Sunday, December 20, 2009

Singapore Healthcare- A Personal Perspective

Hi Friends,

I know our healthcare system is not perfect.

And our doctors are definitely not “angels”.

But there are still Singapore doctors out there who are ethical and abide by the spirit of the Hippocratic Oath (even in the private sector) that I feel a defence of our system is warranted here.

Is our healthcare more expensive than our neighbours’ ? Are there times when we wished that the results from surgery or treatment were better? Are there black sheep in our system who are “outliers” as far as indications for treatment or treatment fees are concerned? The answers are of course “Yes”!

But would I still recommend my loved ones to be treated here in Singapore? Of course (except for the most trivial conditions).

In all hospitals (public and private), volunteer doctors and other personnel sit in committees to look into how healthcare can be better delivered to our patients.In my hospital, Gleneagles Hospital, amongst other things, committees ensure that there is Quality assurance; that all deaths are independently reviewed and surgical specimens from patients confirm that operations were really needed etc.

When near-misses or actual mishaps happen, we help the hospital to diligently look for the root causes and design correct processes to plug gaps in the system. We are often pleasantly surprised to know that in many near-misses, these mistakes are identified further down the line by another vigilant colleague who actually helped to avert potential disasters.

An “honour” system where healthcare workers including nurses and doctors, voluntarily submit “Hospital Occurrence Reports” (HOR) whenever such incidences occur. These range from serious ones such as prescribing patients with drugs that they are known to be allergic to, to trivial incidences such as patients having broken skin when plasters are removed.

In fact, reporting near misses is not unique to the healthcare industry. The aviation industry also reports near misses and the familiar safety rule of turning off electronic devices that can interfere with navigation equipment, is a result of this.

However, when staff (including doctors) are recalcitrant and disregard established safety norms, they are investigated and disciplinary actions are taken when appropriate. Some doctors have had their working privileges suspended or get reported for further action by the Singapore Medical Council and the Ministry of Health.


Dr Huang Shoou Chyuan

The unabridged letter (20.12.09) ( I will append Salma Khalik's letter the moment I find a digital copy) Click here for the "edited" published letter.

Dear Editor,

I refer to Salma Khalik’s article “Make hospitals and docs more accountable”.

Khalik refers to the unfortunate case where the tissue biopsy diagnosis from a “quick analysis” frozen section (FS) (usually obtained within minutes while the patient is already in the operating theatre) differed from the final permanent section (usually reported at least one day later). It is internationally accepted practice for a surgeon to rely on FS for guidance as to whether a major operation should proceed.

In this case, the final permanent section showed “no cancer” – by which time major surgery had already been done as the FS reported a diagnosis of “cancer”.

FS is an invaluable tool used by surgeons. However, as with any diagnostic tool, there are limitations that allow errors to occur, including the initial selection of tissue by the surgeon, the tissue sampling by the pathologist, the technical expertise required to prepare the slides, errors in interpretation, and delivery of the result back to the surgeon.

Some diseases are so complex that even the most renowned pathologist would make errors in the FS or even in the permanent section!

To complicate the issue, a converse situation could also happen. The FS could report “benign” and surgery aborted, only to be proven wrong much later- by which time cancer might be too advanced for curative treatment.

Let me cite an actual example. My patient had thyroid surgery in another country. FS was not done and only partial resection was done. On re-evaluation of the tissue slides by our pathologist, “cancer”was confirmed and a second operation was needed for total resection of the cancer-bearing organ. If initial surgery was planned with FS, he would only have needed one operation.

Despite what Khalik has written in recent times, I sincerely feel that Singapore’s healthcare in both public and private hospitals has proven, time and again, to meet the needs of Singapore’s residents. The “complaints” published in the media pale in comparison to compliments we hear about our system from our patients and families.

Doctors, especially in the public hospitals, frequently miss meals as the 5-10 minutes slots allotted for outpatients are not sufficient for complex cases and those needing procedures.

Yes, mishaps do regrettably happen and on a daily basis too, but these are mainly minor with no “adverse outcomes”. This is unsurprising as Alexander Pope had said that “To err is human”.

Time does not permit me to elucidate measures taken by hospitals to minimize mishaps.

