Five Years One thousand eight hundred and twenty-days.Seven hundred and seventy-three posts.Thanks for reading. Whose "health" is it anyway? (Posted on the Singapore MD blog) Confidence Goods 15 (Posted on the Singapore MD blog) Funny thing is, it's got these pictures of horses and all, but Wildfire was a pony...I'm just sayin'... Ignoring the Elephant (Posted on the Singapore MD blog) Subsidy and Other Preoccupations 21 Fellow-blogger Dr Huang has a letter to the ST Forum published today:Get GPs back on trackWE ARE doctors specialising in various fields at Gleneagles Medical Centre and we support Dr Lee Wei Ling's gallant attempts to bring medicine in Singapore back to its noble roots ('Train GPs to be family physicians'; April 21).We suggest the following:- Invasive aesthetic procedures should be carried out only by doctors who have had adequate surgical training. Only then will the practitioner be able to recognise the early signs of complications. Complications happen even in the best surgeon's hands, but it is often how soon these are detected and the course of action taken that determine the fate of the patient. Aesthetic medicine is here to stay and the Ministry of Health (MOH) should organise properly sanctioned courses for all doctors who are keen to carry out invasive aesthetic procedures. The bar must not be set too low, and being allowed to carry out such dangerous procedures after attending dubious one- to two-day courses should be a thing of the past.- General practitioners (GPs) are the vanguards of our health-care system. We want each GP to take his proper place as a 'specialist in taking care of the entire patient'. All of them have undergone training at great expense to the state or their families. MOH should make available rotation positions at various hospital departments for all GPs before they start work and at regular intervals after that, to provide opportunities for 'refreshers' to those who feel they need updates or have gaps in their knowledge of certain specialities. National service 'reservist-style' make-up pay is innovative and workable for this.- Government subventions for GPs to treat subsidised cases is a win-win for all. GPs get more income and hence will be less likely to go for the more lucrative 'aesthetic medicine' route, and the already overcrowded polyclinics will be able to perform even better. In the same vein, many private specialists are also keen to help by treating subsidised patients who are presently referred to overcrowded specialist clinics at public hospitals.The medical profession should do regular soul-searching, and if we find that we have deviated from our intended paths, we should have the courage to take remedial actions to rectify this.Dr Huang Shoou Chyuan angry doc thinks Dr Huang has correctly identified why many GPs are doing aesthetic medicine - it pays better.However, angry doc doesn't think that more training is what is required, or that having the government to put more money into subsidising healthcare is a fair thing to do, or that it will reduce the number of GPs doing aesthetic medicine or the number of complications arising from it.GPs don't go into aesthetic medicine because they don't know how to be "a 'specialist in taking care of the entire patient' "; many already possess post-graduate degrees or diplomas in family, and regardless of whether they do or do not all of them are required to attend a minimum number of hours of Continual Medical Education every two years. The learning opportunities and resources are there, and those who want to be better at their craft will utilise them, while those who do not will perhaps just sign the attendance form and take advantage of the free lunch and check their email on their iPhones while the speaker drones on; you can force doctors to attend training, but you cannot force them to learn, or to practise what they been taught in their daily practice.Doctors will learn when they perceive that it is to their advantage to do so, and GPs who practise aesthetic medicine regularly take time off their practice to learn about new techniques and new equipment. They don't need MOH to pay them for their time, do they?Will making the government pay GPs for seeing non-aesthetic cases work?angry doc thinks it may make GPs give up aesthetic medicine and return to family medicine if (and it's a big and important 'if') the trade-off seems favourable to the GP, and that means that at the end of the day the GP should still make as much if not more money than if he did aesthetic medicine. However, the cost involved makes it unlikely that our Health Minister will likely propose that.And even if we do subsidise patients who visit a GP for non-aesthetic problems, patients will still visit GPs for aesthetic procedures (they have been doing so, and won't have any reason to stop now), and GPs who have been doing aesthetic medicine will still do aesthetic medicine (again, they have been doing so and won't have any reason to stop now either). In fact, angry doc may even argue that with part of the cost of their non-aesthetic medicine paid for by the government, patients will now have more money to spend on aesthetic medicine. OK, maybe with more money to spare now they will visit a specialist for their aesthetics needs and not a GP.angry doc thinks that the 'problem' of GPs doing aesthetic medicine is really a reflection of how doctors and patients