleged forced exorcism attempt. She claims the incident left her traumatised and unable to work.Father Tan, who was ordained in 1998, testified that exorcism is “hardly practised” and has “never heard” of it in his ministry.But, Mr Bajwa asked: Couldn’t the priest have stopped the prayer session as Mdm Amutha Valli was strangling herself and assuming the voice of a dead soldier?Father Tan said he did not understand why she had manifested violent behaviour, but there were at least three occasions she snapped out of her trance.Her family had brought her to the church to be prayed over so that she could get some comfort, added the priest.While he did not advise the family of any risks involved, Father Tan disagreed with Mr Bajwa’s question if “safeguards” should have been in place. The priest said there were cancer sufferers, for example, who turned to the church and religion for prayers and comfort.But wouldn’t he stop to think if a devotee had prior medical history?Father Tan disagreed, saying the incident arose from “a simple request from her family to pray”.He added: “If I start using my mind, be self-conscious of the risks, a lot of Catholics would suffer. I would become neurotic if I’m afraid of being sued.”The hearing continues.angry doc wonders if the presiding judge even cares whether what happened on the day was an exorcism or a "prayer of deliverance"; what matters more would be what exactly did the priests and other church staff do for or to the plaintiff that day, and whether those things led to the illness that the plaintiff claims to be suffering from.Whether it was an exorcism (which it technically was not) or a "prayer of deliverance", there is probably no doubt in anyone's mind that Father Tan acted out of good faith and in good faith (and had assumed the same of the plaintiff that day!). However, under the law (the Penal Code to be precise, which presumably does not strictly apply to this case), "[n]othing is said to be done or believed in good faith which is done or believed without due care and attention".What that means, angry doc believes, is that the law recognises that while we may help someone in need with good intentions, the person being helped may sometimes actually suffer harm from our intervention. The law seeks to protect those whom we help by requiring that the person rendering the help has good reasons to believe that his actions will help that person, and at the same time not cause harm to that person.So does Father Tan have good reasons to believe that a "prayer of deliverance" was the correct thing to administer to the plaintiff for the state which she was in on that day?Of course, to even decide whether or not a "prayer of deliverance" was the right thing to administer, one would have had to decide what the plaintiff was suffering from.It seems that the Father had provisionally excluded "possession" and "mental illness", and that working diagnosis was "not usual behaviour".Was that a reasonable conclusion to make?Is a "prayer of deliverance" a reasonable intervention for "not usual behaviour"? How often does it work? What are the risks and benefits of a "prayer of deliverance" for "not usual behaviour"? Surely that is relevant, because the plaintiff is claiming that she suffered harm from the process.Unfortunately it doesn't seem that the lawyers pursued that line of questioning. angry doc doubts that if the lawyers had asked Father Tan those questions he would have been able to answer with figures and statistics, because it is likely that those questions never crossed the good Father's mind - or as Father Tan put it himself:“If I start using my mind, be self-conscious of the risks, a lot of Catholics would suffer. I would become neurotic if I’m afraid of being sued.”Poor Father Tan. Maybe that was the problem to begin with. Homeopathy beats Acupuncture Well, not quite, but "[w]omen given sterile water injection experience less labour pain compared to women given acupuncture."Sterile water injection for pain relief? Is it evidence-based? Are there like placebo-controlled trials to prove that it works?Well, yes. Several, in fact. It's apparently a commonly-practised non-pharmacological (and non-homeopathic) method of pain relief in some places.But if water is the substance being tested, what does one use for a placebo?Well, believe it or not, saline*.Thanks to Medscape, angry doc learns something new every day...