Vol. 50 No. 2 FEBRUARY 2018 MCI (P) 050/01/2018. news

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1 Vol. 50 No. 2 FEBRUARY 2018 MCI (P) 050/01/2018 news

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3 Vol. 50 No EDITORIAL BOARD Editor Dr Tan Yia Swam Deputy Editors Dr Tina Tan Dr Tan Tze Lee Editorial Advisors A/Prof Daniel Fung A/Prof Cuthbert Teo Dr Toh Han Chong Members Dr Chie Zhi Ying Dr Jayant V Iyer Dr Jipson Quah Dr Jonathan Tan Dr Jimmy Teo Dr Alex Wong EX-OFFICIOS Dr Wong Tien Hua Dr Lim Kheng Choon EDITORIAL OFFICE Senior Manager Sarah Lim Assistant Manager Sylvia Thay Editorial Executive Jo-Ann Teo news CONTENTS Editorial 04 The Editor s Musings Dr Tina Tan Feature 05 Still At It 25 Years and Counting A/Prof Eillyne Seow 07 At Life's End Dr Grace Yang President s Forum 08 Longitudinal Primary Care: Keeping the Fire Burning Dr Wong Tien Hua Opinion 19 Economics Can Never Replace Morals and Values Dr Wong Chiang Yin SMA CMEP Medical Practice 20 Treating Loved Ones and Yourself: When to Step Aside Dr Neeta Satku Insight 22 Fellowship Matters: How to Get Into a Good One? Dr Lee Ser Yee, Dr Chai Shu Ming and Dr Chan Chung Yip ADVERTISING AND PARTNERSHIP Li Li Loy Tel: (65) adv@sma.org.sg PUBLISHER Singapore Medical Association 2 College Road Level 2, Alumni Medical Centre Singapore Tel: (65) Fax: (65) news@sma.org.sg URL: UEN No.: S61SS0168E DESIGN AGENCY Oxygen Studio Designs Pte Ltd PRINTER Sun Rise Printing & Supplies Pte Ltd Opinions expressed in SMA News reflect the views of the individual authors, and do not necessarily represent those of the editorial board of SMA News or the Singapore Medical Association (SMA), unless this is clearly specified. SMA does not, and cannot, accept any responsibility for the veracity, accuracy or completeness of any statement, opinion or advice contained in the text or advertisements published in SMA News. Advertisements of products and services that appear in SMA News do not imply endorsement for the products and services by SMA. All material appearing in SMA News may not be reproduced on any platform including electronic or in print, or transmitted by any means, in whole or in part, without the prior written permission of the Editor of SMA News. Requests for reproduction should be directed to the SMA News editorial office. Written permission must also be obtained before any part of SMA News is stored in any retrieval system of any nature. Council News 10 Highlights from the Honorary Secretary Dr Lim Kheng Choon Letter 10 NEHR: Will These Changes Make a Difference? Dr Choo Kay Wee Eulogy 12 In Memory of Dr Khoo Chong Yew ( ): Past President of SMA Prof Wong Tien Yin 14 In Memory of Prof Chia Boon Lock ( ): Doyen of Cardiology A/Prof James Yip, A/Prof Poh Kian Keong and Prof Tan Huay Cheem Calendar 17 SMA Events Mar Jun 2018 Reflections 18 A Lot to Think About Dr Teo Boon See Hobbit 27 Survival Medicine: The Modified Montgomery Test (Part 2) GP Matters 30 Why Family Medicine? Dr Ajith Damodaran AIC Says 32 Enhanced Patient Care in the Community through Primary Care Networks Agency for Integrated Care Indulge 34 Where in the World is Okinawa? Dr Jimmy Teo

4 editorial The MUSINGS A few months ago, a doctor in one of our public hospitals made social media news for allegedly being negligent in the care of a young child. There was much public discourse on the matter. The hospital in question put forward a factual statement to defend their employee, another doctor s social media post went viral for his defence of the first physician (introducing the hashtag #targetzeroabuse), and the original posts with its allegations were eventually taken down (though the reasons why are unclear). Although the furore has died down, this debate caused a stir in many of our hearts for various reasons. It is a given that healthcare professionals need to be treated with respect and this was briefly highlighted in last month s issue of SMA News. In this issue, though, we want to take a more positive spin on things. What makes us all tick in our everyday work? How do we plough on despite the difficulties and disappointments we may face? Where and how do we find our joy when at work? We ve invited doctors from various fields; namely, emergency medicine, palliative medicine and family medicine, to talk about #joyatwork. A/Prof Eillyne Seow writes about the difficulties faced by emergency physicians, who battle at the frontlines of our hospitals A&E departments every day without fail. Dr Grace Yang submits a heartfelt piece sharing her work as a palliative medicine consultant and how she pushes on despite the nature of her job. As part of our GP column, Dr Ajith Damodaran talks about the joy he experiences in his work as a family physician, and in our President s Forum, Dr Wong Tien Hua writes about burnout among GPs. This month, we feature Part 2 of the Hobbit s series on the modified Montgomery test, as well as the first in a series of articles by Dr Lee Ser Yee and colleagues on choosing a fellowship for specialty training. We ve also reprinted Dr Wong Chiang Yin s letter to the Straits Times in support of the latest decision to reinstate medical fee guidelines (I believe the new term is benchmarks ). Last December, I received a Christmas greeting from my senior colleague and fellow Editorial Board member, A/Prof Daniel Fung. His message spoke of taking joy and having hope, and in particular, If we are to find joy at work, we must first have meaning and purpose. And in our work, this has to be the patients that we care for. It was a timely reminder for me and I hope that this issue serves as a reminder for all to go about our busy, endless days, always remembering to find #joyatwork. Tina Tan Deputy Editor Dr Tan is an associate consultant at the Institute of Mental Health and has a special interest in geriatric psychiatry. She is also an alumnus of Duke-NUS Medical School. Between work and family life, she squeezes time out for her favourite pastimes reading a good (fiction) book and writing. 04 FEB 2018 SMA News

5 FEATURE Medical professionals deal with a great amount of pressure on a daily basis, but how one copes with stress and continues to find joy at work is the key. In this series, A/Prof Eillyne Seow and Dr Grace Yang, emergency physician and palliative care physician, respectively, share with us how they derive joy from the work they do and the motivation for them to persevere on in their journey of treating those in need. #joyatwork is possible. Still at it 25 Years and Counting Text by A/Prof Eillyne Seow A/Prof Seow started her training in emergency medicine in She worked in the Emergency Department, Tan Tock Seng Hospital from 1991 to She was the head of this department from 2001 to 2010 and led it during the SARS outbreak. She is presently a senior consultant in the A&E Department, Khoo Teck Puat Hospital. It was an atypical start to a Sunday morning shift. Hotel 2, hotel 2 The first standby case was a 78-yearold gentleman with shortness of breath and a low O 2 saturation. The patient arrived just after 0830 hours. There were three more calls on standby for critically ill cases in the next 40 minutes and as we were managing our fourth standby patient, we noticed the paramedics dashing out of their work station, where they had been writing their reports, towards the ambulance bay. Sally, the nursing officer-in-charge for the shift, went to investigate. It has been more than a quarter of a century since I decided to be an emergency physician. When I was invited to contribute my thoughts on the meaning and joy in what I do despite the difficulties and challenges, I paused and pondered and, typical of most emergency physicians, I stepped back to dissect the statement. It was 0430 hours on a night shift when a 57-year-old gentleman was brought in with a low blood pressure. He had been awoken by a severe pain in his left lower limb. The team got to work inserting two intravenous lines, getting an ECG, etc. On examination, there was radio-femoral (pulse) delay; he had a triple A (abdominal aortic aneurysm). Over the next two hours, the team worked hard to resuscitate and stabilise the patient. At 0630 hours, we transferred the patient, accompanied by a doctor and two nurses, to another institution for definitive management. The doctor who accompanied the patient kept in touch with the patient s wife and several months later, the patient and his wife met with this doctor. The patient had recovered. There have been many times like this, though not every day or every week, that are enough to remind me that going to work has its meaning despite the difficulties and challenges. Challenges, challenges One of the most difficult challenges in an emergency department is a queue a FEB 2018 SMA News 05

6 long one. It was a typical Monday afternoon shift. The waiting time was long, the patient care area was chocka-block, the waiting area was crowded, overflowing with edgy patients and antsy relatives; the air was hot (even though the air-conditioning was working overtime), and the staff were stretched and frazzled. Fortunately, there was no one who: 1. wanted to jump queue; or 2. queried why the displayed expected waiting time was two hours, but they had waited two hours and fifteen minutes; or 3. wanted to be attended to NOW! or he would leave; or 4. was cursing away with four-letter words; or 5. threatened to go to the press, to complain to the chief executive officer, or to the Minister. However, a man did approach a nurse passing by and asked politely when his father would be attended to, then another asked the same nurse what he was waiting for, and then another asked how long more he had to wait as he would like to go to the toilet. The nurse was very accommodating and attended to each request: an unfortunate case for the patient who had to wait another 20 minutes before she could attend to him. Another long queue that causes great distress all around (from the top to the bottom of the hierarchy for different reasons) is for a hospital bed. In the (good?) old days, when I had just started out in emergency medicine, the priority was to not discharge patients who were at risk of returning in a worse state than when they left the emergency department. Over the last two decades, our patients have aged considerably, medicine has advanced and expectations have risen; few are averse to being hospitalised even in the seventh lunar month (hungry ghost festival). Due to overwhelming demand, the emergency fraternity was given a new role: gate-keepers to hospital beds. This role is a challenging one for the fraternity, as critics (both internal and external) are armed with retrospective microscopes. Okay, he s asleep, I said, after administering propofol and fentanyl to a 20-year-old man who had a dislocated left shoulder which was back in its socket within a few seconds. A 35-year-old woman came in breathless and lethargic; we recognised that she had undiagnosed diabetes and was in diabetic ketoacidosis. We started treatment and she was discharged after a week in the hospital. A 40-year-old man who was rolling in pain was brought in by the emergency ambulance typical of patients with renal colic. He was given intravenous analgesia and his pain was gone. Remember Sally, the nursing officer in charged of my atypical Sunday morning shift? A 60-year-old man with Stage 4 cancer of the lung was in a taxi. He had become tachypnoeic ten minutes prior to reaching the emergency department. Sally and I did our best to make him more comfortable. The satisfaction of being pivotal in the well-being of my patients gives meaning and joy to what I do and keeps me sanguine despite the difficulties and challenges on the shop floor. Staying the course But how have I managed to shrug off work stress and avoid burnout is the question I have been asked. Who is working afternoon shift today? Need a debrief after work? one of my kakis (slang for friends) asked over our WhatsApp group chat. Debrief what? another kaki asked. He meant supper, another explained. In my younger days, I had considered work stress and burnout to be part and parcel of the deal, but in truth, reflecting on those years of managing critically ill patients who sometimes have unspecified diagnoses, unreasonable relatives, cranky colleagues, an emergency department filled with unattended patients, and corridors full of patients waiting for a hospital bed, I would not have been able to have stayed the course without my kakis. My kakis have laughed and cried with me; heard me praise, scold and moan; consoled me when I failed; and clapped at my successes. Some friends medical and non-medical I would date regularly. We meet to catch up over food and new restaurants are of special interest. A few I travel with or visit once or twice a year. Others share my interest in Chinese tea. When in the mood for introspection, I escape into the world I am creating or read those by other writers. Did I manage to shrug off work stress? not all the time, but my friends have kept me sane and they are the reason why I have yet to experience burnout. 06 FEB 2018 SMA News

