Saturday, December 12, 2009
"Conclusion: Neuraminidase inhibitors have modest effectiveness against the symptoms of influenza in otherwise healthy adults. The drugs are effective postexposure against laboratory confirmed influenza, but this is a small component of influenza-like illness, so for this outcome neuraminidase inhibitors are not effective. Neuraminidase inhibitors might be regarded as optional for reducing the symptoms of seasonal influenza. Paucity of good data has undermined previous findings for oseltamivir’s prevention of complications from influenza. Independent randomised trials to resolve these uncertainties are needed." BMJ 2009;339:b5106
There never was any real data of true efficacy. I had posted on this before. Yes, it reduced the number of days of infection....by 1.3 days!! But we were repeatedly told that Tamiflu was the 'miracle drug' that was going to save the world from this vile and super-virulent H1N1 pandemic. Governments stockpiled tons of Tamiflu. And Roche was laughing all the way to the bank.
So now we are told that supporting detailed data has been concealed by Roche.
I had posted a comment on this previously.
The restructured hospitals have generally done well in making their systems and procedures more accountable. But not necessarily more transparent. Much of the accountability, unfortunately, appear to have been put in place only for accreditation purposes.
The vogue at the moment is to seek accreditation with the US based Joint Commission International (JCI). In this accreditation exercise, reduction of hospital errors is one of the parameters assessed. It therefore became important that the hospitals have systems in place to deal with hospital errors. Or at least have the semblance of being able to deal with errors. But do the hospitals really want to know? If they really want to know they must have in place s system not just for reporting, but one also to audit the reporting, and not just expect to randomly uncover cases of non-reporting.
What do hospitals and the MOH do with these numbers? Do they really want to know the true incidences of errors? Just because there are reporting processes in place, and we can crank out statistics of some sort, shouldn't lull us into thinking that risks of hospital errors have been adequately mitigated.
Anecdotally, I know of cases of obvious practice errors, that go unreported. Recently, a wife of a friend of mine had to be wheeled back into theatre because of an error committed during surgery. I am quite certain the incident was not reported.
Reporting systems need to be audited, and the audit findings made public. Otherwise it will remain a sham. So should it be for hospital reporting - be it for surgical errors, medication errors or nocosomial infections.
Thursday, December 10, 2009
Richard Feynman was a bit of a hero to me when I was first getting into science. He was a great physicist and Nobel Prize laureate, and possibly one of the great scientist of our times. Although not a physicist I was drawn to his writings for that rare and genuine love for science he shared, and the honesty and integrity that he expressed in the science that he practiced.
The following are some of Feynman's quotations that are instructive to us:
"No government has the right to decide on the truth of scientific principles, nor to prescribe in any way the character of the questions investigated. Neither may a government determine the aesthetic value of artistic creations, nor limit the forms of literacy or artistic expression. Nor should it pronounce on the validity of economic, historic, religious, or philosophical doctrines. Instead it has a duty to its citizens to maintain the freedom, to let those citizens contribute to the further adventure and the development of the human race."
"The first ... has to do with whether a man knows what he is talking about, whether what he says has some basis or not. And my trick that I use is very easy. If you ask him intelligent questions — then he quickly gets stuck. It is like a child asking naive questions. If you ask naive but relevant questions, then almost immediately the person doesn't know the answer, if he is an honest man."
"The exception tests the rule. Or, put another way, "The exception proves that the rule is wrong." That is the principle of science. If there is an exception to any rule, and if it can be proved by observation, that rule is wrong."
"Religion is a culture of faith; science is a culture of doubt."
"Looking back at the worst times, it always seems that they were times in which there were people who believed with absolute faith and absolute dogmatism in something. And they were so serious in this matter that they insisted that the rest of the world agree with them. And then they would do things that were directly inconsistent with their own beliefs in order to maintain that what they said was true."
"Science is a way of trying not to fool yourself. The first principle is that you must not fool yourself, and you are the easiest person to fool."
"Learn from science that you must doubt the experts. As a matter of fact, I can also define science another way: Science is the belief in the ignorance of experts."
"The only way to have real success in science, the field I’m familiar with, is to describe the evidence very carefully without regard to the way you feel it should be. If you have a theory, you must try to explain what’s good and what’s bad about it equally. In science, you learn a kind of standard integrity and honesty. "
He also related an interesting account of the now infamous oil drop experiment which was also associated with 'tricks' that scientists use:
"We have learned a lot from experience about how to handle some of the ways we fool ourselves. One example: Millikan measured the charge on an electron by an experiment with falling oil drops, and got an answer which we now know not to be quite right. It's a little bit off because he had the incorrect value for the viscosity of air. It's interesting to look at the history of measurements of the charge of an electron, after Millikan. If you plot them as a function of time, you find that one is a little bit bigger than Millikan's, and the next one's a little bit bigger than that, and the next one's a little bit bigger than that, until finally they settle down to a number which is higher.
Why didn't they discover the new number was higher right away? It's a thing that scientists are ashamed of - this history - because it's apparent that people did things like this: When they got a number that was too high above Millikan's, they thought something must be wrong - and they would look for and find a reason why something might be wrong. When they got a number close to Millikan's value they didn't look so hard. And so they eliminated the numbers that were too far off, and did other things like that. We've learned those tricks nowadays, and now we don't have that kind of a disease."
As it is, the physicists of the American Physics Society are themselves embroiled in the Climategate controversy, with charges of interest conflicts. Quite obviously they do not consider the sciences as being settled in any way. See here and here. They physicists in the APS should learn from Feynman.
Tuesday, December 8, 2009
Word has it that progress has been slow because of turf issues. Not surprising though, if that were true. There are a lot more turf issues here then there were with Duke-NUS. Who sits in the driver's seat is critically important. There are 3 players here, Imperial College (or KI?), NTU and Tan Tock Seng Hospital. Imperial College would want to have a big say if they are to be tempted to come in. But unlike Duke-NUS, where SGH provided an easy walkover, the TTSH would not be so pliant I think. And understandably so too. TTSH over the years have built an almost enviable iconic role in doctor training. Students love going to TTSH for their posting, and rank them highest among the hospitals. They would not (and should not) lie down so easily and give away their core mission to a foreign institution.
But I am only speculating here. I really have no idea what's happening here and what state of discussion the 3rd Medical School at. But I worry that there is some element of truth in my conjectures. I don't want to see TTSH lose their mission, and submit to an external agency. If I had my way, I would like to see TTSH firmly in the driver' seat. NUS/NUH had somehow disappointingly sold their soul, and seem to have lost their mission for medical education. I hope the mistake will not be repeated for TTSH.
