Tuesday, October 6, 2009

Forgiving our transgressors

There were two letters in today's Straits Times forum page. One from the President of the Singapore Medical Association and the other from the President and Council of the College of Family Physicians, about the recent comments Salma Khalik made about greedy doctors. Both decried the perceived unfair criticism of doctors. One even suggested that Ms Khalik's article was 'callous and unpatriotic'. huh??

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.


angry doc said...

Well, once again I agree with you. It's sad to see that the two presidents reacted so defensively to what was to me a fair and factual article.

JW said...

Well I don't agree. I thank the 2 presidents for standing up for the rest of us. It's easy to comment. Why don't give positive critcism and come up with some ideas if you have them. How do you suggest regining in these black sheeps? Self regulation does not work, if the problem is big enough and serious enough then legislate it. As Dr Chong said, some of the BZD has been suggested to the authority to be put into the category of controlled drugs which I also agree. Self regulation for these kind of things DO NOT work. We can talk and debate about moral bearings of the doctor and not ethical and what not. At the end of the day, the doctor or business has to survive but hopefully not from these type of dealings but thru good proper medical care and be paid accordingly.

There is already an SMA complain department and SMC. Any TOM DICK or HARRY can just post a 25 cent stamp and send it to SMA to complain and the poor doctor will already be in hot soup! Those doctors who are doing these things are either not aware of the consequences or damn daring or foolish. So for those daring/foolish ones, legislate it and see if they dare to cross that boundary- good luck to him as he will have no sympathy from the rest of the medical community.

The presidents did not deny that some doctors do it. But to use the word "Greedy" that's disgusting and tasteless. Why don't we call the Press "Blood Suckers" since they love to GP bash to sensationalise their story to boost readership.

I say well done Prof Goh and Dr Chong. Give it to her (Salma Khalik) We are no punching bags.

We ain't shedding "crocodile tears". I personally find your article pointless
"Both decried the perceived unfair criticism of doctors. One even suggested that Ms Khalik's article was 'callous and unpatriotic'. huh??" If you are our "professional sibs". Please think before you write. There are many good doctors trying to maintain and repair the damage done by the black sheeps and we surely do not need someone like you to add fuel to fire. If have any positive/helpful points to help the profession, DO IT. Don't go bashing it somemore.

gigamole said...

What I can't wrap my mind around is that, although Salma Khalik's article pointed out a professional problem with respect to the over-prescription of slimming pills. (And yes, she did sensationalize it somewhat). But all some members of the profession can see is how unfair her comments were, and the hurt it causes the practitioners and the profession.

Anyone interested in rectifying the problem, rather than shooting the messenger?

And old acquaintance said...

I think many doctors have discussed this before. I remember discussing with angry doc a few years ago.

One way is of course to separate dispensing and prescription as Ms Khalik has been clamoring for some time.

But then there is no guarantee that the problem will be nipped in the bud. As it is, is the problem a widespread one where the majority are not prescribing responsibly? Or is it a small number who are doing it on a large scale?

Wholesale separation of dispensing and prescribing also takes away the many advantages that patients enjoy at present (convenience, efficiency among others).

Some have suggested applying the separation rule only to drugs that have high abuse potential eg BDZs, Subutez, Codeine based syrups, Phentermine.

This would make it more difficult for doctors to profit from prescribing those drugs but yet allow patients convenience when they have need for other drugs eg chronic meds, antibiotics etc

It has been suggested to MOH but so far we have received no response from the authorities.

The important point we have to note is whether the Salma Khalik's comments actually apply to the majority of GPs. The tone of her article suggests this is so. And to have headlines suggesting GPs are greedy as a whole may be slander if it is indeed untrue.

To put things in perspective, if one day we found a few MPs from the PAP to be involved in some cheating scam, would it be right to have a headline screaming "Greedy PAP?"

I sincerely doubt so.

