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VO L . 5 1 N O . 2 | F E B R UA RY 2 0 1 9 | M C I ( P ) 0 8 3 / 1 2 / 2 0 1 8
The Sky
is the Limit
Ethical Issues around
Medical Certificates
news
CON T E N T S
Vol. 51 No. 2 2019
EDITORIAL
BOARD
Editorial
04 The Editor’s Musings
Editor
Dr Tan Yia Swam
Dr Tan Yia Swam
Deputy Editors
Dr Tina Tan Feature Opinion
Dr Tan Tze Lee
05 Called to the Same Profession – 22 Ethical Issues around
Editorial Advisors
A/Prof Daniel Fung
Brothers in Medicine Medical Certificates (Part 2)
A/Prof Cuthbert Teo Dr Benjamin Soh, Dr Reuben Soh, Dr Neeta Satku
Dr Toh Han Chong Dr Keith Liang and Dr Kevin Liang
Members
Dr Chie Zhi Ying President's Forum Calendar
Dr Jayant V Iyer
Dr Jipson Quah
10 Passion and Compassion 25 SMA Events Mar-May 2019
Dr Jonathan Tan Dr Lee Yik Voon
Dr Jimmy Teo
Dr Alex Wong From the Heart
Council News 26 Neighbourhood Health Service:
EX-OFFICIOS 13 Highlights from the
Dr Lee Yik Voon The Nation’s First Integrated,
Dr Lim Kheng Choon Honorary Secretary Community-Based, Holistic
Dr Lim Kheng Choon Health Screening
EDITORIAL
OFFICE Benjamin Tan Kye Jyn and Koh Ying Ying
Senior Manager Reflections
Sarah Lim 14 The Sky is the Limit AIC Says
Assistant Manager Dr Tan Tze Lee
28 Holistic Preventive Care Plan for
Sylvia Thay
Your Patients in 2 Steps!
Editorial Executive
Jo-Ann Teo Review Agency for Integrated Care and
16 Time Waits for No One Health Promotion Board
ADVERTISING AND
PARTNERSHIP Dr Tina Tan
Li Li Loy
Tel: (65) 6540 9174 Indulge
Email: adv@sma.org.sg Hobbit 30 The Stormy Seas of a
18 About that $100,000 Fine Budding Restaurateur
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editorial
The
EDIT R'S
MUSINGS
In the past weeks, two prominent
events were highly featured on my
inappropriately. But it can also be
used well to inform and educate. Tan Yia Swam
social media feed: the death of Mr The petition with more than 6,000
Aloysius Pang while on Operationally signatures seems to have triggered
Ready National Service reservist, and a wave. Clicking a button is easy, but Editor
a $100,000 fine. one wonders how much real change
it can do. The professional bodies Dr Tan is a consultant at the Breast
Like most people, I was saddened
are not as ineffective or gormless Department of KK Women’s and
and shocked by Mr Pang’s death,
as some of my acquaintances think. Children’s Hospital. She continues to
especially in the wake of the other
Real change happens when there is juggle the commitments of being a
training-related deaths, and I await
a meeting of like minds and real life doctor, a wife, the SMA News Editor and
the results of the official inquiry
action in slow gradual steps. the increased duties of a mother of three.
with great vested interest. My three
boys are still young, but they will be I appeal to the disgruntled She also tries to keep time aside for
serving National Service in the years keyboard warriors to step up and join herself and friends, both old and new.
to come and I want to know how committees in the professional body
such tragic events could be avoided. of their choice and be the change
they want. There are the SMC, SMA, While loving and looking after
The $100,000 is another life- CFPS, AMS, and Alumni Association. others, don’t neglect yourself either
changer, at both a professional and Take your pick, or set up your own if – self-care is important, be it in the
national level. A lot has been said you really feel that none of the above form of food, drinks, rest, meditation
on this – some learned, some not so meets your needs. or exercise. One of my favourite
much. We carry an adapted version of restaurants is Pasta J, and I’ve invited
the Hobbit’s article in this issue. With Onto more light-hearted updates
– the Lunar New Year and Valentine’s John, the owner, to tell us more
her usual insights and bluntness, she about it. I love the food and it’s a
gave a critical analysis of the event Day have always been about family,
friends and loved ones for me. With great meeting place, especially if you
right after the news broke. There have have fur babies.
a family theme in mind, we have
been many developments; meetings,
brothers – Drs Reuben Soh and Going full circle back to death,
parliamentary questions and answers.
Benjamin Soh, and twins Drs Keith Dr Tina Tan reviews the book When
The Singapore Medical Council (SMC)
Liang and Kevin Liang – share their Breath Becomes Air. How would you
held a meeting with key appointment
thoughts about brotherhood in face your own mortality? Would you
holders of the Academy of Medicine,
medicine. (Off hand, we didn’t know live your life any differently if the
Singapore (AMS), College of Family
of many sisters in medicine; if you end date is brought forward?
Physicians Singapore (CFPS) and SMA
are keen to share your stories, I’d
to clarify the processes that resulted in It is not too late for New Year
love to hear from you!) Dr Tan Tze
the $100,000 fine. Dr Lim Kheng Choon Lee and his wife run a clinic in the resolutions. Rethink your personal
gives a brief report (see page 13). There north where they have managed life; rethink your professional life.
is ongoing discussion on the problems their practice successfully while Are you the person you want to be?
that this has caused. The medical raising their kids over the past 20 Are you the doctor you want to be?
fraternity awaits proper guidance. years. He shares pearls of wisdom Take back ownership of the doctor-
on maintaining a harmonious patient relationship.