In science, this is called committing a Procrustean crime. Wikipedia explains a Procrustean solution as being:
"the undesirable practice of tailoring data to fit its container or some other preconceived stricture. A common example from the business world is embodied in the notion that no résumé should exceed one page in length.
In statistics, instead of finding the best fit line to a scatter plot of data, first choose the line you want, then select only the data that fits it, disregarding data that does not, so to "prove" some point you are making. Its a form of deception that rhetoricians make so to forward their own interests at the expense of others. The unique goal of the Procrustean solution is not win-win, but rather that Procrustes wins AND the other loses. In this case, the defeat of the opponent justifies the deceptive means."
Sound familiar? Seems to me that this was what the climate scientists were doing. They had a model of global that they knew had to be right. Just too bad that some of the data didn't quite fit in with the model. So they just did what Procrustes did.
Interestingly there is actually a Procrustes analysis of climate data. Even though the context is a little different. :)
There is a nice simple write up about theoretical thinking here.... something even I can understand; even though the climate scientists seem to have difficulty with these concepts.
"The second reason you can't prove a theory true is that there is never just one theory that fits the facts. A theory is really just a narrative. A tale that explains. But stories can be told very differently. In a sense, there are always an infinite number of theories that fit the facts."
But for climate science, we are told repeatedly that the science is settled. Theory proven.
Procrustes would have been proud.
The opinions expressed in the editorial was reasonable enough but what was really scary was the leader to the editorial, on the top left hand corner of Page 2, under the caption Viewpoints....
"The science of climate change and its conclusions are settled. The sceptics must be denied, or precious time will be lost in futile disputation."
Conclusions settled? Sceptics must be denied? Seems to me that AGW has indeed moved from a scientific hypothesis to become scientific dogma and orthodoxy. It is ironic that they label sceptics as flat-earthers.
Just to make things clear with regards to my position....I have no vested interest in taking sides in this debate. I am inclined to believe global warming is happening, but I remain unconvinced that it is entirely man-made.
Thursday, December 3, 2009
A] Global warming?
I used to be convinced that global warming was real. But now I am not so sure. If the data was fudged, how can one be certain? If climate scientists were happily excluding data that was uncomfortable to their starting hypothesis, and bully dissenting voices into silence, how can we now accept their proof of global warming? How can it be that raw data of such importance is not made publicly available so that this globally crucial issue can be analyzed from as many perspectives as possible, and proper conclusions drawn? How can such important data be held hostage to commercial and proprietary interests?
But let me be clear about something - this new found skepticism does not in any way lessen my conviction that there is far too much consumption/wastage in our society and too much pollution. There is no doubt whatsoever that we need to learn how to manage our environment, and to preserve the world for our future generations. But this is independent of issues with respect to global warming, and its causes (if it indeed is warming). (My personal impression for many years had been that, yes, there is global warming but this is not necessarily due to human activity. So ClimateGate has not done much to change my views here.)
B] The corruption of Science
Whether science is indeed dying, I do not know. I guess we will find out when it is finally dead. But it is clear that science is corrupted and sick. Once, we could depend on scientists to speak their opinions, and we could count on their being 'objective' (within limits of course). But nowadays, these limits have shrunk. Science has sold its soul to big business and is now the pawn of big corporations and governments. Can anything they opine be objective? If the scientific community as typified by the University of East Anglia (apparently the NASA of Climatology) bigwigs be so petty, conniving and corrupted, what can we expect of lesser mortals whose careers and livelihoods be dependent on lifelines handed out by granting agencies with big commercial/governmental agendas? How do we deal with this scientific hegemony that has been driven by big money?
For the sake of our future generations, we need to weed out these negative and destructive forces now at play in the scientific environment. For this small critter, this is a far more important issue than whether or not there is global warming.
C] The corrpution of our mainstream mass media (MSM)
How sad that too, that our MSM has also been held hostage to commercial interests (government control?). Not so? Well, how do you explain then that even as this massive academic scandal swirls around the scientific community like a typhoon, the MSM is so deathly quiet. The Straits Times today can just squeak out pretty articles about Copenhagen. Surely ClimateGate is newsworthy? Afterall it is arguably the biggest academic scandal of our generation. One does not have to take sides in this controversy, but merely to report the breaking of the scandal. But....no...there's just this deathly silence.
This silence speaks louder than any possible expose of the lack of independence of the MSM. That both SPH and Mediacorp have been equally silent points perhaps to the size of those controlling interests.
Here's an opinion piece by Daniel Henninger of The Wall Street Journal:
Science is Dying
Surely there must have been serious men and women in the hard sciences who at some point worried that their colleagues in the global warming movement were putting at risk the credibility of everyone in science. The nature of that risk has been twofold: First, that the claims of the climate scientists might buckle beneath the weight of their breathtaking complexity. Second, that the crudeness of modern politics, once in motion, would trample the traditions and culture of science to achieve its own policy goals. With the scandal at the East Anglia Climate Research Unit, both have happened at once.
I don't think most scientists appreciate what has hit them. This isn't only about the credibility of global warming. For years, global warming and its advocates have been the public face of hard science. Most people could not name three other subjects they would associate with the work of serious scientists. This was it. The public was told repeatedly that something called "the scientific community" had affirmed the science beneath this inquiry. A Nobel Prize was bestowed (on a politician).
Global warming enlisted the collective reputation of science. Because "science" said so, all the world was about to undertake a vast reordering of human behavior at almost unimaginable financial cost. Not every day does the work of scientists lead to galactic events simply called Kyoto or Copenhagen. At least not since the Manhattan Project.
What is happening at East Anglia is an epochal event. As the hard sciences—physics, biology, chemistry, electrical engineering—came to dominate intellectual life in the last century, some academics in the humanities devised the theory of postmodernism, which liberated them from their colleagues in the sciences. Postmodernism, a self-consciously "unprovable" theory, replaced formal structures with subjectivity. With the revelations of East Anglia, this slippery and variable intellectual world has crossed into the hard sciences.
This has harsh implications for the credibility of science generally. Hard science, alongside medicine, was one of the few things left accorded automatic stature and respect by most untrained lay persons. But the average person reading accounts of the East Anglia emails will conclude that hard science has become just another faction, as politicized and "messy" as, say, gender studies. The New England Journal of Medicine has turned into a weird weekly amalgam of straight medical-research and propaganda for the Obama redesign of U.S. medicine.
