The patient-doctor relationship - a relationship between unequals

Today's Straits Times carried an interesting report of  contest in a coroner's court between a mother who is a nurse, and a surgeon. The mother, who had lost her daughter in a liver transplant contended the surgeon provided sub-standard care because she had a spat with the surgeon earlier.

She did not convince the coroner. However, the case highlighted the inherently unequal relationship that exists between a patient (and relatives) and the doctor. Here, every patient is in essentially a subordinated position, and generally hesitant to offend the attending physician/surgeon. This is generally the case, unless the relationship is based on a completely elective and unnecessary procedure, when a more commercial/contractual relationship may apply.

This is why I am concerned about how the physician/surgeon goes about taking consent for procedures. Often the consent is taken by the care giver. In this case, the patient is often afraid of offending the doctor. This unequal relationship very clearly does not create the circumstance when a truly voluntary consent can be obtained. This ethical lapse, also applies to the situation when consent is being sought for participation in a experimental procedure or clinical trial when the researcher or care giver is himself/herself the one administering the informed consent.

The more academic hospitals compound the problem further by expecting patients on admission to consent to giving up rights to tissues and genetic material for research purposes. This consent is often taken at most inappropriate times when the patient and his/her relatives are most dependent and submissive.

The hospital ethics committees applying their very utilitarian logic, obviously do not disapprove of these ethical lapses.

Returning Singapore to Singaporeans? Dare we wish?

It is hard to feel betrayed. Gigamole says 'feel' because that is what it is, only a feeling. Gigamole can understand the logic of our political leaders, and I don't think they had any real malice in the decisions they took. But Gigamole thinks they were misguided, and Gigamole, like many others, feel betrayed.

Mind you, Gigamole was one of those who stood in the rain for the first National Day parade. And Gigamole was one of those who dug into pocket money to give to the Singapore National Defence Fund.

Whether it is about birth rates, education or academic achievements, where we are now, and who we are is a result of policies in place during the early years of nationhood. Until the 1980s, the thinking about university education was that we were training too many graduates. University education was seen to be an 'evil' contributing to frustrations and social discontent. The university was deliberately kept small. We were producing too many doctors. Not good, because doctors were woolly headed and bleeding hearted.

Gigamole remembers that medical research was regarded as a 'luxury'. Research funding was only available to allow medical scientists to 'tickle' their minds and keep them interested in their science. Gigamole remembers how we all had to troop, hat in hand, to the Singapore Turf Club to ask for a small sum of money to do some research.

What a turn around in the 1980s when the university began to expand, and research became a much sought after activity. In the years that followed, Gigamole has seen hard working colleagues given the boot because they did not have the research track record that was comparable to academics from developed countries who had spent a lifetime doing research. Foreign talent they were called.

Since then or universities and research establishments have turned into wonderful performing whale-ariums populated by non- Singaporeans. Mind you, Gigamole is not against foreign talent. Just that it has become too easy a solution to rent (not buy, mind you) performing whales in order to vicariously capture research glory. It is really no different from buying Olympic gold medals on Ebay. Now almost every department in the Universities and Research Institutes are headed and staffed by non-Singaporeans. It looks fantastic on paper, but only on paper. The reality is that the local content has been severely hollowed out. To make matters worse, the current crop of 'foreign talent' mostly do not want to teach, and do not engage in any technology transfer. The Nanyang Technological University, for example, under their Swedish President, is fast becoming a totally foreign university, desperately trying to catch up with the NUS in glbal ranking. The Lee Kong Chian Medical School with their Deanery imported from Imperial College, London, seems engaged in political struggle with the more indigenous Tan Tock Seng Hospital for pre-eminence. No prizes for guessing who is backed by higher forces, and who will eventually win.

Even the student population appears to have been done in. Gigamole has often wondered about the logic of building so many elitist universities, that our own Singaporean children have no choice but to venture overseas if they want a university education.

So Gigamole is not happy. Gigamole can't help feeling betrayed.

The bathtub effect? A Singapore problem.