prioritise their wants and resources. Trying to reverse the trend by asking people to be 'noble' isn't going to work, and throwing more tax money at it isn't always a solution; if good primary care is so important that we can consider forcing doctors to provide them, then why shouldn't we require that those who benefit from it take personal responsibility and pay for it? Elite-bashing There has been several letters to the ST Forum this week 'bashing' elites, in response to this article by Ms Sandra Leong.Many of the anecdotes on the cluelessness of the 'elites' are pretty funny - angry doc's favourite is this one:"A church-mate who lived in a landed property in District 10 - definitely not an RGS girl, and I venture to guess, not even a graduate - once, in all sincerity and innocence, prayed for all those who had to take public transport and live in HDB flats, for God to give them strength to bear these trials. "Of course, there is no one agreed definition on what makes a person an elite, which makes it hard to discuss the issue intelligently. But what worries angry doc is an assumption that many people hold, exemplified by what Ms Leong wrote:"... the pursuit of intellectual excellence to the exclusion of character or value excellence breeds an exclusionary attitude to the rest of society. Many of the products of our top schools forget they have to give back to the society that allowed them so many opportunities."What is implied there is that people who are successful owe a debt to society, and that if they refuse to "give back" to society, there is something faulty with their character or values system.But angry doc would like to ask: who in society is calling for this debt to be repaid? On whose behalf is Ms Leong calling for elites to "give back"? What makes us think that we are entitled to the time, effort, or the fruits of the labour of those in society who have succeeded?"Opportunities", you say? Certainly most people could not have succeeded without the infrastructure which 'society' created (schools, roads, utilities, a civil service, industries), but does that entitle us to make demands on them? Did society create all these infrastructure so that these people could succeed, or did we do so because we wanted to utilise these infrastructures ourselves, so that we too could have a chance to succeed? Society may have provided the opportunities, but by claiming that we have a right to the fruits of their labour, we are dismissing the importance of the individual efforts which made the success of these people a reality - we are laying claims to the result of something which we did not give to. The opportunities were open to everyone, but we choose to ignore the 'debts' of those who did not succeed, and present an invoice to those who did and have something to "give back". Makes good economic sense, of course.angry doc is not against people who feel that they want to contribute to society - certainly there is nothing to prevent them from doing to; society provides many avenues for them to do so. What puzzles angry doc is why some people feel the need to claim that others must do so too.To conclude, angry doc would like to do some "Ayn Rand spouting", via youtube...(For readers who are unfamiliar with "The Fountainhead", here is a succinct summary...) 'Right' to healthcare "One of the misconceptions of rights today is that man has a ‘right to a job’, a ‘right to health care’, a ‘right to education’, a ‘right to a house’ – that man has a ‘right’ to things simply because he claims he needs or wants them.The sanction of such alleged ‘rights’ is the first step toward the destruction of rights. If man has ‘rights’ to health care, to education, to a house, then the appropriate questions to be asked next are: Who is to provide them? And at whose expense?Jobs, health care, education and houses are not products of nature, nor can they be products of government – because by the nature of government, it cannot be a corporation and a producer – but the products of the men who produced them.If a man is entitled by ‘right’ to the products of others, it means that those others are deprived of their rights to earn and keep their own property and their rights to sell to whomever they choose. If a man is entitled by ‘right’ to the products of others, those others are essentially condemned to slave labor. A ‘right’ that violates the rights of others is a contradiction in terms. No such ‘rights’ can exist."- Ho Say Peng Sing along (click on the picture if you don't have a clue...) Support Love 7 Spread the word. Take our rights... please! angry doc is quite disappointed by this piece of news.Now long-time readers will know which side of the 'religious vs. LGBT' divide angry doc is on, and new readers need only look at the sidebar on the right to know his alignment; it is precisely because of his beliefs in these causes that angry doc feels the making of the police reports represent more of a disservice to the LGBT community than help.While our laws are currently biased against gay people (S377A) and in favour of people of religion (S298), angry doc does not believe that the solution to this state of inequality lies in appealing to the authorities to gag or punish those who speak against the LGBT community (or for that matter any segment of society).By appealing to the law to take away the right of a person to express his opinion publicly, even