7 FEATURE Text by Dr Grace Yang A group of seven ward nurses are standing around Mr Tan s* bed three on each side and one at the head. They have just helped Mr Tan put on a smart-looking long-sleeved shirt and Mr Tan is feeling breathless. He needs to rest for a few minutes before the nurses can transfer him from his ward bed to a trolley bed. His daughter is standing along the corridor just outside the room, dressed in white and putting on lipstick. She is getting ready for her tea ceremony which is about to take place in the ward s day room. I come in to check on how Mr Tan is doing; he looks very apprehensive about being transferred to the trolley bed. I stand beside him and say: Don t worry Mr Tan, I am here. Let s do this. If you are breathless, I will give you some extra medicine. We then transfer him to the trolley bed, comb his hair, put on his tie and wheel him to the day room where he is served tea by his daughter and the groom. Mr Tan was referred to the palliative medicine division on Thursday, just one day before the tea ceremony, because his advanced cancer was rapidly progressing. It was making him breathless with minimal exertion even talking made him breathless. He had one last wish: to attend his daughter s wedding and give a father s blessing to the newlyweds. So, we started him on some opioids to control the breathlessness and made logistical arrangements so that he could participate in the tea ceremony on Friday morning and attend the wedding dinner on Saturday night. With the help of everyone in the team, he managed to attend the wedding dinner and came back to the hospital all smiles, happy that he was able to fulfil his last wish. He passed away just over a day later, in the early hours of Monday morning. That was it he was referred in on Thursday and died four days later on Monday. At least we managed to fit in a tea ceremony and a wedding dinner during those brief four days that we were caring for him. Energy to carry on Days like these remind me of why I studied medicine and became a doctor: to make a difference in people s lives. Days like these keep me going and give me joy. Yet how do I find joy in my work, which is widely perceived as utterly depressing? Each of my patients has a serious illness most commonly advanced cancer, sometimes end-stage heart failure or respiratory disease. Each of my patients has a limited prognosis usually months at most, sometimes weeks, sometimes only days. All of my patients are dying. Yet the truth is that all of us are dying. Some of us are just more aware than others. Some of us are forced to face the inevitability of our mortality, while others get to live in denial of it. As a palliative medicine doctor, my patients constantly remind me of my own mortality. It may seem counter-intuitive, but knowing that my life is only transient makes me treasure it even more. It motivates me to focus on what really matters. It reminds me to make the most of every day and savour each moment. It reminds me to live each day well, because after our days are spent comes certain death. Teach us to number our days, that we may gain a heart of wisdom. (Psalm 90:12) With my limited and transient life, why did I choose to work with the dying? The dying are, in fact, still living and palliative care is about helping patients to live well until they die. It is at this time that they are often most vulnerable, suffering from pain and other physical discomforts while being forced to contemplate the value of the lives they have lived as they face the reality of approaching death. Being able to journey with patients at life s end, and to ease their suffering along the way, is a great privilege. This is why I chose to be a palliative medicine doctor. The opportunity to connect with another person and make a difference is what keeps me going. It makes it all worthwhile. *Mr Tan is not his real name and details have been altered to protect his identity. Dr Yang is a palliative medicine consultant in the National Cancer Centre Singapore. She is married with two children aged five and six. FEB 2018 SMA News 07

8 PRESIDENT'S FORUM Keeping the Fire Burning Text by Dr Wong Tien Hua A review of burnout in primary care physicians by Dr Lawrence Ng was published in the Singapore Family Physician (SFP) in It quoted Maslach s description of burnout as... an erosion of engagement with the job. What started out as important, meaningful, and challenging work becomes unpleasant, unfulfilling, and meaningless. Energy turns into exhaustion, involvement turns into cynicism, and efficacy turns into ineffectiveness. A burned out physician feels depleted of energy, unable to connect to or care about his/her patients, and becomes incompetent and unproductive at work. The doctor-patient relationship suffers along with effective care delivery. Medicine is an uncertain art and this is especially poignant in the primary care setting where patients present with undifferentiated illnesses. Dealing with uncertainty is a clinical skill that has to be mastered, but it is counter-intuitive to junior doctors who are trained in the hospital setting where the latest diagnostic facilities are available and where diseases have evolved and become more apparent. This transition from specialist-based training to the community setting, where one has to rely on clinical acumen amid limited resources, is a stressful endeavour. Society has also always placed high expectations on doctors, with patients now more knowledgeable and connected than ever before. Patients are more demanding and intolerant of uncertainty, because they are used to the fact that they are in control of many aspects of their lives. However, even with the power of the Internet, which provides information at the touch of a button, patients who are not medically trained may find such open access to information to be overpowering and confusing. Their sense of self-control may be threatened, leading to anxiety and frustration which they pass on to the physician. As addressed in the paper, difficult patient encounters are a major predisposing factor to physician burnout. The demands of family practice in Singapore means that the physicians need to spend long hours in the clinic to ensure accessibility. Most often, the evening and weekend sessions are the busiest times for family physicians whose practices are located in residential neighbourhoods, resulting in less time spent with one s own family and on leisure activities. The ethos of a good doctor is to place the needs of patients above self, and this renders the doctor prone to spending excessive time at work to the detriment of family. Setting up a family practice in the community is indeed a daunting task for doctors who wish to take the plunge into the private sector. One starts off with the task of selecting the right location with the right overheads, then applying for the clinic licence, stocking up and hiring of staff. Once the clinic opens, one has to worry about maintaining the business and ensuring a good level of service so that patients would want to make a return visit and recommend it to others. Needless to say, there are a lot of responsibilities and worries that a family practitioner has to bear. If this is coupled with the long hours spent confined within the four walls of the consultation room seeing repetitive cases, then the work may become mundane and even meaningless, leading to physical and mental exhaustion. There are many interventions available to tackle burnout, including self-care techniques described in the aforementioned issue of the SFP. Staying engaged If Maslach describes burnout as an erosion of engagement, then the ability to stay engaged in one s practice is critical especially over the span of a doctor s career. I believe that the key to combating the feelings of detachment and depersonalisation that occur in burnout is to focus on nurturing a strong doctor-patient relationship, especially among primary care physicians. The well-known Stott and Davis model for primary care consultation describes four essential tasks for the doctor at each encounter. 2 Looking after the acute problem Managing any concomitant chronic problem Modifying health seeking behaviour Opportunistic health promotion The model recognises that each patient encounter is not just about the acute problem at hand or about managing the patient s chronic illness, but that each encounter actually carries far more potential with unique opportunities to 08 FEB 2018 SMA News

9 Dr Wong is President of the 58th SMA Council. He is a family medicine physician practising in Sengkang. Dr Wong has an interest in primary care, patient communication and medical ethics. Illustration: Dr Kevin Loy engage the patient in behavioural change, and to nudge the patient towards a better quality of life. For this to happen, two conditions must be present: 1. The doctor and the patient must be committed to a therapeutic relationship of trust; and 2. The relationship must take place over an extended period of time. This means that the element of time played out over months and years is a necessary component of effective care delivery for family physicians. Each encounter is no longer an isolated event beginning with the patient entering the consultation room and ending with the patient leaving the clinic. Instead, the patient encounter can be seen as part of an ongoing conversation that is picked up where the previous one had ended. The interval between each encounter can be months or even years, but each individual consultation is part of a continuum and a touch point that makes up the dots that form a continuous line the longitudinal line of care. The doctor is aided by having a comprehensive medical record of each consultation, including the conversations that occur, building on the previous knowledge base with new insights and information about the patient. A change in attitude A doctor s approach to his/her patients will change once he/she adopts an attitude of long-term holistic care, with the realisation that he/she is going to bear the responsibility for his/her patients over decades. What is not addressed today may come around and strike years later. For example, if a smoking habit is not addressed, both the patient and the doctor may need to deal with the consequences of lung cancer in the future. I do not think that this attitude can be instilled or that it is a skill that can be trained; instead, it is a perspective that the doctor comes to appreciate over time. The uniqueness of practising family medicine in the community is that as the practice matures, so too does the doctor-patient relationship. The relationship strengthens as the doctor learns more about the patient and eventually the patient s entire family, a nd is able to appreciate the context behind each and every encounter. An established clinic also tends to have a loyal pool of patients who are more open to behavioural change. The initial few visits are usually business-like as patients seek consultation for biomedical problems, but at the same time, these patients also subconsciously observe the doctor to see if they are comfortable enough to share their intimate medical information. Patients who do not click with their GPs will eventually move on to other practices and in this way, an established practice self-selects its patients over time. It is with this insight of longitudinal care that the practice of family medicine is so engaging and interesting, because even though patients may seem to present with similar and repetitive medical conditions, each encounter is actually quite unique. Ultimately, the experienced family physician makes use of valuable contact time to steer patients towards better health. References 1. Ng CLL. Burnout in primary care physicians and interventions an evidence-based review. Singapore Fam Physician 2016; 42(1): Stott NCH, Davis RH. The exceptional potential in each primary care consultation. J R Coll Gen Pract 1979; 29(201): FEB 2018 SMA News 09

10 council news Dr Lim is the Honorary Secretary of the 58th SMA Council. He is currently an associate consultant at Singapore General Hospital. Report by Dr Lim Kheng Choon SMA feedback on the PHMC (Publicity) Regulations On 8 January 2018, SMA submitted preliminary comments regarding proposed amendments to the Private Hospitals and Medical Clinics (PHMC; Publicity) Regulations. In it, SMA agreed with some amendments, but also sought clarification on the types of publicity allowed within clinic/hospital premises; the types of Internet advertising allowed; the use of testimonials; participation in reward/point promotions; and whether certain prohibited terms could be acceptable in certain scenarios. We will continue to engage stakeholders to give constructive feedback on behalf of our Members. Re-nomination of SMA s representative to the WSH Council (Healthcare) Committee SMA is happy to re-nominate Dr Wong Sin Yew as SMA s representative for the Workplace Safety and Health (WSH) Council (Healthcare) Committee. Dr Wong has been SMA s representative since The WSH Council will be re-appointing Dr Wong for a two-year term ending 31 March We thank Dr Wong for his volunteer service to SMA. letter NEHR: Will These Changes Make A Difference? This reply was submitted in response to a letter published in the January 2018 issue of SMA News ( Dr Choo is a family physician at A Life Clinic Pte Ltd. Text by Dr Choo Kay Wee I would like to thank Dr Lee Pheng Soon for clarifying the ethical rights of the patient with regard to the National Electronic Health Record (NEHR). Would the following changes made to the present status of the NEHR help in any way to eradicate the anxiety and ambiguity surrounding patients rights? 1. There should never be access to any raw data in the NEHR unless for forensic examinations or detailed research studies. 2. The information in the NEHR should be treated as confidentially as our Central Provident Fund (CPF) accounts or Inland Revenue Authority of Singapore records; ie, the patient would be able to print and submit the information to the caregiver as per printing out the CPF relevant statement when buying a house. 3. This means that the useful information in the NEHR should be carefully summarised and recorded for the above purpose. 4. Another way, perhaps, is to treat the information as if it is in a safe deposit box with both the patient and the caregiver holding separate keys or tokens. They must be used concurrently to access the summarised records, unless in an emergency when a master key is used. 5. The information collected earlier without the patients well-informed consent (ie, ALL NEHR records) should not be included unless freshly authorised by the patients, but they should be kept for the purpose of forensic examinations or research studies. 6. Finally, no research should be done without proper consent. 10 FEB 2018 SMA News

11 SMA MEMBERSHIP PRIVILEGES AT A GLANCE The core of SMA s work is in the many issues that we have advocated for, in hopes of creating a better local healthcare landscape - for doctors, for patients The amount of time and effort that the relevant SMA Committees and Members spend cannot be easily quantifiable, and the value and impact of our advocacy work may be overlooked at times. Nonetheless, we are ever thankful to all our members for your strong support and membership over the years so that the Association can continue to speak up on matters that are close to your hearts. The more tangible SMA Membership privileges are listed below and on our website at Log in to your Membership Portal to enjoy the uniquely SMA privileges as well as sign up for courses and events! SMA s Work Receive complimentary or subsidised rates as an SMA Member Utilise resources available for your convenience and order medical products anytime, anywhere Gain access to permanent or locum positions through our recruitment platforms, and hire SMA-trained clinic assistants SMA s Promotional Partners SMA Membership is based on an auto renewal basis and annual subscription fees would be due at the start of each calendar year. Any requests regarding your membership status should be sent in writing via mail or to membership@sma.org.sg, subject to approval from the SMA Council.