When Transport Minister Lui Tuck Yew was recently pressed on why newer train systems were breaking down, he attributed this to the "bathtub effect". This is a cutesy metaphor that engineers like to use to give the impression that they have a human side, and that they do take baths.... sometimes. Essentially the metaphor refers to the high frequency of breakdowns in machines early during installation, and then again much later in its life cycle. The breakdown frequencies show a bathtub shaped curve.

The early breakdowns are usually due to the operator being relatively naive. The later breakdowns are due to the expected wear and tear when the machine nears the end of its lifecycle.

By referring to the bathtub effect, Minister Lui is essentially telling us that the SMRT had synced the train systems so well that the old system was failing at the same time as the new ones were. The sides of the two bathtubs were in perfect alignment. Well done, guys! You were precise about this, at least.

There is actually another interpretation of the bathtub effect. This is a metaphor used more by environmental scientists. Essentially here, the bathtub represents that container where the water level is determined by the rate of water flowing in and the rate of water draining from it.

The ENV people know this very well as this is the cause of the frequent 'ponding' observed in recent times, during heavy rainfall.

This is actually a more important interpretation of the bathtub effect, because it explains so many of the problems we see in Singapore nowadays. So much of the Singaporean angst, whether it is about housing, transport, healthcare or education is really about the water level in the bathtub. The capacity of these systems are woefully inadequate compared to the demand. So the water overflows from the bathtub.

One can't help wondering why this is so. Considering the 'excellence' of our civil service and that the government has had uninterrupted power for such a long time, it seems a critical neglect that they have gotten the models all so screwed up. Why they did not anticipate the rate of population growth and did not build enough capacity to cater for this growth, I simply cannot understand. Was it because all these scholars were so blind that they did not see the threat of overflow? Or was it that they were all only concerned about short term KPIs? Let the bathtub overflow on someone else's watch! 

So much for a government that claims credit for long term planning. So, thank you Minister Lui for sharing with us this important metaphor. Now we understand why the bathwater is ponding all over the living room floor.

Was the valve used in National Heart Centre operation approved as a medical device?

While the HSA was conducting their briefing about how they were going to tweak the regulatory processes for low risk devices, we have this bit of exciting news about the groundbreaking operation done at the National Heart Centre.

Exciting because it was the first such operation done in Asia. Essentially, the operation was a minimally invasive insertion of a bioprosthetic (cow tissue in steel) valve to correct for a mitral valve failure. The valve-in-valve design was developed in 2007 when it first underwent clinical studies. In November last year the Edwards SAPIEN valve received a much heralded approval from the FDA. But here is where there is a bit of problem. The FDA approval was only for the use of the valve for aortic valve stenosis, not for correction of the mitral valve. And only in patients who are too ill for open heart surgery. In fact the US FDA had made a note in its approval that the valvular operation, even for aortic stenosis was not without problem - patients had 3 times more chance of developing a stroke.  But there had been no similar FDA approval for a modified valve for mitral valvular disease. Gigamole is not sure if any major regulatory agencies have approved the mitral version of the valve, let alone the HSA.

So here are Gigamole's questions:

a] Did the FDA approve the mitral valve-in-valve as a medical device?
b] Did any regulatory agency world wide approve the mitral valve-in-valve medical device?
c] Did the HSA approve the mitral valve-in-valve medical device?  And if so, on what grounds? If not, what was the approval process for surgeons at the National Heart Centre to go ahead and operate using an FDA and HSA unapproved medical device?

Please do not mistake my questions as being anti-innovation and anti-progress. Devices such as this valve-in-valve device needs to be properly evaluated in terms of risk benefits before use. The aortic version was studied since 2007 before it was approved by the FDA. Although the valve had been modified for mitral valve use also in 2007, this never received the same warm response, and as far as Gigamole is aware, the FDA in its wisdom never gave approval for the mitral valve version. Treating the mitral valve is not as straightforward on terms of risk-benefit assessments as for aortic stenosis. To those who advocate that we blindly follow the FDA's approval must also accept that we should also take guidance from the FDA's tardiness in approving this procedure.