Social media is powerful and
can create social unrest if used partnership in work and life. 18 February 2019
04 FEB 2019 SMA News
Called to the
FEATURE
m e P r o fe s s i
Sa thers in Medicine o n
Bro
d
ju st a pr ofes sio n; it is a calling – to serve an
Medicine is more than ever wondered
et he r as a un ite d pr ofession. But have you
do good tog In the
ving a sib ling wh o sh ares the same calling?
what it’s like ha the
ar from tw o se ts of brothers who reflect on
following pages, he of medicine.
d do wn s (m os tly up s) in their common pursuit
ups an
Text by Dr Benjamin Soh
My brother and I have always been quite different. It is perhaps curious that we both ended up in
For one, we grew up ten years apart with no siblings medicine and coincidental that we both took an
in-between (no, I’m not an accident), so I often felt interest in musculoskeletal medicine. While I can’t say
like we grew up in different times; his – the era of for sure how much influence my brother had on my
SEGA, ICQ and dial-up modems (remember when joining medicine, thanks to our large age gap, I had a
your internet got disconnected every time someone pretty decent personal idea of the road ahead of me.
called your house phone?) and mine – the era of the In particular, I have often been asked why I chose
first Xbox, MSN Messenger and broadband. He grew to do family medicine (with a view to do sports
up athletic, representing the school in track and field, medicine) instead of orthopaedics, given that my
while I took a liking to more artistic interests, joining brother was already in the field and could mentor
debate and later the drama and photography clubs. me. For that, the answer was clear – I saw the intense
ant
Dr Reuben Soh is a consult
in the Dep artm ent of
Orthopaedic Surgery, Dr Benjamin Soh is currently
al.
Singapore General Hospit a final-year resident in the
ng,
He tries to juggle teachi SingHealth Family Medicine
ies,
performing spine surger Residency Programme who
e with his wif e
spending tim hopes to further his interest
his
and three daughters, and in sports medicine after
suits.
occasional sporting pur completing residency. When not
stressing out over his MMed (FM)
preparations, he can usually be
found lifting weights in the gym.
Reuben & Benjamin
FEB 2019 SMA News 05
rigours of surgical life and decided that it wasn’t If it seems like there aren’t many (if any) downsides,
for me! My brother worked in pre-residency times that would be because my brother is who he is – an
and I would often meet him going home at 7 to 8 ultra “chiongster” who juggled work and examinations,
pm on a regular day – the one day I met him going served NS, raised three children and ran triathlons,
home at 5 pm, he was doing post call! As someone and yet was still one of the first in his batch to pass
who struggled to stay awake after post-call rounds, I his exit examinations. Not only that – he is also a kind
couldn’t imagine another six to ten years of surgical and nurturing teacher who won the Dean’s Excellence
training of that nature. Awards thrice, and rarely ever scolds his junior
At the same time, I must say that the benefits of residents. Perhaps the only downside is thinking how I
having an older brother in medicine are amazing will ever match such an amazing roster of achievement!
– from MBBS tutorials (my clinical group got a Ultimately, I do feel that my brother and I have gotten
three-hour “everything you need to know for closer from being in the same profession. We once grew
orthopaedics during the MBBS” tutorial from my up in different times, but now we share similar amusing
brother), to smooth integration with seniors (mainly stories from clinical practice; we once had our own
in my orthopaedics posting, but also during National mutually exclusive circles of friends, but now we know
Service [NS]), to having a first-hand alternative many of the same people from the SingHealth circles; we
perspective as a junior doctor of the benefits and once had differing relationships with our relatives, but
challenges that consultants may face. now just give them free medical consults!
Text by Dr Reuben Soh
being in a small unit, was
orthopaedic registrar and
Passion is the fuel that driv es me dic ine . e, given that he has seen me
frequently on call. I suppos
medicine, I see the post-call, falling asleep on
Reflecting on my journey into falling asleep on the couch
my path. Two significant Year reunion dinners and
many lighthouses that guided the floor after Chinese New t
ht. My mother worked as a it would have been eviden
ones shine particularly brig appearing chronically tired, for the faint-
certain ly not
ny interesting stories of to him that doctoring was
staff nurse and often had ma me . Ho w and wh y the less , it daw ned upon me one day
intr igu ed hearte d. Ne ver
the hospital. Those stories t so e the passion for medicine,
ma ke dec isio ns that impact the patien tha t he must certainly hav
do doc tor s
ly, why did they ask for a arly see what lay ahead.
profoundly? More important especially since he could cle
stat near 3 pm, causing my it was interesting to have
patient to be ser ved meds Being born ten years apart,
ulting in me mis sin g my ic tutorials to his class. It
mum to come home late, res the chance to give orthopaed
mme? ispering towards the end
favourite television progra was always funny to hear wh drew the reply:
e (JC ), I wa s fort una te to get an of tut oria ls, to which my que often ry
In junior col leg tures you share with Ben
est hes ia and that one week certainly “W e can’t quite agree which fea
observ ers hip in ana s whenever my residents
tan d wh at life is like in the operating Soh!” Recently, a smile appear
hel ped me und ers smates) introduce me to
n, who performed a hernia or medical officers (Ben’s clas
room. I saw the same surgeo Hulk/Silver Surfer, or as the
appendicectomy in the others as the brother of the
repair, hemicolectomy and an st doctor.
the night, with several brother of Singapore’s stronge
day continue to work through days, I saw many
icectomies. However, what Throughout his undergrad
abscesses and more append e a che erfu l ng part of Playhouse (an
ed to hav ts in bei
struck me was how he continu parallels in our interes
hours of the mornin g as he n), building props for rag
disposition even in the wee inter-batch play competitio
in and thigh of a pat ien t the freshmen orientation
proceeded to debride the gro day, as well as being part of
s certainly insp iring to see k that our “true” age gap
with necrotising fasciitis. It wa committee. Certainly, I thin
ing tho se 36 hou rs. rs as we have many fun
how many patients he impact
ed dur has lessened over the yea
events that sions chatting abo ut the dynamics of our workplace
re we re oth er ses
While I am sur e the llenges of residency.