The East Anglians' mistreatment of scientists who challenged global warming's claims—plotting to shut them up and shut down their ability to publish—evokes the attempt to silence Galileo. The exchanges between Penn State's Michael Mann and East Anglia CRU director Phil Jones sound like Father Firenzuola, the Commissary-General of the Inquisition.
For three centuries Galileo has symbolized dissent in science. In our time, most scientists outside this circle have kept silent as their climatologist fellows, helped by the cardinals of the press, mocked and ostracized scientists who questioned this grand theory of global doom. Even a doubter as eminent as Princeton's Freeman Dyson was dismissed as an aging crank.
Beneath this dispute is a relatively new, very postmodern environmental idea known as "the precautionary principle." As defined by one official version: "When an activity raises threats of harm to the environment or human health, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically." The global-warming establishment says we know "enough" to impose new rules on the world's use of carbon fuels. The dissenters say this demotes science's traditional standards of evidence.
The Environmental Protection Agency's dramatic Endangerment Finding in April that greenhouse gas emissions qualify as an air pollutant—with implications for a vast new regulatory regime—used what the agency called a precautionary approach. The EPA admitted "varying degrees of uncertainty across many of these scientific issues." Again, this puts hard science in the new position of saying, close enough is good enough. One hopes civil engineers never build bridges under this theory.
The Obama administration's new head of policy at EPA, Lisa Heinzerling, is an advocate of turning precaution into standard policy. In a law-review article titled "Law and Economics for a Warming World," Ms. Heinzerling wrote, "Policy formation based on prediction and calculation of expected harm is no longer relevant; the only coherent response to a situation of chaotically worsening outcomes is a precautionary policy. . . ."
If the new ethos is that "close-enough" science is now sufficient to achieve political goals, serious scientists should be under no illusion that politicians will press-gang them into service for future agendas. Everyone working in science, no matter their politics, has an stake in cleaning up the mess revealed by the East Anglia emails. Science is on the credibility bubble. If it pops, centuries of what we understand to be the role of science go with it.
I hope they will cut the expensive salaries of their prima donnas rather than to divert much needed resources from their teaching budget.
The Nanyang Technological University has yet to 'fess up to their losses.
Wednesday, December 2, 2009
Climategate - the unravelling academic scandal that threatens the credibility of the anthropogenic climate warming position
Earlier this month, the scandal now nicknamed 'Climategate' began with the publication of hacked emails from the Climatic Research Unit, University of East Anglia, showing how corrupted and conniving the climate change scientists (big guns, not small fry, mind you....from the IPCC - Intergovernmental Panel of Climate Change) have been in promoting the global warming agenda.
For details please read Lord Christopher Monckton's report.
The Daily Telegraph's report is also good reading.
For me, this is a sad indictment of how far academia has sunk. Once we could trust the objectivity of reports that came from academic centres. Or at least it did seem that way. Now, it seems the universities and research centres have all fallen prey to money wielding organizations, or self serving politicians. Can we trust academicians now?
Some may say that this is an isolated incident involving a unrepresentative group of academics, but the cynical in me believes this may in fact be more prevalent than we want to admit.The silence of the main stream media is deafening. Governments and politicians who have invested much in the global warming hypothesis have much to lose should it be proven to be a hoax. A gargantuan industry has already been built up around technologies to mitigate global warming. What will become of these should there be no global warming?
Let's not even think of the possibility that we might not have been told the whole truth about other issues such as the H1N1 pandemic, or stem cell research, or gene therapy, or the need for cancer screenings.... The list goes on.
I had made the point earlier about the need for more objective data. This is even more urgent now. The question is where will it come from?
Tuesday, December 1, 2009
The fact that reports had been made compulsory by the Ministry of Health is an important one, and the Ministry should be given full credit for biting the bullet on this issue. But the question is why the need for secrecy here? This data is not found on the MOH website, and not in the public domain (unless I have been looking in the wrong places). If not for ST's report on this issue, we would not know. But ST's report is somewhat tentative and 'kiasu', for it says something, then goes silent. Why, for example, does it not report of the trend of such occurences over the last 7 years? Is it going up or coming down? These numbers should be reported for each hospital, and denominated by the hospital size so we know which hospital runs a tighter ship where error mitigation is concerned.
Is this the death knell for evidence-based medicine?
Thursday, November 26, 2009
The Singapore Heart Foundation just recently published lists of all the organizations and places where automated external defibrillators are installed. A consolidated list of places can be found here. My gym isn't on the list. Neither is the East Coast Park. Nor is the Prince George's Park Residence gym.
Wednesday, November 25, 2009
The HSA reported a series of 27 cases, with one particularly problematic case of Sweet's Syndrome.
Canada reported high frequencies of unusual adverse reactions and some deaths, which resulted in cessation of the vaccinations, and withdrawal of the GSK vaccine.
Earlier China had reported 2 deaths, but evidence later discounted their relationship to the vaccine.
But actually, despite the fact that they are all H1N1 vaccines, they are all essentially different products. The China vaccine is China's own special product. The Singapore vaccine, I believe is pretty much the CSL version at the moment, while the Canadian vaccine is a GSK product manufactured in Canada.
It's interesting that the Canadian product is called Arepanrix and the Singapore GSK version is called Pandemrix. According to the GSK website, the difference is that Arepanrix is translucent and has particles..... Hmmmm...... poor manufacturing giving rise to allergies? We'll wait for the werdict.
First of all is, whether there are adequate support for cardiopulmonary resuscitation to be done?
Although it was reported that CPR was started but was unsuccessful, I really question if proper CPR was at all possible. I can't imagine that there would be trained gym instructors at a hostel gym. Furthermore I really doubt if proper CPR equipment was available; don't even mention a defibrillator!
Which was a tragic shame....because in a young man with cardiac arrest, CPR/defibrillation could be life saving.
Which raised in my mind, a second question - how many gyms in Singapore are properly equipped for CPR? At the gym in the club I frequent, I discretely asked the instructor if there was any CPR equipment available. He stammered a bit and insisted there was. When I asked where, he stammered a bit more and said he didn't know.... perhaps it was out of order and sent for repairs. Then he said it was in the store room. Who had the key? That question really got him. I didn't want to embarass him further so I left it there. Bottom line was that even if there were CPR equipment it was not accessible in any way should an hapless auntie collapse from coronary insufficiency.