The Singapore Medical Council Physician's Pledge - What motivates doctors nowadays?

Pointing the finger at the SMRT for their Freudian slip prodded me to think about what motivates our doctors nowadays. Or at least what should motivate our doctors nowadays.

It seems to me that many doctors nowadays are quite happy to regard their practice as a business. Quite understandably so since every other aspect of health care has become such a business. Ever since the mid 1980s in Singapore, when Medicine became defined as one of the pillars of our economic growth, the practice of medicine has become increasingly premised upon a business-like quid pro quo relationship between doctors and patients.

Yet the very ethos of Medicine is not built upon any kind of a business model. In fact the Hippocratic traditions de-emphasized the rights (pecuniary or otherwise) of the physician and instead focused on the duties of the physician. The Hippocratic Oath was really all about the duties of the physician. Likewise, our SMC Physician's Pledge is heavy on duties and does not even mention payments for services rendered.

In fact the very first line of the Pledge reads: "I solemnly pledge to dedicate my life to the service of humanity". Some will of course argue that this is wholly unrealistic, and that doctors do have to make a living, and perhaps even to live in the lap of luxury. But they forget that this was the pledge they took. Theirs was to dedicate their life to the service of humanity. If this was unrealistic, perhaps they should not have taken the pledge.

The great Canadian physician Sir William Osler, made it equally clear - “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.”

In today's world, this calling is so easily brushed aside in favour of the allure of "Income Opportunities". I do not mean to belittle the sacrifices of many doctors who do have their hearts in the right place. Indeed there are many of them. Many I have had the privilege of knowing as teachers, friends and colleagues. But I think even they would not disagree that the practice of medicine in Singapore has to a large part, degenerated to a mere trade or business.

What is the purpose of the Physician's Pledge if we are not to take it seriously?

On another note, I wonder why hospital CEOs are not expected to take a similar pledge of service and duty to patients. After all, it is their management performance indicators that compel doctors to behave after a certain fashion. Can we expect a doctor bound in service to a hospital to put the patient's interest first, and disregard the clarion call to seize the hospital's "Income Opportunities"?

Early history of hospitals ... Happy Deepavilli!

Historically the care for the sick tended to occur within temples and other religious establishments. This I believe was largely related to the tendency to associate illness and healing with spiritual events. Thus the early concept of hospitals in Europe was nothing like what we encounter nowadays.

The earliest evidence of a specially constructed facility for the care of sick was apparently in Sri Lanka. This was early as the 3rd to 4th Century BC. According Wikipedia, the Carakasamhita (Compendium of Caraka) and descriptions by the travelling monk Fa Xian, India probably had the first "organized cosmopolitan system of institutionally-based medical provision" in the world. This was approximately at the turn of the first millenium. Europe continued to develop their hospital concept largely as part of the religious establishment, the modern hospital concept seen in Asia and Persia never really took root until the social and civic reforms following the French Revolution.

This perspective is important to have as we look at the continued evolution of health care provision. The usually eurocentric portrayal of medical history tends to convey the fallacious idea that all things good flowed out of Europe. This is only true to a certain extent because of the renaissance and the industrial revolution. But it is important to recognize that that renaissance was deeply rooted in wisdom that had originally flowed westwards from Asia.

This is a good account to read:
Medicine and Society in the Medieval Hospital by Tatjana Buklijaš (2008)

India was very much where the action was in the development of the modern hospital concept. And they were more than half a millenium ahead of Europe.

Nice to know that....especially as we head towards the Deepavalli celebrations.

Happy Deepavalli all!

Black swans in Singapore?

The black swan metaphor was introduced to us by Naseem Nicholas Taleb to describe a high impact outlier phenomenon that no body expects and one that takes everyone by surprise. The recent global recession related to the collapse of Lehman Brothers was such a black swan event. And like all black swans it can be rationalized after the event, when everyone kicks themselves in the backside and wonders why they never recognized it coming.

Although not global in magnitude, there have been a number of black swans seen in Singapore recently. The GE2011 results for example, caught many people in the PAP by surprise. The flooding in Orchard Road was another such event. In retrospect however, these events could have been easily predicted, and now we have the unusual situation where many people in the gahment are kicking themselves wondering how they missed the picture.