pur sue medicine, those two or grumbling about the cha
shaped my dec isio n to hectic work schedules and
Ho we ver, I never actually Thankfully, despite having
par ticu larl y sta nd out . better over the years
r as I did not want to being on call, we have gotten
related these to my brothe isio n. You see, par ticipating in family me esp als ecially during the
car eer dec at
overtly influence him in his tinue to be peppered
n me in his gra des. With his fes tive season. Family meals con
Ben was always bet ter tha ed in the operating room
aur eat e sco re, he could have easily with stories of what happen
International Bac cal t my daughters are
els e and be in the running or polyclinic, and I’m sure tha
secure d a cou rse any wh ere ching a spark of the same
ola rships. eavesdropping, perhaps cat
ma ny pre stig iou s sch Mu mmy, Uncle Ben and
for
, I told Ben passion that drives Daddy,
and uni ver sity
At his crossroads of JC Aunty Charmaine.
gh. I was then a first-year
that a life in medicine is tou
06 FEB 2019 SMA News
Dr Keith Liang is a
senior resident in the
Department of Paediatric
Medicine at KKH.
g is a
in Lian
Dr Kev sident in the ic
re tr
senior ent of Paedia
tm
Depar H .
e at KK
Medicin
Kevin & Keith
Text by Dr Keith Liang
Being wrongly called over the phone
by fellow which microbiology notes to use, prep
colleagues, nurses and pharmacists aring for the
; being greeted final MBBS examination or surviving
in the lift by strangers and seeing thei housemanship
r embarrassed – I always held his advice in very high
reactions shortly after; facing bewilde regard.
red parents of Embarrassing as this may sound, he
patients who cannot believe their eyes even walked me to
when they my ward a number of times during my
encounter us one after the other – initial months in
these are just a few KKH as a new house officer!
examples of a day in the life of a pair
of twins at KK
Women’s and Children’s Hospital (KKH Years down the road, Kevin is not only
). my lunch
The good old twin jokes and questio buddy but also my study partner, a
ns somehow source of support
just never get old in the department. and my lifeline at work when the goin
Kevin and I have g gets tough.
been working together in KKH for abo I know that I can always count on him
ut six years now, to help me
and ever y now and then we still face review a new admission in my ward
the usual barrage or help with a
of questions we’ve been answering difficult intravenous plug. I will alwa
since we were ys remember
young. From time to time, there’s even the bittersweet memories of studying
that little game and practising
of “spot the difference”. together for the MMED examination,
failing it
together (with the exact same scor
Having a twin brother in the same prof e), and then
ession and subsequently passing it together and
residency programme is a privilege celebrating the
that I deeply treasure. fruit of our labour. To put it plainly,
I entered medical school one year later we just can’t get
than Kevin as I enough of each other at work, and
failed to get in the first year I applied. our colleagues
That was naturally often joke about how ridiculously clos
tough, given that we had been in the e we are. Call it
same class almost separation anxiety if you like, but you
every year since primary school. It was can’t blame us
also humbling as considering that we’ve spent most
my younger (by one minute) brother of our lives (plus
was now one step 36 weeks in the uterus) together!
ahead of me in the journey of medicine
. However, I knew My journey in medicine would nev
that it was part of God’s plan and alth er be the same
ough I probably without my dear twin and I certainl
haven’t said this enough, I have alwa y wouldn’t have it
ys looked up to Kevin any other way. God has blessed us
during this journey. I have relied heav with this privilege
ily on his tips and that only few have, and I look forw
advice throughout these years; whe ard to many more
ther it was choosing years of “twinning” together in this
journey.
FEB 2019 SMA News 07
Text by Dr Kevin Liang
learnt to look
ssion, let tennis team. From a tender age, we had
I never dreamt that I would be in this profe out for one another, take care of each othe r and even
twin brot her in the
alone be working alongside my stand up for one another when the need aros e. This
nt. Our fathe r had passed
same hospital and departme spirit, I’m proud to say, has not chan ged one bit over
in our early teen age year s and
on when we were still the years.
cons train ts, we did not ente rtain the
due to financial in the
thought of this career path. However, God
prov ided for Having the opportunity to work together
and gran daun t and depa rtme nt has certa inly been an
us financially through our granduncle same hospital
us support,
to
who saw us both through medical scho ol. answer to our prayers. This has allowed
cially during
on a encourage and help one another, espe
My initial journey in medicine started off busy night calls. It’s always hear tenin g to know that
rece ived my acce ptan ce
bittersweet note. When I we’ve got each other’s back (and tum my) at work . Till
Loo Lin Scho ol of Med icine ,I
letter from NUS Yong today, we’re still one anot her’s faith ful lunc h, stud y
ever, this joy was shor t-live d as I soon have
was elated. How and work compani on. Som e even say that we
ted a plac e.
found out that my twin had not been gran started to develop separation anxiety!
ol, I hope d
Throughout my first year of medical scho gs about an
and prayed that Keith would one day join
me on this The fact that we look identical also brin
s, cons ultants,
journey. Well, he eventually did, and for that I am so interesting twist to daily work. Our peer
us for each othe r
thankful to God. juniors and even patients mistake
a resu lt, we have train ed
and I to almost on a daily basis! As
In God’s divine plan, He allowed both Keith ourselves to respond promptly when calle
d by either
the Sing Heal th Paed iatric s Resid ency
be accepted into e or wave to anyo ne who greets us,
ed alon gsid e name and to smil
Programme at KKH, where we have work whether we recognise them or not.
rtun ity to
one another since graduation. The oppo and hospital
pursue paediatrics together as a career
has indeed Being together in the same profession
bond with
been a huge blessing for us and one that we are really has definitely helped to strengthen our
such a spec ial
grateful for. each other. This journey has been
not want to
to have and meaningful one for us and I would
Looking back, it has been a real privilege have it any other way! I’m than kful for this blessed
Grow ing up, Keith and I have never ahead,
a twin brother! opportunity and I look forw ard to the road
, we’ve been
been far apar t. For most part of our lives serving othe rs alon gsid e my dear brot her.