if that opinion is wrong or unjustified, we are effectively supporting the belief that the law has that right. What is needed is not for more of our rights to be taken away, but returned to us. The solution to 'bashing' from religion is not to demand that they be silenced, but for the right to challenge the contents of that 'bashing' to be returned to us.Regardless of the outcome of the police reports being filed, angry doc cannot see how the LGBT community can stand to win from this situation: if nothing comes out of it, then the police would have effectively given the 'go-ahead' for all other persons of religion to make similar speeches against them. If Pastor Tan is made to apologise and undertake not to repeat his speech, then we have merely reinforced the state's right in shutting people up without subjecting the issue to open discussion and debate. If we as a nation, as a society allow the right to openly discuss and support or condemn a point of view to be taken away from us, if we allow the decision of whether someone has a right to express an opinion to be made not collectively by us but by a few who are not endowed that right by us, then we will all become poorer.If we say to the police: "shut this man up for what he says offends me," then can we really complain when the police tell us to shut up because what we say offends another man? Trust (Posted on the Singapore MD blog) When I was a houseman... angry doc used to work with a (not much more) senior colleague who used to start every other discussion with the phrase "when I was a houseman...".Prof Lee now does the same in her latest article in the papers:(exerpt)Time to reverse 'narcissism epidemic'The young today are more self-centred and less driven, possibly due to their upbringingThe principal of a mission school invited me to give a talk to his teachers recently.'The purpose of inviting guest speakers to the school is to open up my teachers' minds about new possibilities and the demands of the real world,' he told me.I was unable to give the talk but volunteered one of my doctors, an old boy of the school and a superb and compassionate doctor. I told the principal: 'My perspective on the education of these relatively elite boys is to teach them that they owe society a duty.'The principal agreed, but observed: 'Unfortunately, given the changes in Singapore... my teachers are increasingly pushed by larger societal forces that worship the relentless pursuit of academic excellence as a means of material gain... While there is nothing wrong with pursuing academic excellence, it cannot be an end in itself.'I and many other senior doctors have noticed that a significant percentage of newly graduated doctors are more self-centred and less hard-working than we were.For example, there are more house officers with each passing year, and in some departments, there seem to be too many of them. The total work has not increased much, but this is divided among more house officers. Yet house officers complain that they are stressed out and they cannot cope with the work.When I was a house officer, there was no payment for being on call. As a medical officer, I was paid $40 for the first four calls in the month, and $100 for each subsequent call. There were no mandatory maximum or minimum number of calls for house officers or medical officers.But some time after 1990, house officers were not allowed to do more than six calls a month and medical officers were not allowed to do more than four calls. House officers are now paid $110 a call on weekdays and $150 on weekends. Medical officers are paid $210 a call on weekdays and $300 on weekends.We used to have to do eight to 10 calls a month, and the number of patients I saw each time I was on call was considerably more than the numbers seen by house officers and medical officers today.But despite having to do less work, junior doctors apparently have less time for self-study today.Consequently, many training programmes now set aside 'protected time' during working days for them to study. In addition, most departments have structured teaching programmes for young doctors - a far cry from the bad (or good) old days when there was no time during working hours for structured teaching and most of us learnt from patients or senior doctors. And to reinforce our knowledge and ensure we missed no crucial information, we would read a standard textbook from cover to cover.All of the above would appear to be exceedingly difficult for the present generation of junior doctors. For some years, I wondered whether this was the fault of our medical school or indulgent parents."angry doc belongs to the generation of doctors who benefitted from the enlightened view that doctors should be paid appropriately for their time on calls ($40 for an overnight call would be way below minimum wage if we had one) and that they should not (in theory) be made to work more than six calls a month. Nevertheless, his personal record was 11 calls in one month, and he can remember a few where he did not catch a single minute's sleep.Housemanship in his days was tough - angry doc has seen it reduce grown men and women to tears - and even then angry doc heard his share of "when I was a houseman" from his senior doctors. angry doc is willing to bet that as a houseman, Prof Lee too got her fair share of "when I was a houseman" from her senior doctors, who remembered how housemen