Then I thought a bit more..... what about at our parks? When I was at the East Coast Park the other weekend, I couldn't help marvelling at the thousands of weekend warriors who flock there every Sunday. If someone collapses, how does one do CPR? Does anyone know if there is a defibrillator anywhere? Why can't the park have well signposted CPR stations at regular intervals?
I wonder who is responsbile for ensuring there is adequate support for public cardiopulmonary resuscitation in Singapore? Or is everyone wishing someone else would do it?
Tuesday, November 24, 2009
a] the IPCC (Intergovernmental Panel on Climate Change 4th Assessment Report) which predicted a range of possibilities based on various scenarios. The worst case scenario being 26-59 cm for the 21st century; and
b] a report by Siddall et al, Nature Geoscience 2, 571 - 575 (2009), projecting a rise of 7-82 cm rise in sea levels; and
c] a report by Grinsted et al,Climate Dynamics 2009, forecasting a meter rise in sea levels.
How will Singapore be affected?
It's hard to tell for sure since there is very little in terms of survey data out there. But I came across this cool website put up by some NUS students called 'Mapping Potential Sea Level Rise in Singapore' with some simulations and projections done using the 2001 IPCC Report.
The 2 figures below show projections based on an 82cm and 120cm increase in sea levels. For more info please go to their website.
Monday, November 23, 2009
"Global temperatures have already risen by at least 0.7 degrees Celsius. Global warming above 2-3 degrees in the second half of the century is likely unless strong extremely radical and determined efforts towards deep cuts in emissions are put in place before 2015.
The melting of the Greenland (GIS) and the West Antarctic Ice Shield (WAIS) could lead to a Tipping Point scenario, possibly a sea level rise of up to 0.5 meters by 2050. This is estimated to increase the value of assets at threat in all 136 global port mega-cities by around 25.000 billion USD.
On the North-eastern coast of the USA and due to a localized anomaly, the sea level could rise up to 0.65 meters, increasing the asset exposure from 1.350 to about 7.400 billion USD. "
The gahment should tell us explicitly what they are doing to mitigate the effect of this rising sea level. If they have done any geographical surveys and modelling, they should let us know what the impact is on our coastlines, and the risks of flooding should sea levels rise by 0.5m.
We have a right to know.
I was tempted to feel sorry for it until I was reminded of the whopping size of its reserves. $270 million!!! This pretty much the same as when it ran into the TT Durai scandal in 2005. I couldn't help thinking that even if the charity couldn't ever do better than this recession year, and had to dip into into its reserves to the same degree for the next 100 years, there would still be a sizeable pile of cash in the bank.
By comparison, the Community Chest in 2007/8 raised $52 million and disbursed $49 million.
Annual Report 2007/2008
Saturday, November 21, 2009
a] Only one type of pump capable of being programmed for hourly or daily delivery rates. The mistake was in the programming.
b] Two similar looking pumps - one for hourly delivery and the other for daily delivery. The mistake was in the wrong pump being used.
I really have no way of establishing which of these stories are true. We'll wait for the BOI to release their findings....if they ever. But in both of these scenarios, the design of the pump is also important in minimizing the risks of operator error.
By the way, these pumps are actually regulated by the HSA as 'medical devices'. I wonder if they these design problems into consideration when they approve these pumps? Or just look at the brochures?
Friday, November 20, 2009
The timing of the revisions is pure coincidence, they say.
The debate did focus my attention on how difficult it is to get truly objective information. I don't really know too much about who is right in this debate, but it did seem to me that at least the Task Force did try and base their findings on objective scrutiny of evidence. What disappointed me was that the major physician and oncology groups just lent their voices to the din by adding more and more anecdotes to support screening. Where is the objectivity? Where is this much touted 'evidence-based' medicine? (see NPR Report)
My question is, can we count on doctors to be objective in their recommendations? Can we even count on governmental reports to be objective given that governments themselves have become players themselves in this game of medical monopoly.
In a recent CNN report Alice Park writes: "If the brouhaha following a government advisory panel's recent change in breast-cancer-screening recommendations has proved anything, it is that even modern medicine does not rely on statistics, scientific facts and clinical outcomes alone."
This debate will not end soon. So far the Ministry of Health and Health Promotion Board have remained silent. How objective will they be, I wonder?
Wednesday, November 18, 2009
A recent report from the La Jolla Institute for Allergy and Immunology: "...the conservation of a large fraction of T-cell epitopes suggests that the severity of an S-OIV infection, as far as it is determined by susceptibility of the virus to immune attack, would not differ much from that of seasonal flu. These results are consistent with reports about disease incidence, severity, and mortality rates associated with human S-OIV (swine-origin H1N1 influenza virus)" further confirms its lack of threat.
How did we all get it so wrong? And what are we going to do with all those vaccines that nobody needs?
What he didn't mention was which hospital was at the bottom of the survey.
We all know... but we but won't tell. (Hint:It isn't anything to do with Dukes as they have been credited with 'superior pedagogy')
Tuesday, November 17, 2009
" Mr Khaw laid the blame on the similarity in appearance of the two pumps which were mixed up, and said that he would be providing feedback to the manufacturers.
He said: ‘The pumps look almost exactly the same…This is very dangerous when there are two pieces of equipment and one is millilitre per hour, and one is millilitre per day – you are causing unnecessary risk to the users of this device.’
The key thing, he emphasised, is to learn from this incident and prevent similar mistakes from occurring. "
While it is right that the staff involved should bear some responsibility for being careless, Minister is right in not over apportioning blame on the hands that pulled the trigger.
A significant part of the responsibility should lie with the manufacturers, who were too dumb to design their pumps properly. Did they not consider the user in their design? Sadly it is too common to see engineers in their rush to get a working piece of equipment out into the market place, sacrifice all human factors considerations. It doesn't matter if the user gets into all kinds of problems, or have difficulties in getting the equipment to work properly. This is something I hope the new Singapore University of Technology and Design will address. It's not just a matter of getting an innovative product out into the market place, it is about getting a well designed product out. One that takes into considerations the needs of the user. This is called Human Factors Engineering.
Yet another part of the responsibility should be borne by the management. Did they not see this as an accident waiting to happen? Did it not seem clear to them that if you have two pieces of equipment looking exactly like each other, some one's going to make the mistake of using the wrong piece of equipment? Did they not do a risk assessment of the procedures they used in the chemotherapy unit? Even though the design of the equipment left a lot to be desired, they could just as easily have stuck on a strip of red tape distinguishing one from another. A simple solution that could have prevented this disaster. Just that nobody bothered.