in the same
attending the same classes and training
SMEnAd LeUCM arket
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PRESIDENT'S FORUM
Passion
AND
Compassion Text by Dr Lee Yik Voon
February is here again and both of medicine based on compassion When I speak to the different
Valentine's Day and the Chinese for our patients and their sufferings, subsets of our medical fraternity,
Valentine's Day fall in the same month not to take advantage of them. Our I am often surprised to see many
this year. Both days are about passion code of ethics and professionalism disillusioned doctors. They now
and romance. continually reminds us of this. realise that medicine is not how
they envisioned it. Some are
In our profession, we too often talk
about passion in what we do. When
Passion for medicine exhausted from the heavy and
What is passion for medicine? demanding workload, actual or
was the last time you looked back
Year in and year out, I see many perceived, and have lost their joy in
and reflected on the reasons why you
of us toiling long hours in clinics, what they are doing.
embarked upon this journey to be a
healer? Was it because of your passion doing research, conducting home Does embarking on a journey
for this noble profession? Do you have visits or volunteering on overseas to pursue the study and practice of
enough compassion for your fellow mission trips. Personally, I feel good medicine require such a huge sacrifice
human beings? Many of us wanted solving the medical problems of my that we need to forsake everything
to be doctors because we care about patients, helping them see what else? There are many examples of
others. We believed that our passion their problems actually are and both extremes but I think it is about
coming up with practical solutions what you really want in life and the
to study medicine was to fulfil our
that they can adopt. trade-offs that you are willing to
ambition. When we graduated and
became house officers, reality hit us Although most of us end up accept. Take for example a friend of
and became a wake-up call for many. practising clinical medicine, a mine, who got so tired of the medical
smaller number gave up clinical scene in Singapore, he emigrated
Ideally, we should know our to Canada and worked as a factory
medicine and realised their calling
patients inside out. It is a human after graduation. You may have worker in an assembly plant. He
failing for us to take advantage met medical doctors fulfilling sells bak kwa as a side business. But
of them when we know so much their calling in non-medical or medicine is still his calling and in his
about them. We are expected to non-clinical fields, like in politics, blood. He ended up taking the local
not develop romantic feelings for health administration, clinical medical examinations there and
our patients or even more so enter and medical management in passed it. He is now working as a GP
into relationships with them. Our pharmaceutical companies, banking in a Canadian Chinatown and is more
calling and passion is the practice and manufacturing. matured in the way he handles similar
10 FEB 2019 SMA Newsmedical practice issues that he used when solving challenging problems good succession plan so that we can
to face in Singapore. I suppose this is for my friends and patients. Will this be better taken care of when we grow
an example of a growing up process passion and longing die out in the older and become patients ourselves.
faced by a fraternity member. years to come? Will I end up like At the end of the day, for some of
We have numerous female doctors those who burn out and no longer us, when we hang up our stethoscope
who are able to strike a balance find clinical work exciting? and seek what we have been yearning
between serving as a wife and One of the reasons that we end for all along – that is our real passion in
mother, and working as a medical up in this state is that when we were life – only then will we be truly happy
doctor. I am sure they have to make younger, we felt that we should push until we grow old and fade away.
sacrifices but they are able to come ourselves hard because we believed Till death do you part, but for me,
to terms with their decisions. that we will become more resilient I see medicine riding with me as I
with time. gradually disappear into the sunset.
Sustaining our passion Will we regret when we fall and
I previously aspired to be a can no longer look after our patients?
paediatrician and even sat for my As doctors, we need to look after
MRCP entrance examinations. After ourselves so that we can do our best Dr Lee is a GP practising
in Macpherson. He is
passing that, I left the service to join for our patients. Will patients be
also a member of the
the pharmaceutical sector to gain forgiving when we slip up due to tight current National General
exposure to the corporate world. After work schedules or insufficient sleep or Practitioner Advisory Panel.
five years of jet setting, I stopped as when we are fatigued? Or will patients He is a pet lover at heart
I dearly missed clinical work. I then prefer that we love ourselves so that who is the proud owner of
a dog, and regularly feeds
worked as a part-time locum, but that we are in better shapes to take care of
neighbourhood community
did not satisfy my calling as I needed their medical problems? cats. He also enjoys playing
to feel ownership of my patients. We also need to extend collegiality online war games and thinks
that playing Pokemon Go is a
Now, after more than twenty to our fellow brothers and sisters in the good form of exercise.
years of running my own private profession. We are one big family and
practice and trying out all sorts of yet we are guilty of pointing fingers
schemes run by private entities when things go wrong. We need to
and the Ministry of Health, and the inculcate a positive spirit so that we can
restructured hospital system that GPs groom future generations of doctors
in Singapore get exposed to over the with the right values and in the right
years, I still feel the adrenaline rush manner. After all, we need to have a
2019 AGM Please send an email to szeyong@sma.org.sg if you wish to:
1. Confirm your attendance (for both the AGM and lunch);
2. Submit resolutions and/or proposed constitution amendments; or
Please mark your calendar for SMA’s
upcoming Annual General Meeting 3. Submit nominations to fill the ten vacancies in the SMA Council.
(AGM). The details are as follows: Do also take note of the following sections from SMA’s constitution:
Article XI, section 1, sub-section (iii)
DATE
14 April 2019, Sunday Any member desirous of moving any resolution at the Annual General Meeting shall
give notice in writing thereof to the Honorary Secretary not less than thirty (30) days
TIME before the date of such Meeting.
2 pm to 4 pm Article XII, section 2
(Lunch served from 1 pm onwards)
The proposed amendments to the Constitution and Rules shall be made in writing to the
VENUE Honorary Secretary at least thirty (30) days before the date of the Annual General Meeting.
2985 Jalan Bukit Merah, Members are invited to submit nominations of candidates to fill the ten vacancies in the
SMF Building, Singapore 159457 Council, in accordance with Article VIII Section 3a of the SMA Constitution.
(meeting room details to be confirmed)
Nominations must be signed by two Ordinary/Life/Spouse Members and contain a
MAP consent to act, if elected, signed by the person nominated.
https://goo.gl/maps/K7Wz4QGWU192 All completed forms should reach us by 12 noon on 15 March 2019.LASTING
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You should not certify an LPA if you are related to the donor or donee, as per section 7(2)
!
of the Mental Capacity Regulations
All registered medical practitioners may use the Medical Report for Activation of LPA
to assess the mental capacity of the donor. The form can be found at the Office of the
Public Guardian’s (OPG) website
*Please note that it will take 1 to 2 working days for the account to be activated
For enquiries, please contact Denise or Jasmine
tel: 6223 1264 or email: OPG_LPA@sma.org.sg.