Often therefore the black swans are not the result of extra-ordinary events but of a lack of foresight, and the reluctance to think outside of mainstream and traditional ideologies. The GE2011 black swanlette was I believe, very much a consequence the failure to really look at the signs, which in retrospect, was everywhere. There was much reluctance to listen to naysayers, and everyone was happy to fuel the emperor's vanity. The flooding story hasn't quite unfolded fully, but I believe the picture will emerge that the black swan really came about because of the reluctance to deal with changing weather patterns as a result of global warming. There was I believe, too much discomfort in wanting to move outside of traditional models looking at weather and flood patterns. After all, to do so would have been to abandon painstakingly collected historical rainfall and flooding data. Yet the world has changed, and these models need to change as well.

The increasingly recognized hospital "bed-crunch" is perhaps not unlike the flooding black swan. Caught everyone by surprise, did it? What absolute crock! The numbers were there for everyone to see. The population was growing at a phenomenal rate. People were aging. Medical tourism was being encouraged. But no one appeared to want to look seriously at the numbers. Either that or there was an absolutely wrong prioritization of healthcare resources to cater for medical tourism instead of community needs.

Singapore hospital bed crunch....again....and again and again

So Singapore is suffering from a hospital bed crunch? Again? Rightly it has been described as a perennial problem. Dr Jeremy Lim last year alluded to it being a 'systems problem'. Of course it is. Like the floods hitting us nowadays, it is a systems problem. When rainfall exceeds a certain rate, the drains must overflow. Likewise, if there are more patients needing beds than there a beds, there will be a crunch. And patients get to sleep in corridors.

When I was a houseofficer, this was a fairly common occurence during every admitting day.

The question is why has this problem not been solved? It is not as if the problem is unknown. Or cannot be predicted. At least for the flood problem we can always blame the vagaries of weather .... global warming etc. But patient bed demands are fairly predictable through the year. Population growth numbers are very well known...at least to government departments. Surely bed demands can be computed and modelled. To me, a bed crunch is a sad indictment of the lack of MoH resolve in tackling this problem.

There was once a model that promised to deliver at least 80% of capacity for local patients, and only 20% was to be for the servicing of medical tourists. Yet the current figures suggest that medical tourists now occupy 30% of bed capacity. Surely this discrepancy can be modelled and provided for. The problem did not spring up overnight!

Another problem relates to the unbalanced provision of beds. Bed occupancies differ in the different hospitals. SGH and NUH has much lower occupancies than TTSH and CGH, and the latter therefore suffer worse bed crunches. Has the MoH over provided for the premier hospitals and inadequately for those servicing residents.

I think MoH owes us an explanation.

The General Elections - die die also must say

These are interesting times. As some have already pointed out, this elections will prove to be a watershed one. A milestone. Whatever the outcome and no matter how much MM Lee wants to downplay it, I believe the consequences will be immense and the results will significantly shape the Singapore of tomorrow.

I am not a political commentator and generally have stayed away from directly commenting on political issues. Maybe indirectly shoot some arrows, but generally I have been quite content to just grumble from the sidelines. I am generally not a political person. Afterall am I not a happy-happy beneficiary of the stable gahment that has allowed me to be educated and trained to be able to provide for my family as a medical professional? I am comfortably ensconced in Singapore society. What is there to really complain about? When I am overseas, who do you think I root for, and defend when others criticize developments in Singapore?

So the recent outpouring of apparent wrath against the ruling party in this 2011 elections seems a bit of a mystery to me. Has not the gahment of Singapore, achieved wonders in bringing a resourceless Singapore into developed nation status? We are the envy of many around the world. The little red dot is only little on the map; we punch way above our weight in the world. By any measure, we have a fantastic gahment here in Singapore.

Yet people are unhappy. Why? Minister George Yeo, MP for Aljunied accused the opposition for imposing an emotional burden on the voters, yet paradoxically, here lies the true emotional burden - that the electorate must struggle between supporting an otherwise effective gahment, and the feeling of heaviness and dissatisfaction, that somehow things are not as good as the official statistics tell us.