Saturday, November 14, 2009
The question is how can such a monumental error occur in a situation which should be regarded as nothing less than 100% error free. I am sure the hospital and the MOH are now scrambling with their Boards of Inquiries.
But I can tell how 2 people checking a procure can make an error.
There are simply 2 people looking at different things and not really checking with each other. I have seen it happen so many times in ward procedures, and you wonder what is the intention for the checking process. Clearly a checking process is instituted without understanding what the process is supposed to check. Take for example the checking on NRIC numbers.... Staff#1 reads of the case sheet while Staff#2 'checks' the number on the patient's bracelet. Sounds good. But wait..... if Staff#2 didn't get enough sleep and reads an 8 for a 3, even if you repeat the process 10 times, the same error will be reproduced. It is true that the chance of a nexus between a case sheet with an 8 meeting a bracelet with a 3 is very small, but when it does occur the error will not be detected. It's like trying to proof read your own report.
Likewise, in this case.
If Staff#1 reads the instructions and Staff#2 inputs the programme, and if Staff#2 makes the error of inputting hours instead of days, the error will be neither be detected nor prevented. The process only prevents errors caused by the same staff reading and inputting the error.
People who write such procedures need to rethink a bit more about what they are doing...
Saturday, October 24, 2009
I remain horrified that we insist on regulating drugs to the nth level. Preclinical studies, clinical trials.... and what not. Pretty much about 10 years of generating data on safety and efficacy before we allow them into the market place. But when it comes to cell based products, whether of animal or human origins, there is this huge blindfold on. The Bioethics Advisory Committee is only concerned about the ethics of doing such research. But if it is for clinical use, there are no regulations in place, and it's pretty much a hands off approach.
I am particularly surprised that when the Health Products Acts was passed in 2007, it only applied to First Schedule items such as Medical Devices and Cosmetics. Wasn't it considered then that cell based products were something to be concerned about? Or for that matter, any biological products that were not technically 'medicines'.
Oh yes, we can argue that such experimental practices fall under the scrutiny of the Singapore Medical Council, who have a Ethical Code and Ethical Guidelines to hit people on the head with. Para 4.1.4 particularly. But this is too ambiguous and subjective to have any real meaning. I mean, what are unproven therapies? If I have 20 anecdotal reports, does that mean it is proven? How about 50? 5000? or 5?
So why aren't cell-based products registrable? Where are the legislative powers for HSA to do this work? Why is there such a big blindspot in our regulatory environment?
Friday, October 23, 2009
A couple of things bother me though. There's been a lot of talk about a second wave emerging. The reason for the vaccinations are to mitigate against this second wave. But I never quite bought into this second wave thing for Singapore. If indeed there is a second wave, given there will be more herd immunity, it would be a lesser wave than the first, would it not? Unless of course, the virus mutates. But it hasn't as yet, and it looks like we are dealing with the same, not so virulent, not so lethal , not so pandemic virus.
Also seasonal flu? That applies to temperate countries with summer/winter type seasons. Since the only winter we have in Singapore is the styrofoam/soap variety in Orchard Road, there isn't going to be much in terms of seasonal change in flu transmission. In fact, a scan of the MOH epidemiological stats over 2004-2008 confirm that the incidence of acute respiratory infections were pretty flat throughout each year. The only interruption to this flatness was the rather short-lived H1N1 pandemic earlier this year. So the only seasonal change we may expect in H1N1 would be due to increased seeding by travelers from temperate zones who carry the virus to us. And given the increased herd immunity, such seeds may not transmit that well.
Actually, I wonder why the MOH does not survey the level of herd immunity in our population beefore embarking on any immunization programmes? This developing herd immunity would certainly be one of the reasons why the earlier first wave pandemic fizzled out. After representing more than 60% of samples at the peak fo the pandemic, it is now hovering at about 24% of cases surveyed.
So is there a rush to get vaccination? Apparently not if the health care workers are polled. But these are still early days.
Wednesday, October 21, 2009
Other types of xenotransplants would be - sticking an animal (e.g.pig) organ (heart, liver, kidney etc) into a human recipient, or putting animal (again usually pig) cells into people (e.g. pancreatic islet cells).
Strangely xenotransplants seem to be a relatively unregulated medical procedure. The HSA regulates medicines, complementary medicines, cosmetics and medical devices but apparently not animal cells. It would seem that xenotransplants would be regulated under transplantation laws, but not so. The Human Organ Transplant Act doesn't cover animal cells into humans, just the use of human organs.
So doctors seems to be pretty unregulated with respect to their sticking animal bits and pieces into people. Possibly it may be considered an experimental surgical technique, but one could argue that sticking sheep fetal cells into someone isn't really surgery. It could possibly be regarded as an experimental procedure or a clinical trial; in which case it should be approved by the ethics committee. But this would assume the doctor would classify it as an experiment. If he maintains that the procedure is not experimental he need not subject it to ethics review.
It then becomes the responsibility of the Singapore Medical Council to consider it under Para 4.1.4 of the ethical guidelines. Unproven therapies. And that seems to be pretty inconsistently interpreted at the moment.
It would seem that Singapore is quite backward and confused where this is concerned.
Here is a list of site where you can read about regulations elsewhere:
Tuesday, October 20, 2009
Monday, October 19, 2009
But the question must also be raised as to what actual law did he break, and what crime did he commit? Apparently he done the unconscionable and had injected sheep foetal cells into patients to slow aging. The Medical Council screamed that this was offering unproven therapy, and not allowed. Such unproven therapy violate the SMC Code of Ethics :
The SMC Ethical Code and Ethical Guidelines para 4.1.4 state very explicitly: "A doctor shall treat patients according to generally accepted methods and use only licensed drugs for appropriate indications. A doctor shall not offer to patients, management plans or remedies that are not generally accepted by the profession, except in the context of a formal and approved clinical trial."
What Martin Huang did was offering a therapy that was uproven, and which was not part of a formal clinical trial. Bad guy.
But then again ( and I have posted on this conundrum before) so many of our doctors are clearly in breach of this. Unproven therapies? All off label use of medications are unproven therapies. Furthermore, their use are often not in the context of a formal clinical trial. How about off-label stent operations? The recent media reports on inappropriate slimming pill prescriptions fall into this category of offense. Yet the SMC did not act.
Not that I am a supporter of Martin Huang. I totally disagree with what he did and fully support the SMC's actions in his case, but the SMC's actions now look horrendously inconsistent. How did the SMC arrive at the conclusion that the offering of sheep fetal cells was so wrong compared to surgeons sticking all kinds of un-trialed appliances into our bodies, and physicians offering all kinds on drugs for un-trialed and unproven indications?