were better in the days of the Raj.Do junior doctors have it easier these days? Certainly. But that precisely why the changes Prof Lee mentioned (limiting number of calls, structured training, protected time) were implemented - we want to make learning a less stressful experience than what we went through ourselves, and we want it to be safer for everyone.Does it matter that the youths of today are 'less tough' than we were? angry doc doesn't think so. The whole point of training for junior doctors is to produce doctors who can function in their role in an efficient and safe manner. They may not have to do 11 calls a month, or take blood for 40 patients in one morning, but they face a more demanding generation of patients (and relatives), and the volume of new information and evidence they have to assimilate and incorporate into their practice is enormous. The old challenges are not the challenges they *need* to face today, just as we did not have to face the challenges that they face today when we were housemen.At the end of the day, when angry doc is ill, he doesn't want a tough doctor who has done his 10th call this month, or a humble guy who thinks he owes society a debt - he wants someone who is rested and has had plenty of time to learn about the condition for which angry doc has been admitted for. It matters not to angry doc that the doctor might have a "positive" opinion of himself - as long as he can do what his job grade requires, it is not an "inflated" view. Look Back In Anger It's a little late to post a look-back of the year, but here goes anyway...The past 18 months have been a time of change for angry doc - some good ones, some bad, but most of which he thinks he has brought upon himself.angry doc's opinions on many subjects have changed. Not surprisingly, this also meant that people's opinions of angry doc have also changed. Curious thing is, you sometimes don't even know what someone's opinion of you is until he or she tells you that his or her opinion of you have changed. Even more curiously (or curioser), angry doc realised that he doesn't really have an opinion of himself anymore, if he ever had one before.angry doc doesn't know how often he will be blogging this year. It's not just because he will be busy with work (you are never too busy to blog, really), but because he is not sure he sees the point of putting his opinions down anymore. Weird? Quote of the week In Singapore, TCM complements western medicine and this mixedsystem is best for consumers. The two operates on very different philosophy andit is hard and unfair to assess one using the other's benchmark.For patients, whether it is east or west, so long as it works,it is the best!- Mr Khaw Boon Wan, Minister for Health, on TCM Busy angry doc apologises for not posting for almost the whole of this month. The end of the year is usually a slow period for this blog, but he has been busier than with work, fighting against racism and stupidity in real life, and the general mechanics of daily living.It will probably be another two or three weeks before he gets his groove back.Thanks for stopping by. Wednesday Monday Dr Tan, I presume? Google is a wonderful thing.This letter on the ST Forum today did not come as a surprise to angry doc:Dispel concerns about complications after vaccinating kids I REFER to Tuesday's report, 'Immunise infants early, specialists urge'.I would like to ask child specialists how much adjuvants are given to children in the form of aluminium and mercury salts in vaccines, besides preservatives, over a two-year period, under the Ministry of Health (MOH) childhood immunisation programme.Scientists have shown that aluminium and mercury are foreign to our biological system and do more harm than good. Does MOH have a register of all complications related to childhood vaccines given in Singapore? According to vaccine package inserts, these complications range from mild fever to severe convulsions and delayed eczema.In a 2007 clinical study of 300 babies aged between nine and 12 months at five SingHealth polyclinics, what was the adverse complication rate and the severity, in terms of morbidity and mortality? Are these babies followed up long-term and for how long?Mothers' concerns about autism and vaccination are real. The incidence of autism is reported to be rising in Singapore. This issue has not been thoroughly addressed as to its causation.Tan Soon KiamSounds familiar?On a whim angry doc decided to google Mr Tan's name, and it turns out that 'Mr' Tan may in fact be 'Dr' Tan.In fact, judging from the topic of his 'concern', he may be the same Dr Tan we encountered on this blog more than two years ago.Dr Tan, as we can see from his letters, is no heavy metal fan. Readers may wish to google his name to find out for themselves why this is so. What's in a name? Fellow skeptic-blogger Singaporean Skeptic's post draws angry doc's attention to a study on Traditional Chinese Medicine (TCM) on ADHD being conducted at IMH.angry doc is one of those people who routinely calls modern medicine 'western' medicine. He does so because he thinks it is a convention that reduces confusion; but Skeptic does make a good point - calling things by their proper name is important in promoting public understanding of science.The fact is, even if "yi shen ke li" is shown to improve the behaviour of children with ADHD, it doesn't mean that TCM 'works', because