People feel marginalized and neglected. It is not that Singaporeans are xenophobic or hate foreigners, even though the tone of comments expressed during hustings may suggest it. No, Singaporeans are not xenophobic. It is merely the feeling that their own gahment appears to value foreigners more than its own citizenry. This is probably not true, but the perception is very pervasive. This is where I believe, the gahment has failed. It has failed in managing public perceptions and expectations with respect to immigration, foreign labour and economic growth. It is fantastic that our economy and GDP continue to chug along at a healthy rate, but the perception on the ground is that the benefits appear to accrue mostly to the elites and the wealthy in Singapore. The gahment's reach out to the poor, the weak and the marginalized is often grudging and calculative. Paltry sums considering the size of our budget surpluses and national reserves. Can we do more? Of course we can..... and please don't tell me this is tantamount to raiding our national reserves. MM Lee's comments about the elderly working till 85 was supremely insensitive although I don't think he intended it. Choosing to work till you are 85, is really not the same as being compelled to work to survive until 85.

Being in power, unchallenged power, for such a long period of our history has bred a level of complacency so that leaders do not feel that the public needs to understand or seriously discuss issues. The most expedient way of going where you want to go is unfortunately via a top-down dictatorial approach. This approach has been over-used. Has there been enough planning and discussions?.... Not much apparently.

In the biomedical area, this lack of planning and discussions have wreaked real havoc in the system. Take for example, the hospital clusters. We have over a period of 20 years gone through various levels of clustering, and declustering, and now re-clustering. Each Minister that comes along pushes a hobby-horse position. Hardly evidence of long term planning. Medical manpower planning? Hardly any, apparently - because we have flipped-flopped from too many doctors, to the present situation of being desperately short of doctors. Suddenly we require 3 medical schools..... of 3 different educational systems? This is planning? Almost overnight, the US residency programme was foisted upon all and sundry. If there had been any long term planning, it was far from evident. Medical education is now in a mess. We have an undergraduate and a postgraduate system existing side by side. We have flirted with problem-based learning, then discarded it. We have integrated and disintegrated the curriculum. And we have the really bizarre situation where our medical students are not expected to have studied biology. Duh? And we are expected to believe there is someone somewhere who is responsible for planning all this?

No one discusses this publicly because everything is driven from the top. Very heavily driven.

Foreign talent is critically important for us to push towards excellence. But without appropriate signals that policy makers are concerned about protecting the interests of our home grown and local medical/biomedical professionals, one cannot avoid feeling that the economic pie is not really for local consumption. The mass of biomedical and life science graduates and postgraduates we produce annually find it hard to find jobs in the sectors they have trained for, despite the very rapid expansion of the biomedical sector.

Whatever the results of the elections, there is no doubt they will be important. I don't think the PAP will lose the right to govern. But I think it is vital for the ruling elite to recalibrate its way of doing things... to relearn how to communicate with the people it seeks to lead. If they truly believe they are servants of the people, they must make this evident. And stop being just rulers.

Selling off our heritage

Some 5-10 years ago, as if at a given signal we started all this nonsense about naming buildings and institutions after dignitaries and philanthropic donors. Now, I don't really care if they name new (or even old) buildings after people who give lots of money. Nor do I particularly care if they want to name institutions and buildings after local 'heroes' and prominent figures who have contributed much to our nation building. But naming established institutions after people who just give money is, I think, way over the top.

I beilieve the NUS was one of the first to lead the charge. The School of Medicine particularly. I for one, was aghast when heard they named the grand old School of Medicine after a Yong Loo Lin. 'Yong who?' was my first response. How could they? Here was my old alma mater, 100 years old, with a proud heritage.....gone overnight. Morphing unceremoniously into the Yong Loo Lin of Medicine. "Yong-who? School of Medicine?" . No consulation with staff.....or alumni. Talk about a top down approach. Many of my contemporaries had been equally appalled. A heritage sold. No matter how the School of Medicine insists on the continued heritage, there is no doubt it had all been destroyed by the stroke of a pen.

