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.

Taming doctors' greed....?

Salma Khalik continues the doctor bashing in today's Straits Times with a report entitled "Tame doctors' greed and protect patients", essentially addressing the GPs' greedy right to make money through dispensing of medications. Hmmmm........

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.