giving a fixed formulation to all patients with a diagnosis that is made by 'western' doctors and which does not exist in TCM canon is not TCM.Rather, it would mean that the active components in 'yi shen ke li' works. If we go on to identify that active component like Skeptic suggested, then it will mean that that active component works. If we continue to give children 'yi shen ke li' in its current form to children, then it would mean that this particular *herbal* medicine works. Either way, it would mean that modern or scientific medicine works, but not that TCM works.Being conducted by IMH, angry doc is pretty sure the trial will be vigorous and have proper control group/s and be properly double or triple-blinded, although he suspects that the results will be like this one he looked at a while ago. He eagerly awaits them , and hopes that a 'negative' trial will also be reported with the same fanfare in the local media. Medium Register An interesting piece of news here:Mediums to be regulatedTaoist Federation aims to weed out unskilled tang kiBy Yen Feng THE Taoist Federation is taking steps to regulate spirit mediums here.As early as next month, it will issue registration forms to the roughly 300 temples affiliated to it, so a register of mediums, or tang ki in Hokkien, can be set up.Federation president Tan Thiam Lye told The Straits Times last week that this was the first in a series of steps to set apart those trained in channelling Chinese deities.Registration is, however, voluntary for now. Down the road, licences may be issued.More immediately, the federation will also produce a free manual to help devotees discern between skilled and unskilled mediums.Saying the federation will take things 'one step at a time', he added: 'It is time for us to regulate them. We must not let the actions of a few bad apples lead to a misunderstanding of mediums and Taoism.'angry doc will be very interested in finding our how to "discern between skilled and unskilled mediums". Maybe they can give a copy of the manual to Father Simon so he doesn't hold a "prayer session" for the wrong person in the future... Discussion (Posted on the Singapore MD blog) WWSKW? angry doc is a little disturbed by two letters that were published in the ST Forum in response to Salma Khalik's article.Fellow bloggers spacefan and Gigamole have blogged about them, and angry doc thought he might venture an opinion too.While angry doc had always had respect for Prof Goh and more recently Dr Chong, he found their letters too defensive in tone; rather than to just stop at admitting that our profession has some way to go to policing our own, both men found it necessary to strike back at Ms Khalik.Prof Goh tried to shift part of the blame for the problem to the media ("including the newspapers"), and in effect called Ms Khalik's article "unfair reporting" which hurt the feelings of ethical doctors.Dr Chong brought in the red herring of the H1N1 pandemic, and accused Ms Khalik of being "callous and unpatriotic".Ironically, the first sentence of Ms Khalik's article reads:"There is no doubt that the majority of the 8,000 doctors in Singapore are ethical professionals."angry doc has no love for Ms Khalik, but over the years he had come to realise that sometimes an 'unfriendly' journalist can in fact be the profession's and patients' best friend, and that the best question to ask when looking at a question on policy or ethics is sometimes: "What would Salma Khalik write if she knew about this?".angry doc had never had his feelings hurt by expose of unethical doctors, because he knew very well how *he* practised; he is responsible for his professional actions as an individual, just as the errant doctors are - he feels no shame for other doctors' actions, just as he does not expect other doctors to feel shame for his actions.Yet the letters from the two presidents have managed to make him feel embarrassed to be a doctor today. Had angry doc belonged to either of the societies, he might have felt ashamed. Chowder is just Chowder Once in a while angry doc learns important things about life from children and cartoons.Yesterday, while watching an episode of Chowder with his young nephew, angry doc asked: "What sort of animal is Chowder?"Rather impatiently, his nephew answered: "Chowder is not some sort of animal; Chowder is just Chowder."Then, seeing the embarrassment on his uncle's face, he added: "Chowder is a kid."He obviously gets it.We should all spend more time watching cartoons with children. Still around angry doc is still around, but he is too busy following up on his small victories to post anything substantial.Still, you can join him in the discussion on the new residency programme over at Singapore MD, where he still drops by occasionally to moderate the comments. Small victories It's been a long day, but angry doc is in a good mood.Important decisions affecting the lives of thousands are often made by one person, but that one person's decision can often be affected by the words and action of a few.angry doc thinks he made a difference today. In fact, he counts three little victories today.It's the little victories that keep us fighting. Most things can be explained.Some things are harder to explain.Some things are better left unexplained... From somewhere else Something better than what angry doc can come up with all by himself here. Oh my God, the sued Simon! You bastards!