12 FEATURE EULOGY In Memory of Dr Khoo Chong Yew ( ) Past President of SMA Text by Prof Wong Tien Yin, Medical Director, Singapore National Eye Centre; Provost s Chair Professor of Ophthalmology, National University of Singapore; Vice-Dean, Duke-NUS Medical School; Deputy Chief Executive Officer (Research and Education), SingHealth; President, College of Ophthalmologists, Academy of Medicine Photo: Raffles Hospital Dr Khoo Chong Yew passed away peacefully on 16 November 2017, aged 78. Here, I would like to acknowledge his vast and profound contributions to ophthalmology in Singapore and the region. Singapore National Eye Centre During the Singapore National Eye Centre s (SNEC) early years in the 1990s, Dr Khoo was a visiting consultant and advisor, Cornea Division; Chairman, Singapore Eye Bank; Chairman, Ethics Committee; and Chairman, Medical Board and its Selection Committee. More recently, Dr Khoo chaired the SingHealth Centralised Institutional Review Board (IRB) A and served as IRB chairman at the Singapore Eye Research Institute (SERI). He was also among the first visiting consultants appointed to the Department of Ophthalmology, National University Hospital, in 1986, and was a clinical teacher with the National University of Singapore. Public service champion of ethical aspects of medicine in Singapore and the Asia- Pacific Dr Khoo s views and advice on medical ethics were highly sought after and respected. He chaired the National Medical Ethics Committee, Ministry of Health (MOH), from 2003 to 2005, on top of the ethical committees of SNEC, SERI and the Parkway Group of Hospitals over various periods. He was also the chairman of the Singapore Advisory Panel of the Medical Protection Society. MOH invited Dr Khoo to several important policy formulation subcommittees, such as the Health Advisory Council, Committee of Specialists Register and the Committee for Medisave for Private Hospitals. He also chaired the Asia- Pacific Academy of Ophthalmology (APAO) Ethics Committee. International achievements in contact lens subspecialty From 1998 to 2002, Dr Khoo chaired the International Contact Lens Council of Ophthalmology. He also co-authored the book, Contact Lenses: Medical Aspects, in He was a member of the Board of Expert Advisers for the Asian Foundation for the Prevention of Blindness and the International Agency for the Prevention of Blindness. Leader Dr Khoo served two terms as President of SMA (1985 and 1986). He was also on the Singapore Medical Council and the Advisory Subcommittee on Specialist Certification, Academy of Medicine. 12 FEB 2018 SMA News

13 1 The SMA Council expresses our deepest sympathies and heartfelt condolences to the family of Dr Khoo Chong Yew on his passing. Dr Khoo was Past President of SMA and was the SMA Lecturer in 1992, delivering the Lecture on The Doctor's Role in a Hi-Tech World. Dr Khoo was Secretary-General of the XXVI International Congress of Ophthalmology (1990), which was perhaps the most prestigious world ophthalmic event to be held in Singapore. Contributions to the community Dr Khoo contributed significantly to the community, chairing the National Eye Campaign in 1984, which organised eye screenings in 75 community centres. He also provided ophthalmic care to needy patients at the Home Nursing Foundation and served on the Executive Council of the Singapore Eye Foundation. He had also led a Rotary Medical Mission to Cambodia to introduce implant surgery to ophthalmologists. Honours and recognition Dr Khoo was accorded the APAO Distinguished Service Award in He did Singapore proud by delivering the Javal Gold Medal Memorial Lecture at the International Contact Lens Council of Opthamology in In recognition of his important contributions to SNEC, Dr Khoo was awarded the SNEC Gold Medal in For his work in the Discipline Committee of the Law Society, Dr Khoo was awarded the National Day Public Service Medal (PBM) in Role model We are indeed grateful to the late Dr Khoo for his outstanding contributions to ophthalmology. As one of the founding fathers of ophthalmology in Singapore, the younger generation truly has an exemplary role model in Dr Khoo. Further readings 1. Lim KH. Leading lights in the Asia-Pacific: XXI Congress, Asia-Pacific Academy of Ophthalmology. Singapore, Lim A. Seri: Singapore's World-Class Research Singapore Eye Research Institute. Singapore, Legend 1. The late Dr Khoo (first row, centre) and the 26th SMA Council FEB 2018 SMA News 13

14 FEATURE EULOGY In Memory of Prof Chia Boon Lock ( ) Doyen of Cardiology Text by A/Prof James Yip, A/Prof Poh Kian Keong and Prof Tan Huay Cheem, National University Heart Centre, Singapore Prof Chia Boon Lock, Emeritus Professor of Medicine at the Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, passed away peacefully at home on 27 December 2017 at the age of 78 years. Prof Chia, an early pioneer in cardiology, joined NUS as a senior lecturer in medicine in 1972 and was promoted to full professor in He was in charge of cardiology in Medical Unit II at the Singapore General Hospital (SGH) from 1975 to 1985 and was also head of the department from 1981 to He then went to the National University Hospital (NUH), becoming head of the hospital s Division of Cardiology, Department of Medicine, from 1986 to 1989 and chief of the Cardiac Department from 1996 to In 2006, he was conferred the title of Emeritus Professor by NUS. Five decades of cardiology Prof Chia devoted his five-decade career to medicine despite his multiple talents, including music and the English language, and was a witness, participant and champion of many changes in cardiology practice in Singapore. In 1963, Prof Chia graduated from the University of Singapore medical school and travelled to Sydney in 1968 on a Colombo Plan scholarship to train as a fellow in cardiology. At that time, the care of patients with acute myocardial infarction was primitive and basically consisted of five weeks of bed rest. 1 He was involved in setting up the first modern coronary care unit and coronary care ambulance in SGH in 1973, and was the first to introduce M-mode echocardiography in Prof Chia had a sabbatical in 1979 at the Division of Cardiology, Stanford University Medical Centre, in Stanford, California, USA, where he trained in echocardiography and coronary angiography, and he pioneered the use of two-dimensional echocardiography in Singapore two years later. Although he had received no formal training in hypertension and lipid management, he soon became a giant in these fields and was a key opinion leader in Southeast Asia. In Singapore, he was the first to introduce ambulatory blood pressure monitoring in 1986 and was involved in various Ministry of Health workgroups for its clinical practice guidelines (CPGs) on lipids and hypertension. He was the chairman of the workgroup for the first and second CPGs on lipids, which spanned more than a decade, and was the advisor for the third and most current guidelines. 2 Despite his contributions to numerous other areas, Prof Chia s greatest love and passion was the field of electrocardiography (ECG). While his peers collected fine wine and rare stamps, Prof Chia collected electrocardiograms. His book Clinical Electrocardiography (4th edition, 2015), a labour of love that he revised in his twilight years, is the bible of local cardiologists and medical students for ECG. As Dr Peter Yan wrote in his review of his book, it is a must-read that can turn a novice into a competent ECG interpreter. 3 Although ECG is an old technology that was invented by Einthoven back in 1903, its shine has not been replaced by newer, modernday technologies. Prof Chia said at the 15th Sukaman Memorial Lecture at the ASEAN Federation of Cardiology meeting in 2014: although there are many pitfalls in the ECG evaluation of ST elevation myocardial infarction (STEMI), with our current ECG knowledge and expertise coupled with clinical 14 FEB 2018 SMA News

15 correlation as well as the present availability of cardiac biomarkers, echocardiography, computed tomography and percutaneous coronary angiography, accurate diagnosis today can be achieved in the majority of cases. 4 This lecture took place a decade after his highly successful ninth Antonia Samia lecture on ECG at the 14th Asian Pacific Society of Cardiology Congress in Prof Chia was also an International Editor of the Journal of Electrocardiology for more than a decade. His insights into ECG reading have helped the interventional cardiologists of today to reduce door-to-balloon time by predicting the correct coronary artery to engage first in cases of inferior STEMI. 5 Even just before his death, he was working on another ECG paper that would soon be published. Medical education Every batch of medical students in NUS from 1972 to 2016 would remember being taught by Prof Chia. Before the era of professional beatboxing, the Introduction to Cardiac Examination lecture by Prof Chia was accompanied by his vocal simulations of every conceivable cardiac murmur, which received standing ovations from his students. His facial simulation of pursing his lips would forever emboss in one s mind the image of the fish-mouth appearance of mitral stenosis. For the bedside tutorial, Prof Chia pioneered the auscultation of cardiac murmurs with the octopus teaching stethoscope, to which multiple students could listen at the same time. As an examiner for the final Bachelor of Medicine and Bachelor of Surgery or cardiology exit interviews, the presence of Prof Chia at the station was reassuring, as students were unlikely to fail, unless deservingly so. After Prof Chia stepped down as NUH s chief of cardiology in 1999, it became a rite of passage for all cardiology trainees to have his final tutorial a few weeks 1 before their exit examination, which covered the entire span of cardiology. Generations of cardiology trainees are indebted to his generous spirit in teaching and his help in passing their examinations. Leadership and honours Apart from his university and clinical responsibilities, Prof Chia was involved in many local and regional societies. Together with the late Dr Tan Ngoh Chuan, he wrote the constitution of and registered the Singapore Cardiac Society in He was past president of the society four times (1977, 1980, 1983 and 1989), and was founder and past president of the Singapore Hypertension Society (2001) and vice-chairman of the former Singapore National Heart Association (1982). He was council member of the Academy of Medicine Singapore ( ) and Chairman of the Chapter of Physicians (1981), and member of the 17th and 18th Council of SMA. In the realm of clinical cardiology, Prof Chia was peerless. His patients ranged from kings to the common man. He received the following honours for these contributions: Dato Paduka Mahkota Brunei (1984), the Lee Foundation-National Healthcare Group Lifetime Achievement Award (2005), Honorary Membership of the SMA (2008) and the Singapore Cardiac Society Lifetime Achievement Award (2014). For his years of service in the public sector, he was often asked if he could be considered the father of cardiology in Singapore. His humble reply was that the honour belongs to Charles Toh, but if you must, I could be considered the doyen of cardiology, FEB 2018 SMA News 15

16 Legend 1. Family photo after the conferring of Emeritus Professorship 2. The late Prof Chia with his son, Dr John Chia, and grandson, Peter Chia 2 a respected person who speaks for others. Courage in adversity At the age of 43 years, Prof Chia was struck with Stage 4 nasopharyngeal carcinoma. Despite knowing the poor prognosis of his condition, he sought treatment in Hong Kong with a new high-dose radiotherapy regimen. In a reversal of the doctor-patient role, he said: Once you have found a good doctor, trust him fully and do everything he says without question. This philosophy of trusting a colleague to care for him helped him through the darkest days of his life. He suffered many long-term complications from his initial radiation treatment, including pan-hypopituitarism, which he said, with tongue in cheek, contributed to his cherubic look. Over the years, he had multiple health issues, including poor wound healing, intubation for epiglottitis and diplopia from cranial nerve palsies. Each time, Prof Chia overcame the issue and returned to teaching in the department. To overcome his diplopia, which stopped him from driving, Prof Chia taught himself to adjust his glasses with a series of stick-on prisms to correct his vision so that he could see his ECGs. This expertise was previously not available in Singapore, but necessity prompted him to master his situation, and Prof Chia became an expert in the field of diplopia correction. The final battle Foreshadowing things to come, Prof Chia said in 2006, at the 16th Seah Cheng Siang Memorial Lecture: Perhaps, as recommended by some experts, the best strategy for all of us is to strive to die young at the latest possible age not just for ourselves, but for the entire population. The best example of this achievement is the world renowned researcher on cigarette smoking, Sir Richard Doll, who died in 2005 following a short illness, at the age of 92 years. But alas for many of us, this is something that may be difficult to attain. 1 In November 2017, he had a recurrence of secondary cancer of the tongue. He had already made up his mind that there would be no heroic surgery or measures this time. He said that his heart was at peace and he slept well at night, unlike 35 years before. Tributes from friends, past students and patients arrived from as far as Brazil The SMA Council expresses our deepest sympathies and heartfelt condolences to the family of Prof Chia Boon Lock on his passing. and Toronto in the form of videos, to reassure the man who had made a difference in their lives. His message to them ten days before his passing was: In my lifetime, I have two major aims: To lead an honourable life and to have an honourable death. The first has been achieved, with your kind thoughts and prayers. I m confident that the second will also be achieved. Ten days later, his wish was fulfilled in the company of his family, whom he loved dearly, with the peace he desired. References 1. Chia BL. 16th Seah Cheng Siang Memorial Lecture the changing face of cardiology practice, training and research in Singapore. Ann Acad Med Singapore 2006; 35: Tai ES, Chia BL, Bastian AC, et al. Ministry of Health Clinical Practice Guidelines: Lipids. Singapore Med J 2017; 58: Yan P. Review: Clinical Electrocardiography 4th Edition. Singapore Med J 2016; 57: Chia BL. 15th Sukaman Memorial Lecture: ST Segment Elevation: New Electrocardiographic Insights in ASEAN Heart J 2016; 24:6. ecollection 2016 Oct. 5. Chia BL, Yip JW, Tan HC, Lim YT. Usefulness of ST elevation II/III ratio and ST deviation in lead I for identifying the culprit artery in inferior wall acute myocardial infarction. Am J Cardiol 2000; 86: FEB 2018 SMA News