One last bit of ranting before I go for my teh-see....
Were the sheep cells licensed to be imported for cosmetic therapy? Here is where HSA has to explain their position. There apear to be regulations for medicines, for biosimilar products, for some medical devices and for cosmetics (external applications)..... but for cell based therapies?? Silence.
So were the cells allowed into Singapore for such use. If they were licensed imports, would this license represent tacit approval by HSA for their use? If they were not licensed, was Martin Huang guilty of breaking an import law? If so, he should be hit with the full weight of the law, as would any merchant intending to trade in an illegal product. Or does this indicate there is a legal loop hole for doctors to violate patients' safety? If so, why is there such a loophole and what are we doing about it?
What are the conflicts of interests within HSA, as they themselves begin to offer cell based therapies? How do they regulate themselves, in the absence of proper legislation for this, and as they come into competition with commercial providers of cell-based therapies?
We need to know.
Friday, October 16, 2009
Deepavalli's roots are shrouded in mystery, but most believe it has its origins as a harvest festival.
Autumn is a significant time of year in the agricultural calendar of the northern hemisphere. Crops planted in Spring ripen and are collected in the harvest. Agricultural communities celebrate this gathering of the harvest through various thanksgiving feasts. Often lights are featured, as in Deepavalli, perhaps as a recognition of the lengthening nights as Winter approaches. Even the Jewish communities celebrate a Festival of the Ingathering. This subsequently became the Feast of the Tabernacles which they use to commemorate the exodus out of Egyptian slavery.
But what of the harvest in Singapore? We have left our agricultural roots long ago.
We need to remember that our plenty of today is a harvest of the seeds sown by the previous generation. As we continue to reap the harvest despite the economic downturn, we should remember those who had planted seeds with foresight and diligence. Some thanksgiving in due.
But going forward, we should also be very mindful of what we are sowing for the next crop. So here's my plea to the leaders of today. Do not look just at the short term gains as indicated by superficial metrics. This has tended too much to be the management norm of today. While there is little doubting the longer term mission spelt out by our senior political leaders, the middle management levels have tended too much to just focus on short term metric indicators of performance. It's tempting to do so because individual performance looks good, but too much preoccupation with short term goals may ultimately undermine our very existence.
So where medical education and practice is concerned, let us please look at look the ultimate future of our health care system. Let's not screw it up or (as frighteningly overheard coming from a very senior person in YLL), cause it to implode.
Happy Deepavalli, all. And have a great weekend.
Well said, Sir!
I hope Prof Satku's public comments on topics pertaining doctor's professionalism and ethics will not be a one-off event. There is much out there that requires a re-boot. Ethics and professionalism has been fast tracking down the wrong road as the medical market place develops. Sometimes legislation is required. But often it is just the regular and consistent articulation of what is acceptable and what not that puts peer pressures on doctors to 'conform' to best practices. I believe most doctors want to do their best, but if things are left unsaid, errancy can fast become the norm.
I firmly urge our medical professional leaders to take up more visible, clear and vocal positions about medical ethics and professionalism. Not just generic statements, but targeted specific comments about issues. This includes not just the Ministry of Health but also the Medical Council and the Medical Association.
It's time to stop the rot.
Thursday, October 15, 2009
In Singapore, more and more gahment type organizations are now holding 'town hall meetings'. I suspect the management teams have all attended some similar senior management courses, and have been told that it was good management practice to do so.
So we hear of town hall meetings from time to time. Sadly most of these town hall meetings are very contrived and generally very poorly attended. I think the reason for this seemingly apathetic response from these corporate communities are because our management teams don't quite get the idea of what a town hall meeting is supposed to be. Instead of having a meeting to discuss and solicit opinions from the community (which means they actually must want to listen to the opinions raised). Most often, our Singapore styled town hall meetings are poorly disguised top down briefing sessions that are little more than for management to tell you more of the same thing. Typically in such town hall meetings, management's voice represents perhaps 90% or more of the proceedings. A poor simulate of a democratic process.
The MOH apparently wants to have a dialogue session, a town hall meeting about the coming residency programme. Great. But I am really hoping they will be more prepared to hear and listen than to just make presentations.
Tuesday, October 13, 2009
I had previously reported that at Giants:
Giant brand normal white Thai Fragrant Rice was retailing at $1.83/kg
They had a hermetically sealed brown rice 5kg @ 11.95 ($2.39/kg)
At Cold Storage:
Song He "Healthy Rice" 2.5kg @ $7.30 ($2.92/kg)
New Moon Red Cargo Rice 2kg @ $4.95 ($2.47/kg)
Paddy King Red Cargo Rice 1kg @ $3.30 ($3.30/kg)
Paddy King Mixed rice (20% red/brown rice) 2.5kg @ 7.75 ($3.10/kg)
NTUC Thai Red Unpolished Rice 2.5kg @ $5.65 ($2.26/kg)
NTUC Thai Brown Unpolished Rice 2.5kg @ $5.15 ($2.06/kg)
NTUC Thai Healthy Rice (20% red/brown rice) 2.5kg @ $5.65 ($2.26/kg)
One thing to note is the amount of mislabelling that occured for the rice on the shelves. Whole grain does not refer to whole grain as we understand it to be, i.e. the unmilled hulled rice grains. What is labelled as whole grain rice apparently means the polished rice grains are unbroken and therefore 'whole'. The biggest culprits for this mislabelling is actually the NTUC brand. The hulled rice is called at NTUC, unpolished rice.
Oh yes, while looking I also scoured the shelves for hulled barley, being the whole grain equivalent for barley. They do not exist on the shelves.
"The HDB owes affected residents a duty to thoroughly evaluate the impact of such change of use on the character and quality of life in the community in question. Although not legally obliged to do so, the HDB should consider polling the views of affected residents now that it has become clear that this issue is certainly no storm in a teacup.
The authorities should be mindful of an important factor not usually captured in land use consideration: Our collective memory. Buildings and other physical structures are an important anchor for a young people like us; to many Singaporeans, the humble wet market is an important part of that memory."
This is in contrast to the recent Straits Times editorial which argued for letting market forces determine the fate of wet markets.
Wet markets are part of the life of the community, and they cannot be allowed to live or die purely through market forces. They are really no different from considerations of whether the HDB estate requires a park, or a playing field/swimming pool. If these are forced to meet bottom line considerations we would not have any parks or sports facilities.