How much was the heritage worth? One hundred million bucks. Sounds big doesn't it? Until you realize how big the annual operating budget for the school is. Let me tell you one hundred million dollars doesn't really go very far. Consider for example, that the NUS operating expenditure is in the range of $1.5 billion.

And so we sold the hundred year heritage for a hundred million dollars. One million for each year. How callous, and tragic (not to even mention that the old original building of the medical school, the female asylum, had much earlier on, been bulldozed over to build a carpark!).

This was most certainly one of the straws that led to the final one for Dr Tan Cheng Bock. He finally resigned in exasperation from the board of Jurong Hospital when they decided to name the hospital after Ng Teng Fong, whose family had also donated some money.... some $125 million of it. Again while the sum may appear big, it is also small compared to the $1 billion the government is spending on the hospital.

So what gives....?

Seems to me that our idea of Total Defence includes the protection our heritage, because it is our heritage that holds us together and gives Singaporeans a sense of that common history and vision for the future. Seems to me that the selling off of our heritage for a paltry 30 pieces of silver is not working in our favour, and undermines all the effort in the building our total defence.

It is time to take stock.

IVF "lapses"

I must say I was disappointed that the MOH could not bring itself to go beyond just identifying "lapses" as being the causes of the error. Though it's kinda expected. It doesn;t say very much. We all know that accidents are due to lapses.

What we want really to find out is why those lapses occured. Was there a systemic problem that increased likelihood of lapses. Were the quality assurance procedures adequate? Were there previous audit findings that were not remedied? Were weaknesses in the system identified before but left unattended to for too long?

Human error can often be the consequence of systemic failures.

Islamic contributions to medicine

It is easy in today's world, especially when anything Islamic is receiving such bad press, to forget how important the Islamic civilization was in the development of modern medicine. While medieval Europe languished in darkness, it was the Islamic civilization that carried the torch for medical education, research and practice.

While we look to Hippocrates as a 'father of medicine', it was probably ibn Sina (Avicenna) who should best be regarded as the 'father of modern medicine'. But sadly, we remember Hippocrates and too readily forget ibn Sina.

Few also realize that the idea of hospitals ( although the word derives from the hospices of medieval Europe), was most likely copied in idea and design from the Islamic centres of excellence. There was licensing of physicians and the hospitals were sophisticated, well organized institutions that were way in advance of what Europe had. It was probably the returning Crusaders who brought some of these ideas back to Europe.

The practice of medicine was held to a much higher standard of ethics than was in Europe. The treatise by Adab al-Tabib (Conduct of a Physician) is well known, though not by those of us with a narrow European perspective of medicine.

He writes:
'If the patient and the one who serves him understand, then the physician describes the remedies to them and allows them to go on with the therapy If it is not understood, then he must, with his own hands, undertake the treatment that is necessary; he (i.e. the physician) does not explain anything to (the patient). In maintaining silence as to the diagnosis for one who would not understand, in case of error, it is better for the patient and for the physician. After he has completed the visit to his patient he must return to the above mentioned office to treat any of the patients and to understand the problems.'

'The physician must better his relationship to and endure the distress of the patients. He must pay attention to any statement heard from them. No matter what the circumstances, he must acquire information from anywhere or anything which may prove beneficial to the recovery of the patient. The physician must not discourage any complaints of the patient or display of his distress since these symptoms which occur may be important in the diagnosis of the illness. The physician must show mercy; this is not possible except by the fear of God. If the physician has these traits, then he speaks only the truth and does good for all the people.'

We can definitely learn more than a thing or two from the Islamic civilization.

Obesity - a KPI? How silly can you get?

Mr Liak Teng Lit, CEO of Alexandra Hospital and the coming Khoo Teck Puat Hospital was reported as saying "....All things being equal, if you are grossly obese, we won't promote you."

My goodness! Obesity as a work KPI (key performance indicator)!

Innovative? Definitely.

Attention grabbing? Most certainly.