17 SMA EVENTS MAR JUN 2018 CALENDAR DATE EVENT VENUE CME POINTS WHO SHOULD ATTEND? CONTACT CME Activities 18 Mar Sun BCLS and CPR+AED SMA Conference Room 2 Family Medicine and All Specialities Shirong/Margaret cpr@sma.org.sg 20 Mar Tue Mastering Adverse Outcomes Novotel Singapore on Stevens 2 Family Medicine and All Specialities Margaret margaret@sma.org.sg 31 Mar Sat SMA Seminar: Tax Obligations on Medical Practice M Hotel Singapore 2 Doctors, Clinic owners and Clinic assistants Jasmine jasminesoo@sma.org.sg 7 Apr Sat Achieving Safer and Reliable Practice Novotel Singapore Clarke Quay 2 Family Medicine and All Specialities Margaret margaret@sma.org.sg 7 Apr Sat Telemedicine Seminar Health Promotion Board, Auditorium 2 Doctors and Healthcare Professionals Jasmine jasminesoo@sma.org.sg 11 Apr Wed Mastering Difficult Interactions with Patients Novotel Singapore Clarke Quay 2 Family Medicine and All Specialities Margaret margaret@sma.org.sg 14 Apr Sat A Medico-Legal Seminar on Mental Capacity Assessment Caring for Persons Lacking Mental Capacity Health Promotion Board, Auditorium 4 Doctors (GPs, Neurologists, Paediatricians and Psychiatrists) Jasmine jasminesoo@sma.org.sg 14 Apr Sat Mastering Your Risk Novotel Singapore Clarke Quay 2 Family Medicine and All Specialities Margaret margaret@sma.org.sg 22 Apr Sun BCLS and CPR+AED SMA Conference Room 2 Family Medicine and All Specialities Shirong/Margaret cpr@sma.org.sg 24 Apr Tue Mastering Difficult Interactions with Patients Novotel Singapore Clarke Quay 2 Family Medicine and All Specialities Margaret margaret@sma.org.sg 28 Apr Sat SMA CMEP Health Law Seminar (Basic) Academia 2 Doctors and Healthcare Professionals Jasmine jasminesoo@sma.org.sg 3 May Thu Mastering Adverse Outcomes Novotel Singapore on Stevens 2 Family Medicine and All Specialities Margaret margaret@sma.org.sg 5 May Sat SMA CMEP Health Law Seminar (Intermediate) Academia 2 Doctors and Healthcare Professionals Jasmine jasminesoo@sma.org.sg 16 May Wed Mastering Your Risk Novotel Singapore on Stevens 2 Family Medicine and All Specialities Margaret margaret@sma.org.sg 20 May Sun BCLS and CPR+AED SMA Conference Room 2 Family Medicine and All Specialities Shirong/Margaret cpr@sma.org.sg Non-CME Activities 15 Apr Sun 58th SMA Annual General Meeting Alumni Auditorium NA SMA Members Sze Yong szeyong@sma.org.sg 12 May Sat SMA Annual Dinner 2018 Regent Hotel NA SMA Members and Guests Mellissa mellissa@sma.org.sg 27 Jun Wed SMA Annual Golf Tournament 2018 Raffles Country Club NA SMA Members and Guests Azliena liena@sma.org.sg FEB 2018 SMA News 17

18 REFLECTIONS PARKING Text by Dr Teo Boon See Some time back, I attended a three-day course for doctors organised by SMA. Most of the doctors at the course were young trainee doctors. I, as a senior family physician, was probably the oldest doctor there. The course was conducted in a hotel ballroom. Next to this ballroom was a car park. There was a parking lot for the disabled right in front of the entrance to the ballroom. The car park was too small, but nonetheless, people respected the handicapped logo and avoided the lot at least for the first two days. On the final day of the course, I arrived early, and witnessed a luxury car parking into that very lot. Out of the car strode a young man carrying the course file clearly a young medical colleague. I asked the young doctor if he knew that the lot was reserved for the disabled. He was taken aback and asked me what that meant. I clarified that it was a lot reserved for the disabled and he should not park his car there. He replied that he did not think anyone else would need it and walked off toward the ballroom. I was upset, but I reserved judgement in case he was having a toilet emergency. Evidently he was not, as he settled down at his table instead. After a few minutes, I approached him at his table hoping to get to know him better. We exchanged pleasantries and I found out he was a young registrar in one of the restructured hospitals, and that he was exiting soon. Throughout this conversation, I did not get any sense of awkwardness or embarrassment from him. After I left him, I was deeply perturbed and I prayed for wisdom to handle this matter. In the end, I felt led to move my car and to offer him my lot instead. He was now having coffee with a colleague. I interrupted them and urged him to move his car to my now-empty lot to vacate the disabled lot. He acknowledged my offer without gratitude. He continued to chat with his colleague and finally moved his car after he had finished his coffee. If you are wondering which course this was, it was the SMA Ethics Course! This course has been made compulsory for advanced specialist training (AST) and family medicine (FM) trainees as part of their training. What an irony it was. Just a few days prior to the course, I was in Tokyo with a friend and we took a ride on a public bus. At one bus stop, an old man in a wheelchair wanted to disembark. I witnessed the young bus driver, who was in his twenties, stop the bus, manually unfold a ramp and wheel the old man off the bus. Returning to the bus, the driver then saw an umbrella left behind, where the old man s wheelchair had been. He left the bus again, running after the old man to return the umbrella. The entire time, all our fellow passengers waited patiently. When the bus driver finally returned to the bus a few minutes later, my friend and I applauded and cheered him for doing what I thought was an exceptional gesture. And so, within the span of a week, I witnessed two young men s behaviour towards the disabled. I felt grieved that of all the people who could have caused the offence, it came from one of our own. Surely, we can do better! Dr Teo is a family physician in private practice. 18 FEB 2018 SMA News

19 Economics Can Never Replace Morals and Values OPINION Text by Dr Wong Chiang Yin This is the original letter that the author submitted to the Straits Times and the edited version was published on 25 January 2018 in the Straits Times Forum. I was the President of the SMA in 2007 when the Association had to withdraw its Guideline on Fees (GOF) so as not to contravene the Competition Act. We did so most reluctantly and amid much anguish. Dr Yik Keng Yeong s letter dated 23 January 2018 to this Forum [the Straits Times] questioned why doctors fees should be put under the spotlight of the Ministry of Health s Fee Benchmarks Advisory Committee, and wondered if this would undermine competitive forces and the free market economy. The defining characteristics of an honourable profession include: a group of people who have undergone extensive education and training and hence possesses special knowledge and skills, and is recognised as such by the public; a profession that adheres to ethical standards and applies this knowledge and skills in the interest of others. The medical profession has all these defining characteristics and therefore, should not live by the bread of economics alone, lest the profession becomes a trade. Competition and the free market are but means to an end. They are not ends in themselves. The ultimate end of any public policy is not adherence to the dogma of market fundamentalism but, based on experience and evidence, the creation of greater societal wellbeing over the long-term, such that all stakeholders can co-exist in a sustainable way. The stakeholders here being patients, healthcare establishments, healthcare professionals, and insurance and managed care companies, among others. In the last ten years without the SMA GOF, things have been running amok. This cannot be good for stakeholders and Singapore. There are limits to economic theory, free market or otherwise, especially when applied to healthcare. Prominent American health economist Victor Fuchs eloquently described the limits of applying economic theory to healthcare: The questions are ultimately ones of value: What value do we put on saving a life? On reducing pain? On relieving anxiety? economics is the science of the means, not of ends it can tell us the consequences of various alternatives, but it cannot make the choices for us. These limitations will be with us always, for economics can never replace morals or values. A certain set of misguided values and beliefs was in play when the SMA GOF was outlawed in 2007, resulting in the miasma of the last ten years. The current initiative to have fee guidelines and benchmarks is but a return to the correct trajectory which we had enjoyed before. Dr Wong is a public health specialist. He has been in the SMA Council for more than 20 years and was the President of SMA from 2006 to His professional interests include hospital administration, health policy and regulation. He has been around long enough to know that very bad things can happen in healthcare as a result of good intentions. FEB 2018 SMA News 19

20 SMA CMEP medical practice Treating Loved Ones and Yourself : When to Step Aside Text by Dr Neeta Satku Almost every doctor has a story about how the course of a loved one s illness has influenced the direction of their career, often in the hope of being able to one day change the outcome of their disease. When we finally find ourselves in a position to use our expertise for the benefit of those closest to us, we must consider the possibility that we may not be the best person for the job. What does SMC advise? The Singapore Medical Council (SMC) Ethical Code and Ethical Guidelines (ECEG) states that doctors may not treat people close to them for psychiatric issues, or when it involves the prescription of controlled or potentially addictive substances. The ECEG goes on to say that doctors may provide those close to them with routine continued care for stable conditions, minor conditions, or in an urgent/emergency situation. 1 Doctors are then cautioned that if they choose to provide further care, they should guard against allowing the nature of their relationship with the patient to compromise the quality of treatment. 1 Several other medical organisations, such as the American Medical Association and the General Medical Council, advise much more strongly against treating one s close friends or family. 2,3 What are the risks? Although it is common for doctors to treat, and even operate on, those close to them, 4 this sometimes takes place without a full understanding of the risks involved. The first hurdle encountered is information gathering. The doctor may assume that he already knows a friend s or family member s history based on their social interactions, or may be uncomfortable asking them sensitive questions. Similarly, patients may not be comfortable disclosing intimate medical information to a friend or relative, in particular one who is in frequent contact with the rest of their social circle, such that a breach of confidentiality might have disastrous social implications. The physical examination may also be incomplete due to sheer mutual embarrassment. Some of these consultations take place informally at social events which may seem convenient, but be warned that history-taking and examination are unlikely to be complete because of the lack of time and privacy. There may be no documentation of the clinical findings, which compromises followup care. Doctors should be extremely cautious about suggesting or prescribing treatment based on these encounters, and mindful of the ethical and legal implications of such prescriptions. Perhaps the most obvious problem with treating close friends or family is the loss of professional objectivity, which may compromise even the most experienced doctor s clinical acumen. A doctor may, understandably, be reluctant to consider an alarming diagnosis in a loved one, or conversely may be so anxious and emotionally invested that he/she over-investigates a minor symptom. Doctors may also be tempted to rely more on intuition than evidence when treating those close to them, and may find it difficult to allocate limited resources impartially. This is a controversial and frustrating issue, because doctors often believe strongly that they are in the best position to treat those they care about. They may feel personally responsible for the safety of their loved ones, particularly because they are acutely aware of the imperfections of the healthcare system. The problem is that one is often not aware of the extent to which one s judgement is compromised in such situations. The relationship between the doctor and a close friend or relative can also be coercive. For instance, a child may feel unable to question a physician parent s recommendations or to voice his/her distress. 20 FEB 2018 SMA News