* - Yes, I know it makes sense. Don't write in. Medicine and Morality It's been a long week and angry doc lacks the energy to write separate entries for two very interesting articles in the newspaper today, so he decided to lump them together.The first article is a news article on illegal organ trade in Singapore.Despite the known benefits of transplant to recipients and the very low risk to donors, the ministry's position on organ donation between unrelated persons is that "organ trading often involves the exploitation of the poor and socially disadvantaged donors who are unable to make an informed choice and suffer potential medical risks".The second article is an interview with Professor Roy Chan, president of Action for Aids, who had this to say about the fight against HIV/AIDS in Singapore:"We have to see Aids as a disease. Clouding the issue with the morality aspects only impedes the treatment and prevention of the disease."Together, these two articles show how much morality affects the ministry's health policies. Whether that is a good thing or not will probably depend on whether you share the same morality. Real and Apparent Danger There is a real and apparent danger in Singapore. (emphasis mine) Toxins in dish-washing detergent? I WOULD like to ask why dish-washing liquid detergents do not carry ingredient labels. This is perhaps an oversight since such detergents leave traces on utensils, even after washing. The danger is even more apparent in foodcourts where mass-washed utensils are coated with unknown ingredients. Recently, there were reports about the danger of methylisothiazolinone, a neurotoxin that is found increasingly in shampoos, except some old, trusted brands. Methylisothiazolinone is possibly found in dish-washing detergent, especially those that tout 'anti-bacteria' formula since methylisothiazolinone is also a biocide. Likewise, can the authorities clarify why formaldehyde is found increasingly in shampoos? The dangers of formaldehyde are already known, such as autism, eyesight degeneration and high carcinogenic effect on contact with water molecules. In addition, there are no standards as to how much formaldehyde is added to shampoo since it is considered a non-food item. But the danger is real and apparent. Michael Yee angry doc won't address the first part of Mr Yee's letter, since he too does not want detergent in his food. But the second part of the letter gets to him. Formaldehyde is a widely used form of preservative. No doubt it can be fatal when ingested, and causes irritation of the eyes and skin when in vapour form (angry doc had personal experience of that back in medical school, he does - ah, sweet, gross anatomy!). But is it as dangerous as Mr Yee described? Does formaldehyde cause eyesight degeneration? Well, yes, if it is splashed into your eye or injected into an eyeball. Does it have high carcinogenic effect? Well, yes, it has been shown to cause some forms of cancers in mice, but it has not been shown to cause more cancers in people who are exposed to it at work (and who presumably use shampoo when they are off work). Does it cause autism? angry doc couldn't find any evidence for that. Mr Yee has given misleading information about the dangers of formaldehyde in the first part of that paragraph, but the penultimate sentence in that paragraph is simply untrure. Shampoos are classified as cosmetic products, and come under the purview of the Cosmetics Control Unit of the Health Products Regulation Group of the Health Sciences Authority. The amount of formaldehyde permitted in shampoos is regulated by the ASEAN Cosmetic Directive, at the concentration of no more than 0.2%. Shampoos manufactured by Unilever contain formaldehyde of 0.04%. There is no evidence that at that concentration, application of formaldehyde to the skin for short durations causes any of the harmful effects Mr Yee mentioned. Formaldehyde is a toxin in the commonly used sense of the word, but to say that shampoos can cause cancers, eyesight degeneration and autism, and that the authorities are not doing anything about it is dishonest and irresponsible. The fact is information about regulations on the amount of formaldehyde permitted in shampoos and the dangers of formaldehyde is available on the internet if one would just search for them. Mr Yee had apparently not done so before sending in his alarmist letter, and the ST Forum editor has in angry doc's opinion lapsed in his duty by publishing it. This lack of editorial rigour is the real and apparent danger. No labs please, we're homeopaths While googling about homeopathy in Singapore, angry doc came across a site that advertised as one of homeopathy's benefits the fact that:"the system does not require expensive tests and reports."Of course. Why wouldn't that be a benefit? Everybody hates lab tests, X-rays, and biopsies, right?Patients certainly hate them most of the time.Practitioners of alternative medicine can often make a diagnosis just by looking at you or feeling your pulse. In fact, some can even feel your energy field without actually having to physically touch you. Who needs tests and reports to know what's wrong with you, or if you are getting better?Western doctors, with their inability to make decisions without time-consuming and expensive tests which often puts the patient at much inconveniece, discomfort, and not to mention risks, seem by contrast primitive and unsophisticated.As