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.

Sex and corruption in medicine

 

The recent sex and corruption case at the Central Narcotics Bureau has certainly woken many people up. But there is really nothing new here other than the titillating stories of trysts  and late night sexting between two very gatal (itchy) people. Sex sells. And all through history women have used their wiles to charm their way into position, power and wealth. So was this corruption, or just two very gatal people acting out their fantasies? We won't know for some time, and Gigamole will not speculate.

Nonetheless, Gigamole is reminded that the medical and health industry is not immune to such sex and corruption issues. Just that many do not get flagged out.

The WHO has estimated that the about US$4.1 trillion is spent globally on health services and of this, US$750 billion was on pharmaceuticals. It is a massive industry. The pharma companies aggressively compete for this market, and many (if not all) resort to unsavoury methods to market their wares.

Recently GSK was fined US3 billion for illegal marketing of its products. Part of these charges relate to providing junkets for doctors and various other kickbacks. J&J also had to pay up US78 million to settle charges of bribery and kickbacks it had provided.

Does this happen in Singapore? For sure. But perhaps not so obvious, because of our CPIB. But bribery and kickbacks in some form definitely occurs. Our doctors (especially)  go on junkets all the time. Not to mention kickbacks of various sorts. These are supposed to be regulated and notified to senior management, but nobody really scrutinizes anything, and consultants regard these as the perks of their practices. Medicines Australia reported that the annual spending by Pharma companies in wining and dining doctors and healthcare workers amounted to about A$24 million. How much "hospitality" spending in Singapore? Gigamole doesn't know. In fact the authorities don't really want to know.The public should insist that this be reported and made known publicly.

Any sex involved? Gigamole cannot prove anything. But suffice to point out that the industry is much bigger than selling the odd IT systems. Anybody stopping to point out that the sales reps for pharma companies are invariably attractive young ladies in short skirts?

This is not a problem that affects just pharmaceuticals. Medical devices suffer the same corruptibility. The susceptibility also extends up all levels of the health care chain....all the way from the prescriber, procurer and possibly even the regulator. Can we trust that we have only the best medical information, drugs and devices? Possibly not.

We need to look at this more carefully. The trouble is that the medical industry is seems rather "protected" and few want to stir the pot to root out these problems within the industry.

Sussing out the Susan Lim saga...

Gigamole is deadset against Dr Susan Lim's grotesque charges for her services... especially as Gigamole has to seriously contemplate a car-less future, in view of the even more grotesque COE values.

Even so, Gigamole has to confess to not even coming close to understanding the charges brought against her.

Singapore has no accepted fee structure for medical consultations. A previous non-binding guidelines published by the Singapore Medical Association was unilaterally and mysteriously scrapped in 2007. Apparently this was to make SMA compliant with the Singapore Competition Act of 2004.  Methinks however, it was in response to pressure to free up the fee structure to market forces so that the competition will drive down health care costs. What the policy makers didn't reckon with however, was that this would work only if it is a perfectly free market. But it never was a buyer's market, and fees were not significantly driven down. Instead, the deregulation allowed the high flyers such as Dr Susan Lim to escalate their costs. She is not the only medical consultant in private practice to exploit the deregulation, just the most obvious and noteworthy one. It might never have surfaced if not for the fact that some rich royalty called the Ministry of Health.

One might argue that the 'over-charging' occurred prior to the deregulation in 2007. But for the 20 years before 2007, even with the guidelines in place, there was never anything binding to the extent that anyone could be penalized for over-charging. Therefore, Gigamole is totally mystified as to how the Singapore Medical Council can determine that Dr Susan Lim over-charged anyone.

The Singapore Medical Council owes us an explanation here.

The SMRT monster-under-the-bed is emerging......

Day by day as the proceedings of the Committee of Inquiry for the SMRT fiasco plays out in the press, it has become clearer and clearer how big the monster under the Transport Minister's bed really is. This is one big mess. How can it be that the problem of national transport can be privatized to a company that showed such wanton neglect of operational necessities? The long awaited appearance of the beleaguered CEO at the COI really only served to confirm how misplaced the entire SMRT agenda was.  But much as we would like to just hang everything on the pathetic past CEO, Ms Saw, we should not forget she was not the only one responsible for this mess.