21 Many of us may turn to our families and friends for support when there is a problem at work; in contrast, the doctor who treats those close to him risks alienating part of his social circle, should there be a poor outcome. His patient may also have limited recourse to legal restitution, due to fear of damaging relationships and/or the social pressure to not take action against the doctor. Deciding whether to treat someone you are close to Answering these questions should allow us to better understand the wisdom of the decision to treat a close friend or family member: 5 Am I trained to address this medical need? Am I too close to obtain intimate history and to cope with bearing bad news if need be? Can I be objective enough not to overtreat, undertreat or give inappropriate treatment? Is my being medically involved likely to cause or worsen family conflicts? Is my relative more likely to comply with an unrelated physician's care plan? Will I permit any physician to whom I refer a relative to treat that relative? Am I willing to be accountable to my peers and to the public for this care? If doctors decide to take family members or close friends as patients, the hazards of an out-of-office consultation can at least be eliminated by scheduling a formal clinic visit. There should be a low threshold for referral to a colleague should a minor illness become more serious or prolonged. Sometimes, the doctor may be the best, or the only, qualified person to provide treatment for a loved one. In these situations, it may be useful to discuss management plans with a colleague and pay particular attention to documentation so as to provide an objective record of clinical findings. The doctor may find it difficult to refuse requests for treatment from those close to him/her. It is perfectly acceptable to make reference to the ECEG and other guidelines when politely declining to treat someone. Remember that there are other ways to be helpful, such as offering to be present for clinic visits or by texting afterwards to find out how things went. Doctors can be excellent well-informed patient advocates, even if we leave the formal medical care to colleagues who are able to temper compassion with equanimity. Self-treatment: concerns and consequences SMC s guidelines expressly forbid self-treatment for psychiatric issues and self-prescription of addictive or controlled drugs. 1 Doctors are permitted to treat themselves for minor or stable conditions and in emergencies, 1 but many continue to do so for more serious problems. This may be the most expedient course of action, but it is probably not the safest. Self-treatment invariably circumvents the rigorous process of history-taking and examination, which can lead to delayed or missed diagnoses. Doctors who self-treat must rely on themselves to prompt lifestyle modifications and ensure adequate follow-up in the management of their own chronic medical conditions. Many of us have also seen colleagues self-administer drugs that they have only anecdotal evidence for (since the privacy of selftreatment means that we do not have to hold ourselves to the same standards as when we treat patients). Doctors cannot remain completely objective when diagnosing or treating themselves, which may not be apparent to them and could result in delays in seeking help. Some doctors self-medicate because they fear that their licence to practice may be jeopardised by a formal medical diagnosis, particularly of psychiatric problems. However, SMC s current application form for the renewal of a practising certificate does not demand disclosure of any or all psychiatric and medical history, but only that which may impair performance. It is also particularly dangerous to self-treat for mental health issues because it usually means bypassing psychotherapy and counselling in favour of drugs, which can lead to worsening mental health issues and even substance addiction. Unfortunately, doctors are also reluctant to both take time out of their own schedules and to bother busy colleagues, and are sometimes even afraid of being ridiculed for asking for help. We need to extend the compassion that we have for our patients to our colleagues, so that doctors are allowed to be patients too. This is a kinder and more effective route than treating ourselves, and it will allow us to provide better care for our patients as well. References 1. Singapore Medical Council. Ethical Code and Ethical Guidelines (2016 Edition). Available at: 2. The AMA Code of Medical Ethics opinion on physicians treating family members. Virtual Mentor 2012; 14(5): General Medical Council (UK). Treating family members. Available at: guidance/10247.asp. 4. La Puma J, Stocking CB, LaVoie D, Darling CA. When physicians treat members of their own families. N Eng J Med 1991; 325(18): La Puma J, Priest ER. Is there a doctor in the house? An analysis of the practice of physicians' treating their own families. JAMA 1992; 267(13): Gold KJ, Goldman EB, Kamil LH, et al. No appointment necessary. Ethical challenges in treating friends and family. N Eng J Med 2014; 371(13): Montgomery AJ, Bradley C, Rochfort A, Panagopoulou E. A review of self-medication in physicians and medical students. Occup Med 2011; 61: Dr Neeta spent several years as a resident physician in anaesthesiology and clinical ethics. She is now a clinical tutor with the Centre for Biomedical Ethics and is eternally optimistic about the next generation of doctors. FEB 2018 SMA News 21

22 INSIGHT Text by Dr Lee Ser Yee, Dr Chai Shu Ming and Dr Chan Chung Yip Part 1 Why is it important? This is the first article in a three-part series on how to choose a fellowship programme for specialty training. In this section, the importance of a good fellowship and how to get started in your search for one is highlighted. Introduction Among all the professions, a medical specialist probably has one of the longest training journeys. Depending on the country, field and subspecialty, it can take up to ten or more years of gruelling training before one can be considered an expert. This stretches up to 20 years or more particularly in some of the more complex surgical subspecialties, as surgical disciplines often require more time for an adequate hands-on experience to allow stepwise progression of surgical skills and to overcome multiple learning curves. 1,2 This is in stark contrast to other professions and occupations in which most will become experts in their field after three to five years. 3,4,5 In many cases, the fellowship serves as the last phase of this marathon. Much has been written about the state and evolution of the medical education and residency system but in contrast, little has been written about this crucial period of fellowship. 6,7 One would expect this important finishing school to be well researched and written about. However, as compared to other professions and fields, there is scanty literature on the process of how one can get into a good fellowship programme. There are several ways to achieve this and one will encounter many processes. There is a variety of factors one will need to consider, decide on and work towards in this effort of optimising their chances of success in getting into their fellowship programme of choice. The thought processes, suggestions and solutions at each phase may be helpful. This is a perspective piece on the intricacies of securing a position in a good fellowship programme written as a three-part series. This is drawn from the collective experience of the authors, their colleagues, mentors and friends. Obtaining a choice fellowship position is as much an art as a science, and maybe also luck. Many factors, some more obvious and objective, some softer and more subtle, can all influence the outcome in one way or another. We aim to share our collective experience and the process in various steps by asking important questions and detailing the things that can be done. Why is it important? Subspecialisation has become more of the norm than an exception, parallel with the decline of general Legend 1. Dr Lee with his Grand-Mentor in Memorial Sloan Kettering Cancer Center (MSKCC), Dr Leslie Blumgart one of the fathers of liver surgery 2. MSKCC Fellows vs Attendings' Annual Softball Tournament in Central Park, New York City. An honoured tradition in the summers. FYI, the Fellows won 1 surgery. 8 The practice of medicine has evolved tremendously; it is no longer enough to be a general specialist without a subspecialty or even a super-subspecialty, especially in tertiary centres or academic medical institutions. 9,10 More and more often, fellowship has become a common and basic requisite of applications for an attending or consultant position at many centres worldwide. Necessity is the mother of invention; in fact, many have suggested that the introduction and flourishment of fellowships is borne from the inadequacies of the residency system. 8 In a large North American survey of fellowship programme directors, there is a sentiment that most of the general surgery residency graduates were not well trained enough or ready for fellowship. 11 Without dismissing the importance of basic medical education and training, I would argue from a specialist s point of view that in this day and age, a fellowship is probably as important, if not more, as a residency or medical school education. It is the skills that one hones during this penultimate training phase that one will need the most when practising as a specialist. 12 Besides these skill sets, this is also when one acquires the experience and clinical maturity required to treat complex conditions or tackle procedures with narrow margins of error. 10,13 Moreover, it is this role that many specialists will be fulfilling on a daily basis in the latter 20 to 30 years of their professional life. The fellowship is the single most definitive period to prepare oneself for that. Despite the growing consciousness of the importance of fellowships,

23 2 glaringly little has been written about how one can get into one. 14 A quick search on Google will reveal that most information on the search term how to get into a good fellowship is hidden in informal blogs and forums rather than in mainstream validated information databases such as PubMed or Google Scholar. The selection process for fellowship is far less organised and more complex than the established processes for medical school and residency worldwide. 15 There is a complex interplay of objective and subjective factors that goes in the minds of fellowship directors and selection committees during every cycle. 15,16,17,18 We shed light on some of these based on our experience. How to get started? It s never too late to think about it and plan for it, if one has not done so already. A mentor once told me: Decide on who you want to be; you can t and won t be training forever. Decide or come to understand what your passion is and more importantly, what you are good at. Simply put, you are more likely to fall in love with something you have a talent or aptitude for than something you don t excel in. Notwithstanding generalisations, if you prefer to work with your hands or have been good with it since young, it s more likely you will like and do well in surgery compared to someone who hated carpentry classes in school and prefers mathematics or subject matters dealing with theories and solving equations. Decide on what makes sense and where your final destination is. Using Hepato-pancreatobiliary (HPB) surgery as an example: Do you want to be just a general surgeon with an interest in HPB (ie, one who does simple gallbladder and liver surgery), a HPB generalist, a HPB surgical oncologist, a HPB/liver transplant surgeon or a HPB minimally invasive surgery (MIS) surgeon? The permutations can go on. Does your dream job include doing some research as a clinical researcher or a clinician-scientist, or running a laboratory full-on and writing grants while doing the occasional surgery? Are you good in teaching or do you like to teach? If so, what would be your preferred workplace? Is it an academic institution, a community hospital or private practice? If an academic setting is your goal, then choosing a reputable academic institution for fellowship will put you in good standing for the next job and will also provide networking opportunities for future collaborations. 19,20 Similarly, a fellowship with big names or well-known hospitals will provide you with some clout and branding to get the private practice job. On the other hand, for those who wish to serve in the community and in non-tertiary establishments, a broadbased fellowship may serve you better in terms of the appropriate skills and experience in the long term. Do your homework and research. Talk to experts in the field about the future of the field you wish to embark in. The last thing you want to do is to blindly, foolhardily and over-enthusiastically plunge into a sunset industry. If one insists on doing so, one should dive in with eyes open. A good start will be by talking to seniors in the field and asking for their insight and opinions of the particular subspecialty and its future. Read widely, and just as importantly, write and publish in and around the field of interest of your destined or desired specialty. A mentor once said: If you write enough, you do not need to read. Attend, present and participate in conferences, meetings and courses these serve well to broaden one s perspective. These are also great platforms that highlight where the cutting edge lies and allow a sharp eye to catch a glimpse of the future; take note of where these innovations or good work are being developed. These meetings also provide an opportunity to talk and listen to the thought leaders and know the industry s who s who, so to speak. Put aside potential future personal achievements; choose a fellowship based on your own insight on your abilities, aptitude and passion, that will help you contribute the most to the field this will be ideal. Forums and blogs are also great resources and contain a wealth of information from people with similar interests and questions, but like everything on the internet, the accuracy of the information is only as accurate as the source. One should read it with some perspective and exercise sound judgement. Lastly, if time and finances permit, visit the programmes or institutions you have in mind at least a cycle before the application opens, as this will allow you to have a first-hand account and experience of the place, its culture and most importantly, its people. Information gained from being on the ground is golden. Besides the programme directors and attending staff, interact with the current fellows, residents and various members of the FEB 2018 SMA News 23