a medical student, angry doc certainly hated "lab".Much of the first two years of medical school, the "pre-clinical" years, were spent in stuffy laboratories, where we had to conduct repetitive experiments.The subject of the week's experiment would vary (this week it would be sugars, the next week proteins, and the week after bilirubin or something), but the physical tasks always consisted of measuring minute quantities of chemicals, diluting them with deionised water from a large plastic vat, then placing the resultant solutions into small glass or plastic containers, which would then be placed inside a spectrometer. The result of each reading would be plotted on a graph, which seemed to be the point of the whole afternoon's labour.It seemed a sadistic way of wasting our time, making us do the same thing with the same spectrometer week after week just to show something which they already knew was true. Yes, the spectrometer works, the values change with different concentrations of the chemical, in a linear fashion which can be represented graphically. We get it! Can we do something else please?(OK, we did do something else. Occasionally we were required to supply bodily fluids as raw material for the week's experiment. angry doc will not elaborate further.)Unlike 'A' level chemistry, lab-work in medical school was not an examinable subject, so angry doc never paid attention and had already forgotten almost all of what happened before the second year ended.To angry doc's disappointment, "lab" did not end with the end of second year, as Pathology involved hours of eye-straining, vertigo-inducing work in the purple-and-pink topsy-turvy world of light microscopy, where moving a slide left shifted the field of view right, and moving it down shifted the field of view up. angry doc had difficulty using a computer mouse afterwards.angry doc resolved to not choose a specialty that required any vision-enhancing aid more sophisticated than a pair of spectacles.angry doc is also vaguely aware of the Radiology module, which he had skipped completely, because they seemed more interested in teaching him about how an X-ray machine worked than how to read an X-ray.The only bit of lab angry doc didn't mind, and indeed enjoyed, was anatomy. Ah, sweet, gross anatomy!It was with little regret that angry doc left the sterile world of lab and entered the wards, where finally! he could get his hands on some patients. When he heard that a classmate was interested in pursuing a career in lab medicine, angry doc thought the fellow was mad.For the next few years angry doc didn't think much about labs. Lab was that mysterious but boring place where he sent his patients, their bodily fluids or some bits of their bodies, in return for which he received reports which allowed him to get on with the business of treating their illness.But now that he has taken on the task of fighting alternative medicine, angry doc appreciates the purpose of all those lab hours.Unbeknowst to him, the boring work in those foundation years demonstrated to angry doc that our work is based on real, quantifiable things which can be objectively and independently measured, and not on the postulation of some wise men, or abstract speculation about invisible life energies that seem to be only palpable to those who believe they exist.Going through the science behind the investigation modalities and performing all those experiments ourselves taught us that we did not have to take anyone's word as authority, but could verify and find out first-hand if something was true, if we understood the scientific principles and had the knowledge.Lab work was an innoculation against the magical thinking and dogma that characterise some of the more absurd forms of alternative medicine.angry doc wishes he had paid more attention in medical school.(If you are a medical student, angry doc is interested in knowing how much lab work you are required to do these days, and also how much exposure to alternative medicine you have in your course. Do share with him in the comments section. Thank you.) What's wrong with the placebo effect? Reader sprachen sie singlish, commenting on this previous post, wrote:Never figured out why the Placebo had such bad rep.Statistically significant improvement for the patient, no side effects. What more could your ask for when apply the Harm Principal?What's wrong, indeed, with the placebo effect?