Don't sensationalize for the sake of it. The majority of doctors are nice honest people who try very hard to serve the public. Don't take advantage of their track record of reticence and use them as easy targets for sensational stories to sell more newspapers.

angry doc said...

Well, if you agree that criticising doctors is "unpatriotic"...

Anyway, I don't see how stopping doctors from running pharmacies will be the end of the world.

If doctors are prevented from making money through selling medicines, they will have to raise their consultation fees to a decent level. All of them will have to do so to survive, so you won't have to worry about your neighbour charging the same old $8 consult because he will soon be out of business. You can still charge $20 per consult, because everyone else will have to too.

As for convenience, if doctors are prevented from running pharmacies, someone will swoop in and open 24hour pharmacies staffed by pharmacists round the clock because there is money to be made.

Sure it will be more expensive overall and less convenient, but people won't start dying on the streets just because we changed the system. If patients have to pay more for healthcare then they had better remember that the next time they are about to buy a pack of cigarettes, a bottle of beer, a tub of ice cream, or even book that trip to Perth for the year-end holiday.

If health is priceless, they they had better be prepared to pay for it.

JW said...

You still don't get it do you? You are not just a messenger. You blog and the public can read what you write. Furthermore you are of the same profession. I don't ask of you to protect your own kind. Those that deserve to be whip should be whipped. But think before you type. You gave your opinion, hence you are not just a messenger. The article you wrote does leave a bitter taste in most doctors I would imagine. It also shows little or no research into the topic or the understanding of the dynamics between the press and the medical farternity.

I hold Prof Goh L G in the highest esteem, and you writing this piece is downright degrading. Remember you are not just a messenger. If you are then don't give opinions. If you want to give opinions then give useful opinions. If you don't already know it, the bond between the public and the doctor is a fragile thing which most doctors appreciate and work hard in maintaining. As I have said before, don't add fuel to fire. Good luck with your blog.

angry doc said...

As for the matter of policing Gigamole and I disagree fundamentally on who should do it. (All the way from since the honeymoon period when we used to disagree on almost *every* topic...)

G believes that we should police our own, while I believe that to have the SMC play police, prosecutor, judge, jury and executioner runs dangerously close to making the medical profession a police state.

I say by all means let the ministry, HSA, or even some NGO with Salma Khalik as their patron do the policing and reporting, and even prosecuting; as long as the judges are doctors I think we can expect a fair trial.

Do it the other way round and you will have doctors feeding their competitors into a Khangaroo court...

angry doc said...

She meant we shouldn't dismiss the message of the article (some doctors are prescribing slimming pills inappropriately) just because Salma Khalik wrote it, JW.

I respect Prof Goh too, but that doesn't stop me from criticising his position when I think it is wrong. If you agree with Prof Goh, perhaps you can point out to me exactly which sentences in Salma Khalik's article is "unfair reporting".

JW said...

Angry Doc, do you run your own practice? If you don't, you have no idea what you are talking about.

If you take away dispensing from the clinic, you will get a RIOT, not from the doctors but from the PATIENTS!! They have comfortably been paying 20+ to 30+ to see their family physician in the most convenient settings. Don't have to go to another place and Q to get his medications in his sick state. Worrying if the pharmacy stocks that particular medicine. Worry if the medicine works (not all generic medications have the same potency or efficacy). I think the health minister knows that. Try suggesting removing dispensing right from the GPs to him and see what he says. I seriously don't mind as I already charge $20 to $30 for consultation.

Most of us are already charging as minimum as possible to keep our clinic going and be able to bring back a decent amount to feed our own family. An amount that is approved by his patient who thinks he is worth that much and is reasonable.

"If health is priceless, they they had better be prepared to pay for it." my my my this is really an obnoxious statement. Most of us GPs value our patients as friends too, and many of us try to get the best value one can get from the healthcare system in Singapore. We try to help them save if possible, go thru polyclinic for those in financial needs, even waive, give discount or IOUs to patients who can't afford, close one eye or even 2 eyes sometime when they can't pay.