But it is the height of arrogance, silliness and preposterousness to even consider such an option. Mr Liak should read the CDC feature, as well as the recent article in Newsweek Magazine, "The Real Cause of Obesity. It's not gluttony. It's genetics. Why our moralizing misses the point."

Perhaps Mr Liak should also penalize those who can't pass their IPPT (Individual Physical Proficiency Test). Not to mention the elderly, myopes, diabetics and hypertensives as well.

What has the 3rd medical school got to do with GSK and the H1N1 pandemic?

A strange nexus seems to have developed between the much anticipated 3rd medical school and happenings with respect to GSK and the H1N1 story.

As we all have been told the planned for 3rd medical school was supposed to be a tie up between Tan Tock Seng Hospital, NTU and Imperial College. One of the champions of the proposed tie up was apparently the past rector of the Imperial College, Professor Sir Roy Anderson. Sir Roy is a pretty influential person and has been listed as a VIP on the Board of GSK. But he apparently has a bit of checquered past. In July last year he was in the middle of a controversy about his role in the British SAGE (Strategic Scientific Advisory Group for Emergencies), a 20-strong task force drawing up the action plan for the H1N1 virus, while holding a highly paid position with the drug and vaccine manufacturer, GSK. Earlier he had been in another series of controversies which led to his resigning from Oxford University. You can read the details here.

In November last year, he abruptly stepped down as Rector for Imperial College. The reasons for his departure is unclear and there have been a number of speculations. His departure has however created a bit of a hiatus in leadership for Imperial College. Sir Keith O’Nions, the Director of Imperial’s Institute for Security Science and Technology, took over as Acting Rector. It is also not clear if the new leadership is as enamoured with the tie up with NTU/TTSH for the 3rd medical school. I hear in the grapevine that the vibes are not that positive. Which means the 3rd medical school is now left in a bit of a lurch and scrambling to find a suitor.

So ....a right royal mess......

Hospital errors - more action needed

Salma Khalik of the Straits Times picks up the thread again today on hospital errors in a report entitled "Make hospital and docs more accountable". Well done.

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.

Hospital errors - more details necessary

The Straits Times carried a disappointingly brief report about the reporting of hospital errors. A total of 401 errors over the last 7 years (since 2002); 339 of which was from public hospitals and 62 from private hospitals.

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.

IVF blunders - Time for a syscheck, Singapore?

Today's Straits Times, prompted by a recent IVF blunder in an UK fertility clinic, carried a report of the rather sloppy processes at such clinics. A recent Daily Mail report can accessed here.

I must say I haven't really thought much about this issue before, but was rather horrified at how frequent mistakes were. The ST report cited a Telegraph report alluding to as much as a staggering 40 mistakes per 10,000 cycles in 2006-07 (up from 15/10,000 in 2003-04). The Daily Mail refers to a report due soon showing 200 such 'serious mistakes' and 'near misses' this year. (The British Fertility Society however without citing figures, reassures that these errors are 'extremely rare'.

I am horrified.

An MOH report 2004/5 on IVF can be found here. In 2002 there were 1569 IVF treatments. Todate we must have done way beyond 10,000 treatments, but I can't find any data on IVF errors in Singapore. Are we that error free? Or have the errors been swept under the carpet somehow?

MOH should enlighten us on how IVF errors are being monitored, or is it that no one wants to know or tell?

The murky world of drug trials in Singapore

I don't particularly like Strait's Times' Andy Ho's writing. They often tend to be over-jargonized, pretentious and generally confusing.

But this Saturday under the Daedalus column, he touched on a topic that has been somewhat troubling to me, that of the conduct of clinical trials by mega pharma companies.

Drug companies claim that the cost of developing a new drug ranges anywhere between US$0.5 -2 billion. (Other people have suggested that this is grossly inflated and that perhaps only about a fraction of 10% of this is actually spent on FDA required activities.) Although the patent life of a drug is 20 years, about half of this is taken up by research activities before licensing of the drug, hence most new drugs entering the market have only about 7-12 years of effective patent life during which to recover the cost of drug development.