Likewise, the wet market.
So my plea to the HDB and the Town Councils is, "Please Sir, let them be!".
And to the residents, please go to your respective Town Councils and let them know your sentiments about the impending doom of the wet markets.
Monday, October 12, 2009
I want to go further and suggest that medical ethics is not just limited to what is being discussed within the profession. Medical ethics, like all other kind of ethic practice and concepts belong to the community and has to be shaped by community values. It is therefore vital that the discussion of medical ethics, whether it be related to organ trading, euthanasia or the over-prescriptions of slimming pills, must occur in the public domain and not restricted to hallowed hallways, and hospital meet rooms.
Here's my plea to the medical community, and to those involved in some way or other in the deliberations about contentious issues.... come out into the public space. Let your discussions be public so that the community can learn and therefore contribute to this process. There is nothing to be afraid of, because public discussions can only enrich the process.
Singaporeans are "used to" working in an environment where the goalposts keep changing. Progress, she is called. After all we live in a rapidly changing environment where targets are non-static. Change or stagnate. In Singapore, any change is implemented so that targets are achieved yesterday.
At about this time last year, the NTU embarked on a large scale review of her staff contracts. Many saw it as a culling exercise. The university's mission had morphed from a teaching heavy one to a focus on leading edge research. So the goal posts moved. And in the process, a large cohort of academics who had given the best years of their lives, and had served the teaching mission faithfully were unceremoniously booted out.
More recently there was the problem about the maths paper in PSLE. A last minute change to allow calculators resulted in a flurry of complaints from concerned parents. Not a real problem here except that Gigamole couldn't see why the goalposts had to be moved. Was it not something that could have been implemented the following year so that the students would not be surprised by the changed location of their goalposts? Was it so urgent a mission that one could callously disregard students' anxieties? Apparently so.
Then today, the new residency programme for the training of medical specialists was outed. Nothing new here, as this has been the hot topic in medical blogs, and has caused immeasurable angst among medical students. But this was really a problem of moving goalposts. Students shouldn't be so upset. This is Singapore. And goalposts change here. Frequently. We know it was done as a last minute scramble to match the graduating class from Dukes-NUS. The question was 'wasn't this anticipated?' Didn't management figure out Dukes-NUS was about to graduate and usher in the residency programme? I figure they had about 4 years heads-up on this. But the goalposts changed at the 11th hour as if the problem developed overnight. One must question, why? Why?
Please don't get me wrong. I am all for change, for dynamism. No problem for me if management wants to move their targets. After all the world is not sitting still. But what is good for management is not necessarily good for staff or students. I believe management is getting away with much of this because, the management style is very much top down. Can staff complain? Not really. Can students protest? Not really? What happens usually? Management issues some bland unsatisfactory statement to gloss over the issue, citing how we need to remain top of ranking, or how we are on the way to performance excellence and everyone quietly swallows the bitter pill. But the bitterness remains.
Effective. Progressive. And scores a lot of points with the man upstairs looking at metrics. But cold, uncaring and soul-less.
Management should be aware that there is a limit to how much of this shifting goalposts angst people can absorb. At some point in time, a price will have to be paid in worker's satisfaction, or student's loyalties. There is a limit to how much one can continue to depend on imported talent to replace disenfranchised citizens. At some point in time management will need to count on its own citizenry to staff the hospitals, and to look after our own. Then by that time, there might be no one left.
Friday, October 9, 2009
I see a paediatrician I know, and some old contacts from the university. He is waiting for his wife, so I know she has been in much earlier than me. Then there's that couple from church, who are trying to get their marketing done before morning service.
The fishmonger yells something at me, but I ignore him. The stalls round the back are much better. I avoid the vegetable stall I used to frequent. I stopped going there when the brother took over the stall after their mother passed away from diabetes. They had a falling out and he brutally pushed her out of the business. I go to the other stall now. Also they have a wider range of vegetables. I used to buy some breakfast soya bean for the vegetable lady because she once told me she didn't have a chance to grab breakfast. The pork lady greets me but I tell her I don't need any this week. Once I used to call them auntie. Now the seniority is reversed. It used to irk me, but I kinda enjoy it now.
The wet market is a strange thing. I think it is our equivalent of the village square. The community meets, says hello and move on with their lives. It's a reference point for their week.
I don't believe the wet market produce is necessarily cheaper than the supermarkets. They may provide a better freshness for the money spent. But for me, those are not the issues. For me, it's the life of the community it represents. I don't begrudge the extra dollar the fruit woman makes, nor that I can get cheaper prawns at Giant's down the road. These are ordinary folks making an honest living. They work hard, and like us, they do need to put their children through schools, and pay their hospital bills.
I feel privileged to intersect my life with theirs on that precious occasion when I wander down to the wet market. I get to know of their pains and struggles. Their domestic politics. Their joy when one of their sons graduate from university. Their anxieties when one gets called up to national service. Or fails an exam.
We lose our wet markets at a cost to our soul. This is not something the supermarket can replace.
The gahment would be wise to heed the concerns of the people on this particular issue.
And I am asking myself if the Ministry of Education's expectations for this examination for Primary 6 students are realistic, or not? For goodness' sake, these are barely 12 year old kids.
An example of a question that stumped many was something like this:
"Jim bought some chocolates and gave half of it to Ken. Ken bought some sweets and gave half of it to Jim. Jim ate 12 sweets and Ken ate 18 chocolates. The ratio of Jim's sweets to chocolates became 1:7 and the ratio of Ken's sweets to chocolates became 1:4. How many sweets did Ken buy?"
I didn't even bother to try it....certainly not before my morning 'teh see'. Not sure if the question was correctly reproduced, but it seemed to me that someone couldn't make the distinction between buying, possessing and eating.
Wednesday, October 7, 2009
Methinks this is not a food borne disease. Because if it were, the clusters would have been obvious by now, and the AVA would be running all over the place making a great show of catching rats. But everything's quiet at the moment. So to my reckoning this must a diarrhoeal disease caused by some other pathogen....an airborne virus perhaps?
Once we start thinking along those lines, one of the likely candidates, especially of recent importance, is the H1N1 virus. The novel H1N1 virus has been reported to be capable, more so than seasonal flu, of causing diarrhoea, and I can't help wondering if perhaps this 'epidemic' of diarrhoea is somehow related to the H1N1 virus. Perhaps it has somehow attentuated to just produce gastrointestinal symptoms.
Just some speculations, but I think, may be worth considering. I wonder if anyone has bothered to assay the virus in these doarrhoea cases.