She essentially reported to the Chairman of the Board, Mr Koh Yong Guan, an eminent guy, but essentially a money guy. Eyeballing the SMRT 2010 Annual Report, we can see that the priorities of the Board really centred around fiscal prudence and health. Corporate risks were essentially only related to financial risks and not operational risks. Clearly the SMRT mission the Board set out for CEO Saw was really about growing the commercial and financial stature of the organization. Was she incompetent? Obviously not by the evaluations of the SMRT Board. At least not until the claws fell off the track and the poo hit the fans.

But who was behind the Board? Who put all this money people into the Board of an operational unit that was supposed to deliver a world class transport service? And how can it be that the transport regulator LTA can audit the SMRT year after year and find nothing but a bed of roses?

Now of course we know that bed of roses really harboured a huge stinky monster.

But going off on a tangent, as I am wont to do, it should be noted that this SMRT fiasco is really not merely an aberration in an otherwise healthy Singapore. Singapore, notwithstanding all the glowing reports in the mainstream media, is really quite dysfunctional. The sickness comes from the government's fixation on high GDP growth at the expense of everything else. Anything of worth is Singapore is denominated in dollar terms. The SMRT and the transport sector are not the only places where there are grossly misplaced missions. The health sector has been hugely corrupted by the pursuit of the medical dollar at the expense of affordable health care for the public. While lamenting the inadequacy of hospital beds, the Ministry of Health encourages corporatized hospitals to continue to build to cater to high end private patients. Meanwhile the universities chase bloated KPIs that have to do with ranking and research glory, rather than focusing on providing solid and affordable tertiary education for the average Singaporean.

There are monsters hidden under these beds that will, like the SMRT one, eventually emerge one day.

So as we head into the Hougang by-election, here is my plea to the Prime Minister. As a Singaporean I am increasing disillusioned by this overemphasis on wealth and elitist ideals. It is as if Singaporeans are not worthy of consideration and support unless they are megadollar earners. Prime Minister, you are wrong in this. Every Singaporean is worthy of support regardless of whether they are able bodied, able minded or not. Or even if they are just plain not-very-smart.

At this year's National Day Parade, I want to be able to say the pledge and mean it.

HSA and the regulation of medical devices - an exercise in agenda setting?

The theories of agenda setting are well known, I believe, to all mass comms graduates as well as journalists. Although the formal theories were only formulated about 40 years ago, ideas that the media can influence public opinion have been recognized since the early part of the 20th century.

The recent brouhaha about the regulation of medical devices by the HSA can perhaps be seen in the context of agenda setting. That the media plays an important role in agenda setting is beyond doubt. How the agenda is set however depends on who plays the media. To the media savvy, the media becomes a collaborator in the shaping of public opinion. A media-savvy politician therefore gets a pretty smooth road.

Where HSA failed has been in not recognizing how important the management of public expectations was in the implementation of complex and public-sentiment sensitive policies such as the regulation of medical devices. By defaulting on this, it has willy-nilly allowed the media to set the agenda in a direction contrary to public policy. So, not only has the media been allowed to tell us what issues are important, but it is being allowed to tell us what opinion we should form  about the issue. Note the teaser on the front page of the Straits Times today - "Patients should worry about vanishing medical devices". Really? Vanishing medical devices?

Poor HSA CEO John Lim is in the hot seat now. It seems like it is the fashion nowadays to run down the CEOs! I am waiting for the day when someone flashes an old D&D picture of him on a sedan chair carried by half maked women! But it should be recognized that the move towards regulating medical devices had not been developed overnight, but has been on the stove for about a decade. During this decade, the policy has been deliberated and refined under the guidance of 2 Ministers of Health and 2 Board Chairmen. I guess the second team has been quite unlucky to be on watch when this policy was finally ready to be implemented. But seeing how the SMRT issue developed, it seems highly unlikely even this team will get any credit for the mess. So, sadly, it looks like CEO John Lim will be the one catching the ball.