There is therefore a mad rush by mega pharma companies to get their products to the FDA finish line. Not many make it. Last year (2008) only 24 made it through. To regulate this R&D process and to make sure that there is global acceptance of the data generated by these rushing mega pharma companies, the clinical trials are 'regulated' by a series of harmonized dos and don'ts called the Good Clinical Practice (GCP) guidelines. There is a global set that has been harmonized by the International Conference on Harmonization (ICH). Singapore has a set that had is based heavily on the ICH-GCP document.

These guideline do give some comfort that the human experimentation that occurs as a result of the need to do clinical trials is to a large extent highly regulated. Even in Singapore. In Singapore, the Health Product's Act covers all such activities and the Health Science Authorities is the delegated authoritiy that approves the conduct of all clincal drug trials. Every investigator that is involved in clinical trials need to be trained in GCP. Every institution/hospital involved in clinical trials needs to have an instituional review board (IRB) which will provide the ethical review for all protocols.

All this looks very nice and comforting. As usual in Singapore, when we want to tell the world we are 'world class' we make sure that we have all the bases covered. At least on paper, lah....

Let me tell you what I have been concerned about... (and I hope the Ministry of Health are listening here)

a] Despite the existence of IRBs in all the restructured hospitals, not all the IRBs function at the same level of professionalism and competence. This gets worse outside of the restructured hospitals. There is no mandated 'training' or certification of IRB members so we do not know how competent or committed IRB members are in reviewing the clinical trial protocols. Most are just 'arrowed' to do the work, without any proper recognition of work done. To make matters worse, none of the IRBs are ever audited to make sure the processes are as intact as people assume they are.

b] Investigators(consultants,professors etc) are supposed to undergo training and be competent in GCP. But the only institutional expectation at both SingHealth and NHG clusters are only for them to be certified through a nominal online certification programme run by the Collaborative Institutional Training Initiative (CITI) (this one, anybody can pass...!!).

c] The IRBs never ever audit the clinical trials done in the hospital unless some shit hits the fan.

d] The HSA never ever audits any institution to see if they have the processes in place, and if they are actually compliant with whatever they say they are doing. I think basically HSA would rather not know.

e] The clinical trial units that do human experimentation are never audited, and there is no mandated certification of the facilities, so we can only assume that these units can handle emergencies and and manage the subjects if anything goes awry.

So do I have much faith in the environment that has been set up in Singapore so that we can play in the big league? Sadly, no. That we have not had a major incident here is probably more due to good fortune, than any good organization.

So do the investigators do what they say they are doing? Who knows? Does anyone really know what is happening? I have my doubts.

Heath care satisfaction down

Patients are apparently less satisfied this compared to last year, by 2 percentage points, from 76% to 74%. Typical of the quality of reporting of our newspapers, no one bothered to ask what was the confidence levels of the data generated by the survey, and whether this difference was statistically significant. It apparently didn't matter to them, as long as a number could be reported. *sigh*.....

In truth, even at 74% satisfaction (or poor bottom place CGH at 66%), it is actually not too bad. Not that I am advocating complacency and suggesting that no improvement is required, but simply that patients and relatives are by and large, quite difficult to satisfy.

What is interesting, and also important to note, is that patient satisfaction does not seem to parallel the amount of investment the hospital put into developing technology, or providing services. I had a recent experience of relative who had been diagnosed with cancer, and I must say I was pretty peeved at the service she received. Yes, there was electronic medical records and transmissibility of information across hospitals, and all kinds of technology access etc, but the common touch that showed the doctor(s) actually cared for the patient was glaringly missing.

This I believe is something the hospitals need to pay special attention to. Increased technology, impressive glass and steel only increase health care costs. Overall patient satisfaction probably can only improved through proper staff training and change in mindsets of our healthcare givers. Let me say that by and large many of our healthcare givers are committed caring individuals.....otherwise the patient satisfaction cannot be 'so high'. But there is a distinct population of relatively inexperienced and poorly trained/motivated staff which drag everybody down. This is where the hospitals need to place their emphases on.