(Or more appropriately, with "placebo effects", since it is an umbrella term that covers a number of mechanisms which might affect a patient's physiology or how he perceives his symptoms.)It is a commonly posed question and a common defence used by proponents of alternative medicine when evidence shows that their favoured modality of treatment is no better than placebo, and that any beneficial effect observed as a result of that therapy is therefore also likely due to the placebo effect.Because it is a commonly posed question and a commonly used defence, it is a question that has been answered many times by science and medical writers and bloggers. angry doc does not claim to be able to answer the question comprehensively or in depth, but he will do the best he can, with regards to the study in question.First of all, the improvement observed in the study is not large enough to be considered clinically significant.That aside, it is also worth noting that while the parents and clinicians all reported improvement in their scores, scores given by the subjects themselves were a more mixed result - some subjects reported improvement in certain domains but felt they did worse in other domains. In other words, the observers thought that the subjects were functioning better, regardless or whether or not the subjects themselves were feeling better - the placebo effect affects the observers, and not the subjects! This of course has ethical implication when it comes to using a treatment on subjects who cannot communicate how they are feeling - patients such as infants, children, those who are mentally-impaired, and even pets; we can think that we are helping them, when in fact we may be doing nothing, or indeed harm to them.Also, it is not true that there are no side effects with placebos or biologically non-active agents. Patients given non-active agents can in fact develop adverse effect to them, as was the case with one patient in this study, who had to drop out of the study. This is known as the nocebo effect. Placebos, because we do not always know the precise mechanism by which they work, are often unpredictable in their effect, and can in fact have the reverse effect from that which is desired.Finally, even if we take the result of this study to mean that placebos are effective for ADHD in children and adolescent, the question of what to give the patients remain: do you give them "a mixture of rice protein powder and a small amount of activated charcoal" or "0.3% hypericin... free of heavy metals, pesticides, and adulterants"? Or something else which has already been proven to be more effective than placebo for ADHD?If you choose to give a patient a placebo, do you tell him you are giving him a placebo, or do you lie to him and tell him you are giving him "something that works"? Do you want to lie to your patient? Would you want your doctor to lie to you?The fact is there are practitioners out there who are prescribing treatment to patients which have been shown to be no superior to placebo. If indeed all that they are giving is the placebo effect, then does it justify the cost to the patients? Does it justify the practitioner's time learning all he learnt? Does it not make the whole practice dishonest?Having said that, all 'healers' use the placebo effect to a degree in his or her practice. The simple ritual of a consultation is sometimes all it takes to make the patient feel better. It is probably impossible to quantify or eliminate such effects from our practice, but angry doc feels that where we know that a treatment is no better than placebo, it is detrimental to the patient-doctor relationship to prescribe it as "something which works", or to not resort to something which has indeed been proven to work. Where many were, how few remain Reader sm asks:Do you happen to know any other public blogs by Singapore healthcare professionals, and could you somehow forward it to me as well?Ironically, fellow-Clearthought blogger black tag just announced that he will quit blogging, after a run of just less than a year. He did not give a reason for his decision, but angry doc suspects that despite his apparent anonymity, his true identity has been discovered by his employers, and he has had restrictions placed on him.Certainly that was the main reason why Dr BL Og, a prominent doctor-blogger when angry doc first started blogging 3 years ago, decided to close his popular blog.Dr Huang, who is in private practice, faces no such restrictions, and can blog without such fear, and does - even if his focus is often not on medicine but on wider social issues.Dr spacefan, who also works in a 'public' institution, seems to have reached an understanding with her employers regarding blogging, and blogs 'semi-anonymously'. Hers is the oldest surviving Singaporean doctor-blog angry doc knows of.There have been other short-lived medical blogs which angry doc used to read regularly, like those of his disciple distinguished mediocrity and Dr dth, both sadly closed.Dr tscd, who angry doc thinks is one of the best bloggers around, seems to be on maternity leave from blogging since the arrival of her first child. angry doc hope she will resume blogging soon, as no doubt her many fans do.Still blogging, but currently not practising, is proud mother of teenagers aliendoc, whose perspective on the practice of medicine angry doc always appreciates.Those are the doctor-blogs that