Tuesday, October 6, 2009
Now there's no disputing the healthiness of eating whole grain, but where on earth do you find it? I went searching for it in Giant supermarket... and found red unpolished rice hanging pathetically where the small packets of barley hung. At $0.83 for a 300gm pack. That works out approximately $2.80 per kilo. And if I were going to feed my family for a month I would have to carry home about 20 packs.
Next went to where the sacked rice were. And among the piles of rice (huge range!!) there, I found only one variety of hermetically sealed brown rice retailing at $11.95 for a 5kg bag. Hermetically sealed?? My calculator went click-click-click and I figured that worked out to approximately $2.40 per kilo. Not too far from it, the housebrand perfumed Thai rice was on offer at 18.30 for a 10kg sack. Only 2 clicks this time....and I worked it out to be $1.83 per kilo.
Not easy to find this brown rice! And it seems that wretched rule of market place was working.... you know, the one that says the less you process the food stuff, the more expensive it gets. So unpolished rice costs approximately 60 cents per kilo more than the conventional white rice.
Then another thing I discovered.... ( I did wonder why the rice was hermetically sealed)... and that is unpolished rice has a short shelf life as it tends to go rancid. Some suggest that the rice be stored in the freezer. Duhhhh.....there is no way I was going to stuff a 5 kg sack of rice into my freezer!!
I guess it's down to buying small packs of unpolished rice ... no more 10kg sacks!
So eat healthy is going to cost ... both in times of $$ and time.
I must say that the letters, while trying to defend doctors against the perceived injustice, really themselves presented a very negative image of doctors. I think their crocodile tears have done more to hurt doctors than the article themselves.
How can I say that?
Well, in neither of the letters do the authors deny that over prescribing of slimming pills were a common practice. They referred to Subutex and benzodiazepines, but these were not the slimming pills in question. Ms Khalik in her article had reported that her svelte colleague did not have difficulty in finding doctors who readily prescribed her slimming pills. Although anecdotal, this would suggest that it was a common practice. Why would a doctor prescribe slimming pills to a svelte young lady other then to make money? Unethical? Most definitely. Such unprofessional practice should be regulated by the profession itself.... why insist that legislation is required?
Yet neither Presidents offered a solution to this problem. Neither would acknowledge that it is a problem.
I would rather the medical profession self regulates such bad practices, but the tone of the letters disappointingly suggests that neither the Association not the College of FM (and likely the Medical Council as well) will proactively deal with the problem. So what can one make of the profession?
It is of course unfair to tarnish the reputation of the profession because of a few black sheep, but here are indications that this is a more wide spread problem than just involving a few melanotic herbivores. The apathy of the professional bodies is quite telling. Perhaps the solution is not about decoupling consultations and dispensing, but their nexus in GP clinics does create the setting for a major conflict of interest that does not acting in the patient/consumer's favor. Pretending the problem does not exist doesn't make it go away. Doctors should know better.
My plea to my professional sibs is this: Do something about it and swallow the bitter pill before something more unpleasant gets forced down our throats.
Monday, October 5, 2009
The speed at which. time just whizzes by never ceases to amaze me. Kinda depressing actually. But it's been a year since Gigamole took the first tentative steps to becoming a blogger.
I never really thought I'd last a year. But here I am, 1 year old, and with 297 posts under my belt. How did find so many things to yak about? Who would have thought that my ramblings and rants would drag in 35,000 visitors in the first year.
So happy birthday Gigs. And many thanks to all my supporters out there.
Friday, October 2, 2009
Bright moon, when was your birth?
Wine cup in hand, I ask the deep blue sky;
not knowing what year it is tonight
in those celestial palaces on high.
I long to fly back on the wind,
yet dread those crystal towers, those courts of jade,
Freezing to death among those icy heights!
Instead I rise to dance with my pale shadow;
better off, after all, in the world of men.
Rounding the red pavilion,
stooping to look through gauze windows,
she shines on the sleepless.
The moon should know no sadness;
why, then, is she always full when dear ones are parted?
For men the grief of parting, joy of reunion,
just as the moon wanes and waxes, is bright or dim:
Always some flaw - and so it has been since of old.
My one wish for you, is long life
And a share in this loveliness far, far away!
Tuesday, September 29, 2009
I have posted on the HPV vaccine before. HSA had ahead of the FDA approved the vaccine for girls/women between the ages of 9-26. The discussion then had been the off label use of the vaccine for women outside of this age range.
This latest fatal adverse event will make a signficant dent in GSK's attempt to compete with the Merck vaccine. The GSk vaccine apparently induces a stronger response because it containsthe controversial suqalene adjuvant AS03. Unlike the Merck vaccine which covers 4 strains, the GSK product covers only 2.
This is really not a new issue. From time to time, this gets surfaced.... the MOH suggestively indicates that we can change.... meets a brick wall of resistance, then it's back to status quo.
www.GeraldTan.com has done us the kindness of logging some of these public dicussions all the way through from 2005-7.
For me a number of things are obvious....
a] There is an enormous professional conflict of interest when doctors make money from dispensing. This is without doubt. The Singapore Medical Association, in all its protestations have never disputed that reality. I am not sure what the average proportion of a GP's revenue come from dispensing, but it must be substantial.
Given this conflict of interest, the burden of responsibility must naturally fall upon the shoulders of the profession to explain how the patient/consumer can know if the best and most cost-effective drug solution is being prescribed. I don't want to suggest how often this occurs, and it may well be limited to the practices of a few bad-hats, but it is clear that over-prescribing and inappropriate prescribing are certainly practices which litter the medical landscape.
b] The only real defence for maintaining the system is 'patient convenience'.
This controversy, to my mind, can be easily resolved if only the Singapore Medical Association can bring itself to face up to the reality that there is a real conflict of interest. There is nothing intrinsically wrong in GP clinics wanting to meet their bottom line, and for doctors to bring home the bacon. But the lack of separation between the doctor's role from that of a money-making dispenser potentially compromises the doctor's objectivity in prescribing. I think it would certainly allow the journalists at SPH (and me too) sleep a lot easier if the SMA itself devices a strategy to deconflict the situation instead of pretending the problem doesn't exist.
One such solution might be to financially decouple without physically separating the two functions. Make clinics lease out the dispensing space to a bona fide dispenser and make it illegal for doctor/proprietors to make money from the dispensing rights. This will remove the financial incentives that compromise medical objectivity, without taking away the patient's convenience of receiving their medicines at the clinics.