24 Dr Lee is a Hepatopancreato-biliary and Liver Transplant surgeon in SGH. A glutton for punishment, he completed double fellowships in New York Presbyterian Hospital- Weill Cornell Medical Center and Memorial Sloan Kettering Cancer Center. He still believes grit is more important than talent. team, if the opportunity arises, and hear what they have to say. You will be surprised what useful information you may garner during an informal social setting, like over coffee or a couple of drinks. Regardless of whether these are good or bad bits of information they may help you make a more informed decision. Also, if you are able to obtain the permission to do so, attending the weekly meetings (eg, mortality and morbidity conferences, and fellow teaching sessions), observing their operating theatres or sitting in for their clinic sessions can be very valuable experiences. These visits will better provide you with the feel of the place and enable you to see if you would be a good fit. Additionally, it will display your sincerity and genuine interest in the programme. We feel that these unofficial ad-hoc interactions and casual conversations may hold more weight in decision-making on both ends than a formal interview where everyone is more guarded and it is difficult to obtain a sense of the working environment. This concludes the first part of the series. Stay tuned for the second part, in which we elaborate further on the options one needs to and should consider in deciding where to go. In other words, how does one choose? Dr Chai is the program director of the SingHealth Ophthalmology Residency Program. She trained in corneal and refractive surgery in New York, and enjoys proving her husband wrong. Dr Chan is Head of Department of Hepatopancreato-biliary (HPB) and Transplant Surgery, SGH. He trained in laparoscopic liver surgery and liver transplantation in Taiwan and Korea. He enjoys the occasional glass of wine and discovering good hawker food. References 1. Chiow AK, Lee SY, Chan CY, Tan SS. Learning curve in laparoscopic liver surgery: a fellow's perspective. Hepatobiliary Surg Nutr 2015; 4(6): Hirschl RB. The making of a surgeon: 10,000 hours? J Pediatr Surg 2015; 50(5): Ericsson KA, Prietula MJ, Cokely ET. The making of an expert. Harv Bus Rev 2007; 85(7-8):114-21, Allen J, van der Velden R, eds. The Flexible Professional in the Knowledge Society: New Challenges for Higher Education. Springer Netherlands, udemy. How long does it take to become an expert? Available at 6. Azer SA. Exploring the Top-Cited and Most Influential Articles in Medical Education. J Contin Educ Health Prof 2016; 36 Suppl 1:S Zhu J, Li W, Chen L. Doctors in China: improving quality through modernisation of residency education. Lancet 2016; 388(10054): Bruns SD, Davis BR, Demirjian AN, et al. The subspecialization of surgery: a paradigm shift. J Gastrointest Surg 2014; 18(8): Altieri MS, Frenkel C, Scriven R, et al. Effect of minimally invasive surgery fellowship on residents' operative experience. Surg Endosc 2017; 31(1): Altieri MS, Yang J, Yin D, et al. Presence of a fellowship improves perioperative outcomes following hepatopancreatobiliary procedures. Surg Endosc 2016; 31(7): Mattar SG, Alseidi AA, Jones DB, et al. General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors. Ann Surg 2013; 258(3): Burlew CC, Davis KA, Fildes JJ, et al. Acute care surgery fellowship graduates' practice patterns: The additional training is an asset. J Trauma Acute Care Surg 2017; 82(1): Helling TS, Khandelwal A. The challenges of resident training in complex hepatic, pancreatic, and biliary procedures. J Gastrointest Surg 2008; 12(1): Plerhoples TA, Greco RS, Krummel TM, Melcher ML. Symbiotic or parasitic? A review of the literature on the impact of fellowships on surgical residents. Ann Surg 2012; 256(6): Joshi AR, Vargo D, Mathis A, et al. Surgical Residency Recruitment-Opportunities for Improvement. J Surg Educ 2016; 73(6):e Egro FM, Blecher NA, Gimbel ML, Nyugen VT. Microsurgery Fellowship Selection Criteria: A National Program Director Survey. J Reconstr Microsurg 2017; 33(3): Socolow DJ. Picking winners. Interview by Diane Coutu. Harv Bus Rev 2007; 85(5):121-6, Dort JM, Trickey AW, Kallies KJ, et al. Applicant Characteristics Associated With Selection for Ranking at Independent Surgery Residency Programs. J Surg Educ 2015; 72(6):e Dominguez-Rosado I, Moutinho V, DeMatteo RP, et al. Outcomes of the Memorial Sloan Kettering Cancer Center International General Surgical Oncology Fellowship. J Am Coll Surg 2016; 222(5): Watts G. Fellowship links researchers in the UK and the Middle East. Lancet 2016; 388(10058): FEB 2018 SMA News

25 SMA Seminar: Tax Obligations on Medical Practice Date: 31 March 2018, Saturday Time: 1 pm to 5 pm Venue: M Hotel Singapore, Banquet Suite (Level 10)* CME Points: 2 (Pending approval from SMC) What are the tax obligations of a clinic set up as a business or as a company? Is one better than the other in the current tax regime? What s new in the 2018 Singapore Budget and can you take advantage of it to future-ready your practice? Answers to these questions, and more, will be explored by our invited speakers during this seminar. Who should attend? Private practice practitioners, clinic owners (especially new owners and those not represented by tax agents) and staff who assist in clinic tax and corporate matters will benefit from this seminar. You will gain basic understanding of this topic to better manage the medical practice and to fulfil its required tax obligations. Programme 1 pm Registration (Lunch will be provided) Topics include: Your medical practice and its tax obligations 2 pm to 4pm Understanding GST Budget 2018 and its impact to your practice 4.30 pm Questions and Answers 5 pm End of Seminar For more information about this seminar and our other courses, please visit our website or contact Ms Jasmine Soo at or jasminesoo@sma.org.sg. *Parking at M Hotel is at $5.80/entry after 1 pm on Saturdays. Booth sponsor: SIGN UP FOR OUR COURSES ONLINE Track the SMA courses you have attended via our membership portal Step 1: Visit the SMA Website Step 2: Log in to your SMA Membership portal. Step 3: Search for SMA Seminar: Tax Obligations on Medical Practice. Step 4: Key in your particulars and click Submit. REGISTER ONLINE Done! You will receive an acknowledgement and see the list of courses you have signed up for within your membership portal.

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27 Survival Medicine: The Modified HOBBIT Montgomery Test (Part 2) This is the second instalment of a two-part reprint from the SMA Hobbit s blog. The first instalment was published in the January issue of SMA News ( MM test: boundaries already creeping? In para. 62 of the High Court Judgement issued by the Court of Three Judges in the Chia Foong Lin case on 27 June 2017, it was stated: When the available tests to exclude Kawasaki Disease (KD) are simple to undertake and when the consequences of no timely treatment of KD could be severe, it is not for a doctor to take chances with the well-being of a patient. If there was a need to take chances, that determination should be left for the patient (or his parents if the patient is an infant) to make on an informed basis. We struggle to understand why such exclusionary tests, which were not harmful to the Patient, were not undertaken, or why the parents of the Patient were not informed of their availability. It is here that Dr Chia badly faltered. 1 It would appear here that having a patient-centric (or rather in this case, parent-centric) approach to advice given not only applies to treatment but has now also creeped into advice for investigation in order to make a diagnosis as well. Is the modified Montgomery (MM) test strictly limited to advice for treatment or does it impact advice for investigation as well? In the Judgement given by the five judges in May 2017 in Hii vs Ooi, 2 it was stated in para. 96: where the diagnostic method is routine, non-invasive and risk-free (as in the case of the measuring of body temperature or blood pressure), the MM test need not be applied. So, if you read the two judgements, one could ask: Does the MM test apply to the decision to order 'unharmful' blood tests or not? Is the reach of the MM test creeping further than originally intended? Was Dr Chia guilty of professional misconduct because she omitted ordering the test, or because she did not give advice to the parents so that the parents could make an informed decision whether to have the test? Or does the Bolitho-Bolam (BB) test continue to apply with great force in the diagnostic context (para. 101)? This Hobbit doesn t have the answer to these questions either. To be on the safe side, this Hobbit will be applying the MM test to all information transfers from doctor to patient, whether the information is for treatment or just ordering an unharmful blood test. The patient will have to decide on an informed basis whether he/she wants an unharmful test or not. This change in practice has become an essential part of my survival medicine toolkit. National Electronic Health Record (NEHR) There is a lot of talk that participation in the NEHR will be made a requirement for clinic licensing (ie, participation in NEHR by hospitals, clinics and doctors will be made compulsory). The doctor therefore will soon have access to years and years of patient information that may be relevant to the stipulation of the MM test that other types of information that may be needed to enable patients to make an informed decision about their health should be given to the patient. Problems arise when a doctor misses out on information in the NEHR that was recorded a long time ago. Is the doctor truly responsible for taking into account the whole record of the patient from birth till present so as to tailor-make relevant advice for every patient, such that the patient can make informed decisions? Is this humanly possible given the constraints of time, resources and simple human frailty? The MM test more or less says that the doctor is not responsible for not taking into account the information if the patient doesn t give the information to the doctor, and especially if the doctor has made some effort to elicit such information. But does this afford the doctor significant protection when almost all information is already in the NEHR and the NEHR is readily available to all doctors? Must the patient still FEB 2018 SMA News 27

28 give the information when the physical consultation takes place? Would the doctor be held liable because of the extensive coverage of the NEHR? The prospect of being guilty of professional misconduct, because the doctor missed out a relevant morsel of information in the cavernous repository that is the NEHR, is real and possibly quite alarming. Defensive medicine The judges have opined that the MM test will not lead to defensive medicine. No one can really predict the future with 100% accuracy, but this Hobbit hopes that the judges are correct. As this Hobbit has said in a previous column, the Hobbit doesn t really know what defensive medicine is. The Hobbit has to practise survival medicine so as to NOT run afoul of Singapore Medical Council s (SMC) requirements and the law, and stay registered as a doctor. Resources required The first likely consequence of the MM test is that advice (and consent-taking) will take a much longer time than in the previous BB test era. A professional s time is a precious resource, be it for a doctor, accountant or lawyer. So, appropriate fees have to be charged to reflect the time and resources spent. With the extensive work that the MM test requires, this Hobbit wonders if consenttaking should be made a separate long consultation by itself and therefore is chargeable as a separate encounter between the doctor and the patient? Since we are on the subject of resources, the private sector actually has it better. The private sector can readily adjust prices or turn away work so as to give each patient better attention and more time so that advice given can be compliant with the MM test. The public sector will find this more difficult. They can neither turn away work nor readily titrate work volume using the price mechanism, since most of their work involves subsidised patients. The end result is that either waiting and appointment times have to lengthen or the system has to employ more doctors. In the distant past, the public sector was able to cut some corners, eg, use junior staff to perform tasks like advice and consent-taking. But this is no longer possible, because from another core ethical principle of justice, private and public sector patients must be accorded the same level of protection under the MM test. Another consideration is that public sector doctors usually know their patients less well than those in the private sector. Many patients see different doctors over time, especially in the subsidised classes, and so the chances of missing out on relevant information about the patient is higher, while the MM test demands that the doctor gives advice in the context and from the perspective of the patient. You cannot give the right advice when you do not even notice the relevant information. Basically, the MM test requires less effort on the part of the doctor, when there is good continuity of care with the same doctor, which is hardly possible in the public sector due to training and service imperatives. My way forward (which may not be yours ) I do not profess to have the solution or model answer to complying fully with the MM test, but I shall share with you what I think will work for me, to the best of my limited abilities. The MM test is divided into three parts. This hobbit suggests that advice-giving could also be divided into three parts: 1. Advice to the reasonable patient 2. Advice arising from information from past medical records 3. Advice arising from information actively obtained from current encounter The first part deals with a doctorcentric model of the reasonable patient. The reasonable patient is an artificial legal/ethical construct that does not exist physically. In the BB test era, as long as the doctor gives advice sufficient for the reasonable patient, he is absolved of wrongdoing. Here, I think standard forms can be designed and used as a checklist to aid both the doctor and patient when the doctor gives advice, especially for common procedures such as a colonoscopy, transurethral resection of the prostate, removal of breast lump, etc. The second part deals with information that can be gleaned from the patient s records, such as the NEHR. This is perhaps where Artificial Intelligence (AI) tools can be designed to automatically screen a patient s electronic record to highlight relevant and important information for both the patient and doctor. I think an AI tool will be far less error-prone than a doctor scrolling and reading a voluminous patient record quickly. But for now, we still have to just go through the past medical records manually and look for aspects that we think, from the patient s perspective, will affect our advice-giving those aspects that happen to be more than what is required by the hypothetical reasonable patient. In giving advice, both doctor and patient should sign off the standard forms, AI-highlighted information and the advice that is consequently given. The third part involves the doctor actively eliciting information that is not expected of the reasonable patient or highlighted from the patient s electronic records and giving relevant advice from the information obtained in the second phase. The doctor can and should ask the patient: Is there any other information you want to tell me that I do not already know from your past medical records that you think may affect my advice to you from your perspective? On top of this, an audio recording, with the patient s consent, of the entire three-part advice-giving process should be made. The patient s decision to give consent or not to an audio recording should be duly documented and acknowledged by the patient in writing (a simple signature in a simple form would suffice, I suppose). If the patient refuses to even acknowledge in writing that he refused giving consent to making an audio recording, then the doctor can 28 FEB 2018 SMA News