For more information on LPA, please visit the OPG website at
https://www.publicguardian.gov.sg.COUNCIL NEWS
Report by Dr Lim Kheng Choon
Dr Lim is the
SMA seeks clarification from SMC defensive medical practice would eat into
Honorary following the Grounds of Decision of what was presently available for routine
Secretary of the Disciplinary Tribunal Inquiry for patient-care. This was summarised in the
the 59th SMA Dr Lim Lian Arn letter to the Straits Times Forum on 11
Council. He February by the Chairman of SMA’s Doctors-
is currently When the Grounds of Decision for this case
were published, SMA Council wrote a letter in-Training Committee, Dr Benny Loo. The
an associate
consultant to Singapore Medical Council (SMC) on 24 letter can be found at http://bit.ly/2DvdrBJ.
at Singapore January 2019 to share comments expressed Other issues discussed included
General Hospital. by its Members about its implications. how some members of the Complaints
Following the letter, the SMA Council met Committee and Disciplinary Tribunal might
with SMC on the evening of 25 January 2019 benefit from more formal training in aspects
to better understand the reasoning behind relating to how to consider expert opinions
the judgement and penalty, and to discuss and how to judge fellow doctors. An offer
practical implications to clinical practice that by the SMA Centre for Medical Ethics and
now arise in consequence. A second meeting, Professionalism to work together with the
also with the SMC presenting, was held on the SMC was accepted for consideration.
evening of 31 January 2019 together with the
The SMA Council will continue to engage
leaders of the Academy of Medicine, Singapore
and College of Family Physicians Singapore. with the SMC and to advocate for greater
clarity and guidance on consent taking.
At both meetings, SMA and other We will keep Members updated as new
participants pointed out to the SMC that information becomes available.
given that the complications experienced by
the patient from the minor procedure were SMA committee against harassment
neither permanent nor debilitating, and as
the harm which ensued was limited in nature SMA recently formed a committee to look into
and extent, the penalty of $100,000 seemed the issue of harassment at work. As a start, the
disproportionate. Questions were also posed committee plans to publish a series of articles
to the SMC about their views on what the in SMA News on this matter. We also look
appropriate benchmark sentence(s) for failure forward to engaging external stakeholders
of informed consent cases ought to be. to organise activities and initiatives. We hope
to raise awareness regarding harassment and
Regarding minor procedures, three very
important points of everyday practice now help reduce the occurrence of such incidents
needed clarification: First, precisely which minor in the workplace.
procedures could be done just under implied
consent; second, how comprehensive was the Predatory publishing
information that needed to be communicated, The issue of predatory publishing was
including under implied consent; and finally, highlighted by the Singapore Medical Journal
whether documentation in the case-notes was (SMJ) Editor-in-Chief, A/Prof Poh Kian Keong,
now mandatory (as opposed to merely good in his January 2019 issue’s editorial. Predatory
practice), including for cases done under implied publishers typically ask for high upfront
consent. Unless definitively clarified, such publication fees without providing robust
uncertainty would only encourage the practice peer review or editorial services. There have
of defensive medicine, which would not be in been several cases where SMJ had to decline
the interest of either doctors or patients. submitted manuscripts which have been
We also pointed out the current published in predatory journals without the
ambiguity and resultant practical difficulties authors' knowledge. We encourage readers
facing the junior doctors over consent taking to find out more about predatory publishing
for minor procedures, and how, without and avoid the pitfalls. The full editorial can be
proper guidance, the time required for found at http://bit.ly/2tdxmQR.
FEB 2019 SMA News 13REFLECTIONS
Text and photos by Dr Tan Tze Lee, Deputy Editor
The town was dusty and the air hung distilled them and presented them relative safety, but the last 20 years
heavy with the scent of fresh cement to an architect friend. A design was have been a roller coaster for the
and diesel fumes. The bus interchange, proposed, the tender was awarded medical profession. For the first time
the centre of public transportation in and eight weeks later, we had a in decades, going to work could
Choa Chu Kang, was operating at a complete clinic space outfitted with mean getting an infectious disease,
furious pace. The MRT line also ended the then latest in clinic innovation. carrying the agent home, infecting all
precipitously there, the extension still and sundry, with the very real risk of
in the distant future. The train emptied An equal partnership succumbing to the illness.
at Choa Chu Kang, with commuters
I couldn’t have done all this on my SARS was a game changer for
big and small, young and old, pressing
own. My better half, L, hovered many. At the time, L and I had the
for space on the myriad feeder buses
in the wings with a watchful eye, feeling that it was going to be really
serving the region.
whispering pearls of wisdom during bad for us. Little did we know how
We walked several times around accurate we were. Many of the cases
the discussions, dotting the i’s
the new town centre. It was empty originated from our wee town and
and crossing the t’s. We have an
– bereft of shops and facilities. A many of the families who worked in
lone coffee shop stood empty and equal partnership in every way. We
the wholesale market in Pasir Panjang
forlorn at the edge of the interchange. voice out our ideas, concerns and
lived in Choa Chu Kang. There was
Fabulous! We must bid for the shop expectations (Yes, we do that too!) to
a real and present danger going to
space opposite! Two months later, each other and always try to come up
work every day; the worry that we
we were the proud owners of the with a final decision that takes all the
could bring the dreaded agent to our
99-year lease space from the Housing ICEs into account.
family was very real. Yet we couldn’t
Development Board. We could finally We have faced many challenges just abandon our patients who had
start on our journey as family doctors over the years. Hand, foot and mouth trusted us for so many years. L felt the
in a new town. disease, bird flu, SARS and H1N1 same way and we decided together
We now had a shop space, but – all this happened on our watch. to continue the clinic’s operation as
how do we maximise the space? They gave us a real fear in our belly usual. It wasn’t easy; with us decked
Ideas and suggestions streamed doing the work we had dedicated out in our personal protection
in from all corners. We took on our lives to. For the longest time, equipment (PPE), breathing and
board many of the suggestions, doctors on our fair shores worked in working was a real effort. Our staff
14 FEB 2019 SMA Newsalso followed our examples – none vice versa. I have come to deeply needs of the family and the practice
took a leave of absence; everyone appreciate that time together, and the paramount in our decision making,
came diligently every day, put on their discussions we have had range from and always strove to find the middle
PPEs dutifully and served the patients the mundane to the very profound. ground that we can both accept.
as best as they could. This has strengthened how we If we have the right values and
manage the practice and the family. support each other in achieving what
Growing together in In every partnership, the partners holds true, the sky is truly the limit!
close proximity have to be likeminded, with the same For we can achieve anything we set
aims and goals. Although L and I our hearts on.