I am particularly heartened to learn that despite suffering from the KKH chemotherapy mix-up, the patients were willing to forgive. They remind me that Pope’s quotation ended with ..” to forgive is divine”.

Dr Huang Shoou Chyuan

Thursday, December 17, 2009

Singapore Athletics' SAA sucks- so please go

Hi Friends,

Singapore’s Athletics, as embodied by the Singapore Athletics Association, sucks and I have said it here before.

It is high-time the government stepped in.

Much as I dislike too much government interference in our lives, this particular move by Balakrishnan and gang is the right move.

When the SAA’s bosses remain intransigent and do not reform ( and improve) for the sake of society, then they should be persuaded, nudged or even forced to make way for those who can perform.


Dr Huang Shoou Chyuan

Thursday, December 03, 2009

English proficiency for foreign frontline service workers

Hi friends,

In May 2008, I wrote to the papers to suggest that foreign frontline service workers be required to take basic English proficiency tests. This will increase productivity (as English is our lingua franca) and reduce the angst of many Singaporeans who had encountered frontline workers who could not understand English.

If such a worker was working at the Chinese Chamber of Commerce, one would not have bat an eyelid, but the thing is that these non-English speakers are working on Mainstreet Singapore.

Anyway, please click here to read my blog post on this.

The government has responded.

In this little red dot, things move- but sometimes at a glacial pace.

So if there is anyone out there with bright ideas- don’t give up.


Dr Huang Shoou Chyuan

Only if they speak English ...
05:55 AM Dec 03, 2009 (Today)

SINGAPORE - It could be the next best thing to outright requiring all foreign service staff to be conversant in English, for those tired of encountering sales assistants and waiters who don't speak a word of it.

From the third quarter of next year, work permit holders in the retail, food and beverage and hotels sectors will need to pass an English language proficiency test in order to qualify for skilled levy status.

It passes the buck, literally, to employers who pay just $150 a month for the skilled workers levy but $240 for the unskilled levy.

And while some industry players applaud this, others lament the cost of training.

The Manpower Ministry will partner NTUC Learning Hub and the Workforce Development Agency to train workers, and they are anticipating a two- to three-times increase in demand for English classes. More details of the tests will come next year.

The move, said Restaurant Association of Singapore Ang Kiam Meng, will force employers to look "more proactively" at the communication problems of foreign service staff. "It will encourage the restaurateur to upgrade their non-speaking English workforce ... As a whole it's positive for the industry," he said. But he wondered if it would prove an "extra (cost) burden" for employers.

At the Migrant Workers Centre, which yesterday saw its first batch of foreign workers graduate from a basic English course, subsidised fees are under $200 a person.

Businesses have other concerns. "Half of our workers will not make it (past the test) and might not be able to continue to work. We're going to face problems," said Ms Christine Chan, human resource manager at Riverview Hotel.

The affected half are mainly the backend staff who do not deal with customers. "When we employed them, we did not expect them to speak good or simple English," she said, pointing out that the hotel might not be able to convert all those who fail the proficiency test to unskilled worker status, as there is a quota for unskilled workers too.

And with the integrated resorts opening, "if we send staff for the English course, if they improve their competency, will they continue to work with us or move on? Cannot make them sign bond, right?" said Ms Chan.

How would the move affect companies' hiring decisions - would they give priority to those proficient in English, or willingly hire first and train later?

"The more enlightened businesses will train their staff before putting them in the frontline," said Singapore Chinese Chamber Institute of Business senior sales and marketing manager Chew Kheng Fui - while another option could be to ensure frontline staff pass the proficiency test but resign to paying the unskilled levy for backend staff.

Or would employers turn to hiring more Singaporeans? "I wish it could but I don't think it will happen," said Mr Chew. "Getting foreigners to do the job will still be much more cost effective. Employers will just be more selective in hiring foreigners that can speak better English - so maybe the Filipinos have the advantage, compared to mainland Chinese."

Minister of State (Manpower and Trade and Industry) Lee Yi Shyan said: "We want to encourage employers to look at it as building a more productive workforce ... If they look at how much better service they can provide, that should incentivise them to send the workers for the programme.

"The cost in training is a small factor. Whether local or foreign, you have to continue to train our workers ... Otherwise, if we stand still in our skill level, our economy will not be competitive."