29 always refuse to carry on with the doctor-patient relationship and stop the consultation in non-emergency situations. (The MM test only applies to non-emergency situations anyway.) I am not advocating this approach to anyone, but it is my personal best effort response to complying with the MM test now which is to make an audio recording. It is useful for both the patient and the doctor when a dispute arises. Survival medicine in the new era Let us now return to survival medicine, which is what this Hobbit is trying to achieve to ensure his professional survival. Recently, three unrelated events have collectively affected me greatly. The first is the new 2016 Ethical Code and Ethical Guidelines (ECEG) and SMC Handbook on Medical Ethics (HME) which have been in force since The new ECEG is 65 pages long and the HME is 155 pages long. That s 220 pages in total and multiples in length of the last version. This weighs heavily on this Hobbit. It s tough reading through both documents and complying with them is even tougher. When the prosecution lawyers throw the book at you today as they draft their charge(s), you can bet there is a lot more book to throw at you all 220 pages to be exact. The second is the MM test. Some of the implications of the MM test have been described above. The MM test demands a lot more effort from doctors, because doctors now do not have to just give advice that is relevant to the reasonable patient, but information that pertains to the particular patient s circumstances and perspective that the doctor should have known. The third is a little lesser known. It is a High Court judgement delivered on 25 July 2016 on the case of Singapore Medical Council v Wong Him Choon. In para. 117 it is stated: As can be seen from Lee Kim Kwong and Kwan Kah Yee, we have on at least one previous occasion referred to and, on another, exercised our discretion to depart from precedents that do not reflect the prevailing circumstances and state of medical practice. In our judgment, public interest considerations weigh heavily in imposing deterrent sentences on errant doctors who are found guilty of professional misconduct. In this regard, we expressed at the hearing that we found the sentences imposed in the Dr K case, Dr L case and Dr Amaldoss case ( the Relevant Precedents ) to be lenient. We observed without reservation that these sentences should have in fact been longer. We highlighted to the parties that this court has given fair notice of its intention to recalibrate sentences across professional misconduct cases, and would do so in the present case. 3 In other words, in many cases, doctors can expect to face more severe punishments than in the past should they be guilty of professional misconduct, especially in cases where the public interest is involved. Personal survival medicine I do feel anxious about the current and future practicing environment. When I ask questions about certain aspects of the MM test to lawyers, many of the answers come back as: We are not sure, this has not been tested in the Courts yet. We have to wait for the first case. There is uncertainty in both medical and legal work (the Honourable Chief Justice made this point as well in the Ransome Oration) and we have to accept that. But still, it is hardly reassuring. I know doctors who would rather have a purulent abscess in their buttocks than be a test case for the SMC or Courts. An abscess you can drain and treat over a few days; a test case can last for months if not years. So, again, my response is to practise survival medicine: be safe, rather than sorry. I am prepared to overcompensate a little out of prudence. Is that defensive medicine? Like I said, I do not know what defensive medicine is. I just know I need to practise survival medicine. I need to survive. References 1. Chia Foong Lin v Singapore Medical Council [2017] SGHC Hii Chii Kok v Ooi Peng Jin London Lucien and another [2017] SGCA Singapore Medical Council v Wong Him Choon [2016] SGHC 145. FEB 2018 SMA News 29

30 gp matters Text by Dr Ajith Damodaran When I applied to study medicine, I could not think of what to put down as my second or third choice. I would not have known what to do if I did not get admission. It was thus a big relief to have gained admission and the rest of medical school was a journey. I never saw it as being five years long. The next big relief was passing the finals. For me, it was just getting over another hurdle so that I could just get on with becoming a doctor. I found all of medicine to be very interesting; while I could have been good in orthopaedics (I like repairing things) or obstetrics and gynaecology, I could not let go of the rest of medicine. Therefore, there was only one specialty to consider: general practice. After serving National Service, I was off to the UK to find a way into their General Practice Vocational Training Scheme. After three months of trying, I had to cut my losses and come back. In the early 1980s, Dr VL Fernandez was a very prominent GP and I wanted to work with him. I was fortunate to have the opportunity to do so in the group practice. Dr Fernandez was very active in promoting the recognition of general practice as a unique specialty, and it was a privilege working with him and his partners. I picked up many pearls of wisdom from him, which has, in many ways, left a big impact in my practice. My venture into solo practice I made a decision to start my own practice in late I was initially very scared as I did not have any idea how to run a business and I sought advice from several senior colleagues who had gone on to do solo practice. Finally, at dinner with a close friend (a much older person), I was asked what my worst fears were. I was then newly married, afraid of losing too much money and basically feared failure. He then led me through several what if s and then what s, which helped me realise that I was capable of dealing with all the worst-case scenarios. I was not so scared anymore and got on with setting up my own practice. I was also very fortunate to have had the opportunity to take over Dr Fernandez's practice. 30 FEB 2018 SMA News

31 I cannot remember ever having a tough time. From the beginning, I worked only two sessions a day from Mondays to Saturdays, and mornings only on Sundays and public holidays. Then came SARS, and I was exposed to a nursing home s staff member, who eventually died from it. Those were the most frightening days having to check my temperature several times a day until I was cleared. I promptly made a decision to stop working on Sundays and public holidays, and to work only one session a day on Fridays and Saturdays, with two sessions for the rest of the week. I have not looked back since. Being a part of each family I have always enjoyed practice and over the years of working as a family physician, I now have a few four-generation families who look to me as their family doctor. I have experienced so much joy in seeing young parents and their children go through years of school, university and then work and marriage. I have been invited to countless weddings and I shamelessly shed tears of joy at each one. I have walked someone, whom I looked after since she was a child, down the aisle at her wedding in Stockholm, because her mother had refused to have anything to do with her choice of husband. I spent many sessions helping her through her struggles until she finally had the courage to follow her heart. I still meet her and her husband whenever they are in Singapore with their two lovely children. I was once referred a lady who lost her husband suddenly while her children were still young. When patients need more time with me during a consultation, they somehow come at a time when I actually have no other patients waiting. This has happened many times. After spending some time in my counselling mode, I realised that she just needed someone to understand her struggles, and to assure her that it was OK to be happy and wear colourful clothes and to start life over. She also needed a prescription for some sedatives, so I wrote one for ten tablets and never saw her again. I received a Christmas card some months later. She said that after she left my clinic, she knew that she was cured. She never had to use the medicine I had prescribed and she had no trouble sleeping. This was an important point in my early professional life: realising the potency of a doctor as the therapeutic agent. I knew the theory from reading Eric Berne and his concept of Transactional Analysis. This was my epiphany, and I have never separated the mind from the body since. I keep my practice very simple, prescribing the least number of medicines that would make a difference. I hold the words doing the common things uncommonly well closely. There was once a mother who brought in a child with an intractable cough, despite having consulted a prominent paediatrician several times. The medications were escalated as the child s condition was not improving with the prescribed inhalers. After taking a history, I asked the mother to show me how she used the inhaler. She very confidently did so, plugging the inhaler upside down onto the spacer. She did this consistently with both types of inhalers. Very gently, I demonstrated how the inhalers will not work when used upside down. A written plan was worked out and a week later at review, the child was doing very well with the inhalers alone. I feel so much joy when I am able to solve such issues with simple or elegant solutions. It is a joy when the child stops getting asthmatic attacks with a simple plan of action I wrote, involving all the medicines they already have. Joy in imparting knowledge Another big source of joy is in teaching. I have always enjoyed having students I have had premedicine students who make a decision to do medicine, and also those who choose not to. One student (patient too), who chose not to do medicine, is thankful for the decision he made to pursue another discipline. For me, students have always been a stimulus for self-reflection. They ask questions that get me thinking about why I do what I do and the basis for my conclusions. I discover my own gaps of knowledge. I keep a journal of my students' reflections written at the end of their posting this is my source of inspiration to continue being a teacher. I have often been asked if I will retire. How can I, when I am doing my best work now? It would be a waste if I stopped. I am still a work in progress and I am learning so much from my ex-students who are now in the early and midpoints of their careers. I look forward to having them as my coaches and also passing on what I have learnt from my 40 years of practice. My relationships with my patients keep me coming back to work every day, knowing that the simple things I do make a big difference to their lives and health. I feel safe being honest with them and not having to practise defensive medicine. I am happy when they trust me enough to take my advice even with no medicine prescribed. I wanted all of medicine and family medicine is where all of medicine comes together. I have it all. A candle loses nothing by lighting another candle. James Keller. Dr Ajith graduated from the University of Singapore with an MBBS in He has been a tutor for medical students and trainees, and is also involved in geriatric and palliative care. Outside work, he does dance classes and is a tinkerer. He dabbles with electronics, photography, cooking and hydroponics, among other things. He received the Dean s Award for Teaching Excellence (2013/2014) from NUS Yong Loo Lin School of Medicine. FEB 2018 SMA News 31

32 AIC SAYS ENHANCED PATIENT CARE in the Community through Primary Care Networks By Agency for Integrated Care Senior Minister of State for Health, Dr Lam Pin Min (left) listening intently as Dr Wong Tien Hua gives his perspective on PCNs. In an effort to provide patients with more holistic primary care, the Primary Care Networks (PCNs) scheme enables patients to be cared for under a multidisciplinary team and have access to ancillary and support services. Under the scheme, General Practitioners (GPs) from private clinics can form virtual networks to share resources and provide teambased chronic disease management in the community. In 2017, the Ministry of Health (MOH) committed a budget of $45 million per year to support the PCN scheme over the next five years. Participating GPs are now provided resources through MOH and Agency for Integrated Care (AIC) to enable more seamless care for their patients with chronic disease. Leveraging on inter-disciplinary expertise through a chronic disease registry administered by each PCN, participating GPs on PCNs are now better supported administratively to closely monitor and manage their patients chronic conditions. The collaborative effort of the GPs, nurses and primary care coordinators in a team-based manner strengthens the support for chronic patients. Coupled with PCN ancillary services, patients can receive comprehensive disease and lifestyle management advice by nurse counsellors to better understand and manage their chronic conditions. Diabetic patients could also receive their routine diabetic retinal photography and foot screenings nearer to them. In addition, the primary care coordinators support patients through appointment scheduling and referrals to other healthcare services and social support if necessary. Following the PCN application call held from 1 April to 31 May 2017, the MOH had announced in January 2018 that eight new PCNs had been appointed on 1 January 2018; bringing the total number of PCNs in Singapore to ten, comprising 340 GP clinics island-wide.. By coming together to form networks, these likeminded GPs can achieve economies of scale and optimize resources to deliver more holistic care in a team-based care model. MOH is committed to supporting the PCNs. Dr Lam Pin Min Senior Minister of State for Health, Ministry of Health Frontier PCN Team, including GPs, nurse counsellors and primary care coordinator, with Senior Minister of State for Health, Dr Lam Pin Min (fourth from left). 32 FEB 2018 SMA News