Anonymous said...

angry doc,

Are you a GP?

Having read many of Salma Khalik's articles, I find that she is usually attacking GPs.

Hence maybe doctors who are not GPs don't feel it as much.

Personally I know that many specialists themselves are pretty condescending when it comes to their colleagues who are GPs.

Perhaps that is one of the underlying problems. Things run deeper than just Salma Khalik. Within the family their is mistrust and hate.

gigamole said...

Let me just make very clear that I have no problems personally re the two Presidents, and I held them in very high regard. I too, have a great deal of respect for Prof Goh and the work he's been doing over the years. And that is why I criticized the letters but never the letter writer.

Again it seems (and perhaps the historical baggage may provide some justification) that this whole issue has been portrayed too much as a battle between journalism and the medical profession. I don't think it is, and I don't think it should.

Does anyone deny that there is an over-prescribing of slimming pills, and that providing slimming pills to a svelte young lady with no real weight problem is not quite the correct thing to do? Why is it wrong for a journalist to point that out?
I am not against GPs, and I have many friends and classmates who are wonderful GPs, all doing fantastic work. But this does not mean I have bite my tongue when something is obviously not right.

The solution is not to immediately ring-fence the profession and develop this seige mentality that the profession is somehow under attack, from without, and now from within (people like myself). But perhaps to take a hard look at whether there is any truth in the allegations that Ms Khalik made, and try and understand where these (mis)perceptions are emerging from, and then perhaps as a profession we can then show that we are a bunch of responsible and caring professionals, who care enough to want to put peer pressures to bear on maintaining professional standards.

angry doc said...

Riot? Wouldn't that be... "unpatriotic"?

Seeing as it is how many riots we get in Singapore every day, we certainly shouldn't take dispensing from clinics and risk another one, should we?

I stand by what I wrote about healthcare costs, JW. In fact, I think your kind of mindset - that healthcare is something to stinge on - distorts the value of healthcare and is ultimately more destructive to the system.

Anonymous said...

Why would a doctor prescribe slimming pills to a svelte young lady other then to make money?

Cause patient demand to look good
Some are cabin crew who will be sacked if they dont look slim
BMI 25 is overweight for Asians.

I agree that we should not prescribe long term, what is wrong with prescribing short term for weight loss and then maintain the weight?

JW said...

"In fact, I think your kind of mindset - that healthcare is something to stinge on - distorts the value of healthcare and is ultimately more destructive to the system."

allo angry doc,

read carefully....I charge 20-30 for consult not 8 ok. People who see me don't stinge on their healthcare. Those who stinge go to 8 clinic already.

Its not about stinging or not. Not everyone is born with a silver spoon? Are you?

Those who can't afford I try to help them get the best value for what they can get in their current situation.

JW said...

If you have been in this field long enough or a GP long enough, you will probably have a feel of the emotional baggage. Your views are simplistic and idealistic. Maybe as the years go by you would probably feel it too.

I am not asking you to bite your tongue. Just think before you type. There are good doctors trying their damn best to practice good medicine and when the two presidents come to clarify things, give workable solutions rather than just criticise. Its always easy to criticise, but it takes a true leader to have the gut to face the media/public and uphold the image of the profession. Again don't go add fuel to fire, be part of the solution if you really want to help your own profession.

Anyway good luck with your blog. I won't be returning any time soon. Got a family to take care of with the limited time one has everyday.

gigamole said...

Simplistic and idealistic? Perhaps so, JW. But we need to establish some clarity about where the lines are. I am not running down the profession, just disappointed that she seems more concerned about her hurt feelings, than trying to find a solution.

As always we can agree to disagree....I believe we all want essentially the same thing. Just that I believe the profession and her standing is best served by holding on to high standards, simplistic and idealistic though they may be.

I will post some more thoughts on this issue as you have suggested, but later tonight, after I have seen to the family dinner and other family needs. Like you, those needs leave little time for luxuries such as blogging... :)

Cheers JW, and thanks for dropping by.