angry doc reads or used to read regularly. There must be many that he has not read - certainly some of his colleagues keep blogs on their hobbies, their children, and what they had for dinner, but angry doc has never read any of them.Fellow-Clearthought blogger Edgar, a dental student, keeps his blog here, and angry doc has come across a few blogs kept by nurses too, although he doesn't have the links right now.Those are the ones angry doc can remember... did I miss anyone out?Blogging is a tricky business for healthcare professionals, as we are expected to safeguard patients' confidentiality. For those who are not their own bosses, there is also the rule of 'not blogging about work'. Over the years angry doc has shifted from blogging about his work to discussing medico-social issues and fighting quackery, so hopefully this blog will survive to its third birthday.If you are a healthcare professional and you keep a blog, do leave a comment and let sm know about it.Thank you. A £10,000 challenge Via Orac, news about a professor of homeopathy who has offered a £10,000 prize to anyone who can "demonstrate that homeopathy is effective by showing that the Cochrane Collaboration has published a review that is strongly and conclusively positive about high dilution homeopathic remedies for any human condition".As far as angry doc knows, no one has taken up the challenge, but Le Canard Noir at Quackometer tells us that "excuses for ignoring the challenge are already being discussed on homeopathic sites and message boards". angry doc believes that the Professor Ernst is familiar with most of them.While not as well-known as acupuncture and TCM, two forms of alternative medicine which we discuss regularly on this blog, homeopathy nonetheless has its presence in Singapore, and from angry doc's personal observation it is growing. While herbal medicine and acupuncture have shown efficacy for certain conditions and have plausible or known mechanisms of action, the same cannot be said of homeopathy.angry doc thinks all healthcare workers should be aware of this relatively new form of alternative medicine, so we can educate our patients about it. Homeopathy simply does not hold water*.* - Sorry, I just couldn't resist. Science and how we know we are wrong 3 This study made it into several newspapers when it was published last week. Science-blogger Orac gives a detailed look at the study, and points out the flaws in the arguments in the accompanying editorial, which tried to defend alternative medicine in the face of evidence of absence of efficacy.In the meantime, angry doc finds the study interesting for a different reason.The study looked at the subjects' performance on the ADHD Rating Scale-IV and Clinical Global Impression Improvement Scale (which are assessed and scored by clinicians) as primary end points, and also analysed the Parent-Reported Child Behavior Checklist or Youth Self Report Form (for subjects 11 years and older), Conners Parent Rating Scale, and parent-report and child-report forms of the Pediatric Quality of Life Inventory (which are scored by the subjects or their parents), and found that there were no statistically-significant differences in the scores before and after treatment between the group receiving St. John's Wort and the group receiving placebo.But that's not all.If you look at the scores (you'll need to register to read the full paper on JAMA), you will find that except for the Youth Self Report Form, scores for both groups improved at follow-up.In other words, the clinicians involved in the trial and the parents of the subjects all *thought* that the children were improving.What's more, children in the placebo group 'improved' more than children in the treatment group, even if the differences in the scores were not statistically-significant.To angry doc, this trial demonstrates the power of the placebo effect, where just the fact that the children are being given a pill three times a day, regardless of whether it contains "a mixture of rice protein powder and a small amount of activated charcoal" or "0.3% hypericin... free of heavy metals, pesticides, and adulterants" can affect a clinician or parent's assessement of their behaviour.So the next time you are tempted to say "I know it works because he got better after taking it", stop and think of this study, won't you? Singapore's Healthcare System angry doc would like to draw his readers' attention to two informative articles on Singapore's healthcare system.The first, via The Singapore Daily, compares the different funding models in the US and the Singaporean system, as well as their respective successes.The second, via Dr Crippen, is an interview with the director of Healthcare Services at the Singapore Tourism Board which describes Singapore's healthcare system in a way that is easy to understand; angry doc must say he learnt a fact or two from the interview himself.Do have a read.