33 Listing of Primary Care Networks Primary Care Networks (PCNs) 1 Assurance PCN 2 Central-North PCN 3 Class PCN 4 Frontier PCN (with effect from 1 October 2015) 5 i-care PCN 6 NUHS PCN (with effect from 1 April 2017) 7 Parkway Shenton PCN 8 Raffles Medical PCN 9 SingHealth Partners PCN a) SingHealth DOT b) SingHealth Regional 10 United PCN Chronic Disease Registry under the PCN scheme What is a Chronic Disease Registry? Chronic Disease Registry (CDR) is a database that contains the personal and medical information of patients that allows monitoring of patients for better care management and follow ups. How does it help with chronic disease patient management? It enables the doctors or clinics to track and monitor patients chronic conditions such as Diabetes Mellitus, Hypertension and Hyperlidemia systematically. This also helps to ensure that patients follow through their care plans and receive the necessary management. The overall data in the registry can also be used to drive improvement in care delivery. On 15 January 2018, the Senior Minister of State for Health, Dr Lam Pin Min, visited Dr Wong Tien Hua from Mutual Healthcare Medical Clinic, a participating GP partner of the Frontier PCN located in north-eastern Singapore. Citing the importance of PCNs in the provision of better healthcare outcomes for Singapore s patients with chronic conditions, he lauded the increasing number of GPs participating in the PCN scheme, such as Dr Wong. To find out more about PCNs or how you can join one, please visit today. You can also write to AIC at gp@aic.sg or call By grouping together and forming a PCN, resources such as Diabetic Retinal Photography, Foot Screening and Nurse Counselling can be shared. The provision of Nurse Counselling services and the close tracking of patients on the Disease Registry will achieve better patient compliance and improvement in patients medical issues. The funding from MOH and AIC also help manage the direct costs of these services for our patients. Dr Jacqueline Yam Medical Director, AcuMed Medical Group PCN Leader Assurance PCN I believe PCN will strengthen the doctorpatient relationship. Patient care is enhanced because the PCN doctors will be better supported in terms of training, manpower and resources to better manage and monitor patients with chronic diseases. The patients will also benefit in terms of easy access to investigations, counselling services and tighter monitoring of their chronic diseases. Dr Lim Chien Chuan Family Physician, Sims Drive Medical Clinic PCN Leader i-care PCN FEB 2018 SMA News 33

34 INDULGE Text and photos by Dr Jimmy Teo 1 Say Okinawa and most people would be hard-pressed to find it on the map. Many will also tend to associate Okinawa with Japan. I learnt more about this island during my recent visit for a conference. Okinawa is the largest island of Okinawa Prefecture and it lies closer to Taiwan than to the mainland parts of Japan (Honshu and Kyushu islands). Intermittent direct flights are available from Singapore but most visitors from Singapore fly via Hong Kong or Taiwan. The Kingdom of Ryukyu History is fluid and often a story written by the victors; the history of Okinawa holds lessons for small island nations like Singapore. The old name of Okinawa was the Kingdom of Ryukyu, and it maintained its independence through exercising a delicate balance of power between Imperial China and Japan. However, at the decline of the Qing dynasty, Okinawa was entirely annexed by Imperial Japan in With the defeat of Japan in the Second World War, Okinawa came under the trusteeship of the US. In fact, I was surprised that it was only in 1972 that Okinawa was returned to Japanese administration, despite an Okinawan independence movement. That said, the US maintains a large military presence in Okinawa even till today. Naha city is the political and economic centre of the Okinawa 34 FEB 2018 SMA News

35 2 Prefecture. Having my meal at a ramen bar was quite an experience. I had to fill out an order form upon being seated at the bar. Not able to read or speak Japanese, I had no clue what I was going to get. Thankfully, many technical Japanese terms are in Chinese characters; so I circled everything labelled standard and one less, presumably for salt. I was pleasantly surprised when my dinner was served Oishii! In any case, there are many restaurants with picture menus, and you may well enjoy the ambience of some uniquely designed restaurants in Naha city. Off the main shopping street (Kokusaidori), one can walk into the market street (Makishi Kosetsuichiba). Here there are many shops selling unique Okinawan products such as cane sugar and sea grapes. There is also the popular Makishi Public Market where there are many stalls selling Okinawan produce, including pork, fresh fish and the unique Okinawan bitter melon. Out of Naha The Okinawa Convention Center is located in Ginowan, right next to the sea and just a short distance from Naha. The public beach is within walking distance of the convention centre. At low tide, you can walk and admire the rock pools teeming with marine life. The fresh air, clear water and moderate temperature allow for a nice long walk, which soon helps us whip up an appetite for the sunset dinner gathering. Our Japanese friends became quite the party animals once they took off their coats and ties! Their friendliness helped to make all conference attendees feel welcome, and the gorgeous sunset performances completed the evening. The conference was well organised and offered many opportunities to network with other clinicians and scientists from all over the world. The opening ceremony even had a performance by a traditional Okinawan music and dance troupe. The conference dinner was held at Shuri Castle, which was rebuilt after being totally destroyed in the Second World War. I also managed to squeeze in a visit to Okinawa World to view traditional Okinawan arts and crafts. In it, there is also the Gyokusendo Cave, which is 890 metres long and filled with many interesting stalagmite and stalactite formations. Even though the conference trip was short and busy, I was intrigued by my visit and I resolved to return to drive around the island like many other tourists. It would also be interesting to go sea fishing, snorkelling and island hopping. I am getting excited just writing about it. See you there! Dr Teo is an associate professor in the Department of Medicine, NUS Yong Loo Lin School of Medicine and senior consultant in the Division of Nephrology at National University Hospital. He is the Division of Nephrology Research Director and an active member of the Singapore Society of Nephrology. 3 Legend 1. Sushi, anyone? 2. Okinawan performance at the conference's opening ceremony 3. Success! It looks edible FEB 2018 SMA News 35

36 SALE/RENTAL/TAKEOVER Clinic/Rooms for rent at Mount Elizabeth Novena Hospital. Fully equipped and staffed. Immediate occupancy. Choice of sessional and long term lease. Suitable for all specialties. Please call or Gleneagles Medical Centre clinic for rent. 400 sq ft. Waiting area, reception counter and consultation room. Immediate. SMS Fully furnished clinic room with procedure room for rent at Mount Elizabeth Novena Hospital. Suitable for all specialties. Please call Buy/sell clinics/premises: Takeovers: (1) D14 HDB/ industrial area (2) D14 Aljunied, good human traffic (3) D20 AMK sub-neighbourhood, MRT (4) D02 Chinatown, MRT (5) D10 Bukit Timah, large space (6) D05 Ghim Moh. Rental of clinic space: (a) D19 Serangoon Central (b) D16 near Bedok Central (c) D07 Selegie, inside mall (d) Novena Medical Centre, 451 sq ft. HP: Yein. Well established family practice clinic in central district ground floor shopping centre for takeover. Newly renovated, 2 consultation rooms and 1 dressing room. Fully computerized with clinic software for CHAS, Pioneer Generation, Medisave and electronic records. SMS to District 10, old solo-practice family clinic for take-over/ partnership. Good location, near market with existing clientele & great growth potentials. Please message/call for private discussions. One year operating GP clinic in the West, Level 1 of mixed development for takeover. 710 sq ft. Newly renovated, 2 consultation rooms + 1 treatment room. Handicapped toilet included in premises. Suitable for specialist clinic. Low takeover fee, negotiable. SMS to POSITION AVAILABLE/PARTNERSHIP New Extending Lasik Clinic: Looking for experienced and passionate consulting ophthalmologist lasik eye doctors to join new eye clinic. If you are interested to grow and build your career yet be rewarded with attractive remuneration, please call Busy Eye Practice 2500 sq ft with OT/lasers looking for Associates/Partners. Please contact All enquiries confidential. Fullerton Healthcare Group welcomes doctors to join our growing practice, both part time and full time. We offer a competitive remuneration package with comprehensive benefits for successful doctors. Interested applicants, please your full CV to michelle.lee@fullertonhealth.com. Position available at TLC Lifestyle [1] Doctors with an interest in non-invasive aesthetic practice with at least 2 years experience. [2] Associate positions for facility sharing. Please write in to hr@tlclifestyle.com to express your interest. Phoenix Medical Group requires doctor with minimum 4 years post HO experience and full registration for rapidly growing GP practice. Terms negotiable, profit sharing/eventual partnership possible. Send resume to askpmg@phoenixmedical.sg or contact for discussion. Doctor required to work full time in GP clinic in western part of Singapore. Contact Minmed Group invites doctors to anchor our clinics strategically located in Jurong East and Yishun. Ideal commitment to be hr/week with Sat am and 2-3 nights preferred. Nice work environment with good remuneration, bonus and profit sharing. Call/WA We are looking for resident doctor for our new clinic in the north. Good working hours and attractive salary. Generous performance-based bonus and long term partnership possible. Please message us at for further discussion. MISCELLANEOUS NEX Healthcare Pharmaceutical Supplies, Medical & Dental Shared Services Provider, Business Consultancy for doctors initiating new clinic or doctors planning to grow their chain of clinics across the island. We provide turnkey solutions in clinic set up, licensing, human resource planning, operational control, financial reporting, business analysis and pharmaceutical supplies to ensure your clinic functions efficiently and effectively at all times. enquiries@nexhealth.com.sg for your free tailored advice today! Date Posted 02/02/ /01/ /01/2018 SMA JOBS PORTAL Position : GO Positions Available: Click on each position's link for a detailed job description. Position/ Job Title Resident Physician General Practitioner Doctors & Associate Doctors, Staff Nurse (Full time & Part time) Organisation Singapore Cancer Society Point Medical Group TLC Medical Practice Pte Ltd Application Deadline Job No 31/03/2018 J /05/2018 J /02/2018 J00208

37 POSITIONS AVAILABLE A well-known healthcare organization in Singapore is looking for O&G Specialist and Doctor. Applicants with existing registration with Singapore Medical Council (SMC) or possess a medical degree registrable with SMC are welcome. O&G Specialist Responsibilities: Provide medical care related to pregnancy or childbirth. Diagnose, treat and help prevent diseases of women, particularly those affecting the reproductive system. Provide general medical care to women. Experience with IVF is preferred. Requirements: Candidates must possess at least a medical degree recognized by SMC. Accredited as a Specialist in O&G by the Ministry of Health (MOH) and SMC. Consultant Physician in Gastroenterology/Hepatology Skills Needed: An ideal candidate must have completed specialist training from either Singapore, USA, Canada, Australia, New Zealand or the United Kingdom. The following qualifications are recognized by Specialists Accreditation Board, Singapore for Specialist licence. FAMS or M.Med (S'pore) Must have completed CCT/CCST from UK Fellowship from UK, Canada, Australia or New Zealand American Board Certification (only Boards approved by American Board of Medical Specialities are accepted) Interested doctors, please send in your CV for a confidential discussion to: xindamedical@gmail.com. We are looking for an enthusiastic aesthetic doctor to join our practice. Extensive and continual training will be provided. AESTHETIC DOCTOR Requirements: 1. Full registration with the Singapore Medical Council & able to go into private practice. 2. Good to have certificate of competence for aesthetics procedures. Please send resume to: yoshiko@tokyogarden-clinic.com Tel:

38 Singapore Cancer Society established in 1964, is a communitybased voluntary welfare organisation dedicated to maximising life by minimising the impact of cancer through research and advocacy, public education, screening, financial assistance, patient services and support, and rehabilitation. Being selffunded, the Society is dependent on public donations to provide quality services to needy cancer patients, their families and members of the public. Resident Physician Job Responsibilities: 1. Provide medical support to hospice team (doctors, nurses, allied health), for palliative care to be delivered in an interdisciplinary and holistic way to hospice patients & their families. Includes communicating effectively with patients & caregivers to facilitate understanding of condition, particularly in prognostication, and optimising symptom control. 2. Palliate and manage patients symptoms & conditions relating to advanced/terminal illness (together with interdisciplinary team). Accountable for planning of care beyond providing medical advice to hospice staff during interdisciplinary meetings. 3. Collaborate with patients other healthcare stakeholders (eg medical oncologist, palliative medicine physicians/nurses/ social workers/therapists) as needed to maintain effective plan of care. Includes communicating via phone or to ensure good transition of care. 4. Assess patients progress towards goals regularly (at least every 15 days). 5. Manage security of controlled drugs. May collaborate with pharmacist if available or designate a senior nurse to co-manage but Resident Physician is ultimately responsible. 6. Provide quality assessment of hospice and alignment of services with National Guidelines for Palliative Care. Help team define and measure meaningful outcomes to assess effectiveness of interventions and medications. Job Requirements: 1. Must possess MBBS (Singapore) or equivalent. 2. Preferably a graduate diploma in palliative medicine. 3. At least 2 years of working experience in the related discipline. 4. Able to do after work hours on call coverage and conduct on call home visits when needed. 5. Compassionate and empathetic with the suffering and has passion in hospice and palliative care. Interested candidates are invited to apply with a comprehensive resume to kristin_lim@singaporecancersociety.org.sg We regret that only shortlisted candidates will be notified.

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