Whenever people find out that L and
have very different characters, we
I work in the same practice, they are
are almost always on the same page
very often surprised that we are able
when it comes to the fundamentals.
to work so closely together in the
L always has her eye on the
same “office”. The usual comment is
affordability of our clinic charges, Dr Tan is a family
that if they and their spouses were
and in this I always defer to her physician in
working in the same office, they would
better judgement. We decide on the private practice in
fight every day! For us, it is quite the Choa Chu Kang.
services we are going to provide and
opposite. As we went through those A GP at heart, he
we interview for new staff together.
difficult times together, we discovered believes strongly
We also decided on the hours we are in family medicine
deep strengths in each other. We are
going to work together, as we try to provided by
indeed more than the sum of our
balance the needs of our young family family physicians
parts when we are together, and are embedded in the
and the needs of our professional
truly thankful for the relationship and community.
service. Very early on, it was clear that
partnership that we have.
we needed to spend more time at
Showing respect for and taking home with our young children. We
time to listen to each other is so jointly decided that L should spend
important. Many times, on the drive more time with the kids and we set
to and from work, L will share with out to recruit doctors to help us with
me things that are on her mind, and our growing practice. We made the
Yesteryears
Our team
FEB 2019 SMA News 15REVIEW
WAITS FOR
Review by Dr Tina Tan, Deputy Editor
I heard about this book when it was Paul’s relationship with his oncologist,
published in 2016. But what struck me Emma, is to be admired. She encouraged Title: When Breath Becomes Air
when I finally read the book was that him to find meaning in his life, refused
Paul – the author – was a surgeon with a to discuss Kaplan-Meier survival curves, Author: Paul Kalanithi
literary flair. I’m not saying surgeons can’t and also offered to “just be his doctor”. Number of pages: 228
be closet poets, but the sheer amount My oncology colleagues, no doubt, ISBN: 978-0812988406
of time and energy that surgical training grapple with such issues on a daily basis.
(in fact, almost all medical training) takes In fact, at one point or another, we will Type of book: Hardcover
might not leave one much time for the face such situations: the patient seated Publisher: Random House
humanities. Therefore, Paul’s account before us is a fellow physician, or that we
Year of Publication: 2016
of medical school and residency has become patients ourselves. How much
a certain heightened awareness and do you let this doctor-patient of yours
sensitivity that he was able to call forth make treatment decisions? Where does
and display. the balance of control lie?
The visage of death hovers The book concludes with Paul’s Dr Tan is an associate
throughout the entire book; it was heartbreaking account of his final day of consultant at the
present in the author’s description of residency, his prolonged hospitalisation, Institute of Mental
and his struggle with what to do with Health and has a
the cadaver dissection during anatomy special interest in
class, in his quotation of the Scripture, the time he had left. The latter is made
geriatic psychiatry.
and in seeing his own patients die before all the more poignant because at the She is also an alumnus
him. The book was also a touching time of his writing, he truly had no idea of Duke-NUS Medical
and brief recollection of his journey to how much time he had remaining. School. Between work
and family life, she
medicine, through medical school and This book is a must-read for medical squeezes time out for
residency. And it was when he was on students and those of us who have “seen her favourite pastimes –
the cusp of completing his residency too much”. If I could paraphrase this book reading a good (fiction)
(on the very day of graduation), that he into a sentence, it’d be: “When a doctor book and writing.
was hospitalised following a massive with a literature degree becomes a
chemotherapy-related infection. Paul patient”. Of course, given the prominent
alluded the experience to climbing to absence of a literature background in
the top of the proverbial mountain and my case, my paraphrasing destroys the
seeing the Promised Land. But what is poetic title. But hopefully, it doesn’t take
tragic is that the reader never knows away from the meaning of the book –
whether he thought he’ll ever reach it, how each of us face death and what we
and what it meant to him. make of the time that is given to us.
16 FEB 2019 SMA Newst T h a t
Abou
Hobbit
I n j e c t i o n
fo r a n
This article was adapted from The Hobbit’s article
originally published at http://bit.ly/2CMqa2I.
Editor’s Note: Since the online publication were quick to surface and temporary: pain a five-month suspension, this Hobbit
of The Hobbit’s original blog post, the and inflammation, discolouration, paper- speculates that their priority is to avoid
Singapore Medical Council has met with thin skin, and loss of fat and muscle tissues. a lengthy suspension. They pleaded
key appointment holders of the Academy What took her so long to complain? guilty at first instance and offered to pay
of Medicine, Singapore, College of Family Secondly, the Singapore Medical the maximum $100,000 fine or take the
Physicians Singapore and SMA to clarify Council (SMC) lawyer asked for a minimum three-month suspension. This
the case. For updates on the meeting, five-month suspension for Dr Lim. is perfectly understandable; a successful
please refer to page 13. We will continue This is mightily interesting. The ill senior orthopaedic surgeon in private
to provide more updates on this matter. effects suffered by this patient are far practice probably makes that amount
So, this is how the practice of medicine, less serious than the ones in the Eu in three to five months. A five-month
as we knew it, dies in Singapore. Kong Weng case, in which the patient suspension would mean that he has no
suffered serious complications. Dr Eu income and still has to bear the fixed
Not quietly or softly in the arms of
was suspended for three months and he costs of running a clinic.
compassion and empathy, but throttled
inadvertently by a $100,000 fine. appealed to the Court of Three Judges. A secondary concern is that should
The Judges commented that had the they offer something low, like $5,000 or
law provided for less, a shorter period $10,000, and the SMC Disciplinary Tribunal
Interesting points
would have sufficed, but they upheld the (DT) accepts it, there is no guarantee
There are many interesting points about minimum three-month period since they that the SMC lawyer will. He may instead
the case. felt a suspension was indeed warranted. choose to appeal to the Court of Three
Firstly, the patient who complained If so, on what basis did SMC’s lawyer Judges. In other words, to avoid what they
against Dr Lim Lian Arn. The H&L injection ask for a five-month suspension? This deem as undesirable consequences, Dr
was administered on 27 October 2014 but Hobbit does not understand. I hope the Lim has to make a generous-enough offer
the patient only complained against Dr SMC President, Registrar and members that both the DT and the SMC lawyer will
Lim on 11 January 2016, some 14 months understand, at least retrospectively. accept. In his self-interest, Dr Lim did as he
later. Especially when she was purportedly Thirdly, the doctor and his lawyer. was supposed to do. Perhaps this Hobbit
unhappy with the adverse effects which Faced with the SMC lawyer asking for would have done the same too.
18 FEB 2019 SMA NewsFourthly, we go on to the DT. Faced replaced the Bolam-Bolitho (BB) test information needs to be given) is solely
with an offer of a $100,000 fine, they had because the five judges (in the Hii Chii from the patient’s perspective and
three choices – they can accept or lower Kok vs London Lucien Ooi case) felt that nothing about what was being practised
the fine, or suspend Dr Lim. Thankfully in the provision of medical advice (which on the ground. Nonetheless, the standard
and rightly, they decided that Dr Lim includes getting an effective informed of care stated in the Grounds of Decision
should not be suspended. It would look consent), the process must be patient- of the DT is Medico-Legal Reality.
very strange if they decided to lower the centric rather than doctor-centric.
fine since the defendant already offered A few doctors, when faced with What’s next
$100,000, even though the DT thought the disciplinary proceedings and medical Let’s get back to the procedure itself: an
closest comparison to this case was that negligence suits, relied on the BB test H&L injection. This is a cheap, effective and
of Dr Eric Gan, in which Dr Gan was fined in their defence, almost to the point common procedure done in the specialist
$5,000. So, as expected, they decided to of abusing it. They would nominally and GP setting. But no more in the post-
fine Dr Lim $100,000, the amount that he come up with a few friendly “expert” $100,000 fine era. This Hobbit would like to
offered. This Hobbit does not think the DT opinions to justify their actions and differentiate by calling the past the pre-LLA
did anything questionable up to this point. pass the BB test. era and the current period as post-LLA era.
What is questionable is the appropriate (Dr Lim deservedly gets naming rights to
This was the weakness of the BB test,
standard of care that this DT promulgated such a momentous incident.)
but it also had its strength – it provided
for taking an informed consent for an H&L for a reality check. The BB test required Ask any business school professor and
injection. They said that for the patient to one to ask what was practised on the he/she will tell you to price in the risk.
give an effective informed consent, she ground by doctors and took reference to Here is how you do it:
should have been told of: such common practices.
(a) post-injection flare, in particular, that: This element is somewhat missing
in the MM test. So, the DT accepted Pre-LLA era price for an H&L
(i) the Complainant may experience
an information dump checklist as the injection by a GP: $50 to $150;
increased pain and inflammation
in the area injected that can required standard of care in giving $100 as a reference price.
be worse than the pain and medical advice when practically no one Number of H&L injections given
inflammation caused by the does this. The only reality check the DT before a patient complains: 100
condition being treated; was seen to undertake was accepting
that it was not universal practice to get a Number of successful complaint
(ii) the onset of the post-injection written consent for an H&L injection. cases (where you pay a fine of
flare is usually within two hours $100,000): one in three
after the injection and typically Dr Lim was charged under the 2002
version of the SMC Ethical Code and Ethical Estimate: 300 cases will result in
lasts for one to two days; three complaint cases, of which
Guidelines. Many respected orthopaedic
(b) the post-injection flare can be surgeons have been on the SMC Council one will be successful
treated by rest, intermittent cold since 2002. In fact, at least one of the Economic cost: one $100,000
packs and analgesics; current members is an orthopaedic fine and estimated $200,000
(c) change in skin colour including surgeon. All the DT had to do was ask (about $70,000 a case) for the
depigmentation, hypopigmentation these SMC members if they routinely gave emotional distress, time lost
and hyperpigmentation; ALL such information to patients going for and effort in preparing for the
H&L injections, and documented as such in complaints, etc.
(d) skin atrophy;
the case notes, to know what the reality on
(e) subcutaneous fat atrophy; Total risk premium: $300,000 for
the ground is. This Hobbit is confident that
practically all of them will fail this simple 300 cases
(f ) local infection; and
test. It’s just that none of their patients Risk premium: $1,000 a case
(g) tendon rupture. complained, unlike Dr Lim’s. New price for one H&L injection:
To me, this is the kind of “information There is nothing in the published $1000 + $100 = $1,100
dump” that the Judges said should be Grounds of Decision that suggests they
avoided when they formulated the did such reality checks; the MM test does
Modified Montgomery (MM) test for not include such an element except Conclusion 1: price of H&L
Singapore in 2017. suggesting that expert opinion could be injection by a GP in the post-
Fifthly, the MM test – now obviously taken into account when appropriate. LLA era: $1,100 (up from $100).
applied in full force. The MM test The test of materiality (in deciding what
FEB 2019 SMA News 19Of course, these numbers will only advice is provided. They promoted
be significantly higher in the specialist Conclusion 2: in the post-LLA era, patients’ rights to autonomy through
setting. An H&L injection by a hand or not many heartland GPs will offer promulgating the MM test.
orthopaedic surgeon may now cost H&L injections. H&L injections The lawyer wanted to do a good
$2,000 to $4,000, after taking into will go the way of dodo bird in job by pushing for a deterrent five-
account their own risk premiums. the heartlands. month suspension. He is defending
Many patients in the heartlands the patient-complainant’s rights
cannot afford a thousand-dollar to autonomy, as well as promoting
The expected repartee from people
jab and the GPs know this. Most of patients’ rights in general.
who are out of touch is that this is not
these patients will then be treated The SMC DT wanted to be seen
about risk premium but about good
conservatively with brace and defending/promoting patients’
consent-taking and documentation.
medication, resulting in unnecessary rights by accepting Dr Lim’s offer of
pain or suffering by the patient (which Frankly, not many doctors are
a maximum $100,000 fine. They also
may cost between $100 and $1,100), interested in this spiel anymore. After
want to send a signal to all doctors
or referred to the public sector. This the Eu Kong Weng case, no doctor
that the standards as prescribed by the
is not to say that the public sector is really sure what will be deemed MM test are well in force when they
doctors can do a better job with effective informed consent-taking promulgated that long list of potential
better outcomes and attract fewer under the scrutiny of SMC or the Courts. complications and side-effects for an
complaints. It is just a simple transfer If I were to take this kind of risk for a H&L injection.
of the risk premium to the public $100 job, I’d rather refer to someone
else to take the job (and the risk). Dr Lim Lian Arn acted as he should,
sector, where much of the costs are
by offering to pay $100,000 or be
subsidised by taxpayers. The richer This is probably the outcome that suspended for only three months.
patients will be referred to the private will take place in the next few months,
specialists because they can afford to if it has not taken place already. Please The patient-complainant is probably
pay the higher charges, and the private do not call this defensive medicine. As satisfied too that the doctor was fined
specialists may refer their poorer this Hobbit has said before, it is called $100,000. Whether she proceeds on to
patients to the public sector. survival medicine. It’s the only practical a civil suit or not, we don’t know.
The patients that will complain to way to survive. For me at least. Every party got what they wanted:
the private GP sector will also likely But it’s not just about H&L The patient, doctor, SMC lawyer, judges
complain to the public or private injections. How about other simple and SMC DT.
specialist sector. In the former, the everyday office procedures like But this Hobbit cannot help but wonder
state/taxpayer takes up the risk and in speculum examination, proctoscopy if Singapore society deserves more.
the latter the risk premium is covered or ear syringing? The same principle
Because the Likely End-Result is
by higher private specialist fees. applies and a heartland GP will
that patients will either find the H&L
Incidentally, fee benchmarks transfer the risk premium to the
injection less accessible or have to pay
currently do not cover office public sector or the private specialists
significantly more for it. Same goes for
procedures like H&L injections. through referrals.
other common, cheap and effective
To summarise – there will be little office procedures. A situation of either
demand for a $1,100 H&L injection Conclusion 3: in referrals scarcity of service providers and higher
in the HDB estates, and GPs are also we trust (to avoid taking on prices will result, leading to unnecessary
unwilling to take up this new risk insufferable professional risks). higher healthcare expenditure.
premium. In simple economic theory, Society will have to pay for this in
the demand and supply curves do the long run. Unless the politicians
not cross and there will be few or no How it came to be and senior civil servants step in soon
transactions (ie, no volume of work). with some form of tort reform for
Consequently, the standard of care You may ask how we got to this situation. medico-legal cases, the practice of
given in the Grounds of Decision of the It is because everyone behaved in a way medicine, as we knew it, has truly died.
DT, while now is Medico-Legal Reality, expected of them. And the biggest losers are the patients
will also in all likelihood become The judges wanted to move collectively and society. Not the doctors.
Virtual Reality in the HDB Heartlands. from a doctor-centric to a patient- I just earn a few hundred less a month,
How interesting. centric process where medical but I’ll live. Don’t worry.
20 FEB 2019 SMA NewsOPINION
Ethical Issues around
MEDICAL
CERTIFICATES
PART 02
Text by Dr Neeta Satku
This is the second article in a two-part an investigation can be made requests from patients may be a result
series on medical certificates (MCs). following any significant work-related of coercion from employers rather
The first (http://bit.ly/2UvPukQ) injuries. Such investigations may be than a genuine desire to return to
discussed the guidelines for writing inconvenient or expensive, leading work early. Coercion can take the form
MCs responsibly, with attention to employers to occasionally request of promises to allow the employee
accountability and confidentiality, for shorter MC durations to avoid to rest with pay or assurances that
as well as the types of certified sick triggering them, sometimes even compensation will be paid even
leave available. suggesting that the doctor’s contract without medical certification, or in the
This article will address the importance with the company hinges on his/her form of threats of repatriation.4 These
of issuing an adequate duration of sick acquiescence.4,5 Employers may also promises may not be kept, leaving the
leave, and the advisability of providing request for MCs specifying that the worker unpaid and unprotected.
patient is fit for light duties, rather than
limited uncertified sick leave. This is an important reason for
unfit to work at all, as these do not have
to be reported to MOM. doctors to reject requests to shorten
Workplace safety medical leave or prescribe light duties
These requests can also come from for work-related injuries. Doctors should
The issue of giving inadequate medical
the patient him/herself. Ordinarily, also be aware that adequate medical
leave following work-related injuries
although doctors should consider only
has recently received much attention in leave is given not merely for the benefit
medical factors when issuing MCs,6
the press.1,2 of the individual patient in this case, but
they may allow their patients some
because it plays a role in maintaining
The Workplace Health and Safety say in the MC duration, such as issuing
workplace safety for other employees
Act requires that employers notify the fewer days when a patient would
through the reporting system.
Ministry of Manpower (MOM) of like to return to work earlier after an
work-related accidents that result illness, as long as it presents no risk to It is uncomfortable for
in workers being given more than himself/herself or others. However, in professionals who are trained to be
three days of sick leave,3 so that the setting of a workplace injury, such compassionate and respectful towards
22 FEB 2019 SMA NewsYou can also read
