Full-Time/Part-Time

40 Pages·2017·11.55 MB·English

CON T E N T S
news
Vol. 49 No. 11 2017
Editorial
EDITORIAL 04 Service before Self
BOARD Dr Tina Tan
Editor
Dr Tan Yia Swam
Feature
Deputy Editors
05 Bringing Affordable Psychiatric
Dr Tina Tan
Dr Tan Tze Lee Care to the Heartlands –
Editorial Advisors Interview with Dr Marcus Tan
A/Prof Daniel Fung
A/Prof Cuthbert Teo
Dr Toh Han Chong President’s Forum
Members 08 General Practice Resilience:
Dr Chie Zhi Ying Solo is not Silo
Dr Jayant V Iyer
Dr Wong Tien Hua
Dr Jipson Quah
Dr Jonathan Tan
Dr Jimmy Teo Council News GP Matters
Dr Alex Wong
11 Highlights from the 22 Specialists and Generalists: Braving
EX-OFFICIOS Honorary Secretary a New Compact
Dr Wong Tien Hua Dr Lim Kheng Choon A/Prof Cheong Pak Yean, A/Prof Goh Lee Gan
Dr Lim Kheng Choon
and Dr Ong Chooi Peng
EDITORIAL 12 End-of-Life Matters – 32nd
OFFICE CMAAO General Assembly AIC Says
Senior Manager Dr Chong Yeh Woei
24 Fostering Stronger Support for
Sarah Lim
Mental Health
Senior Executive
Event Agency for Integrated Care
Sylvia Thay
15 Basic Health Law Course
Editorial Executive
Jo-Ann Teo Jasmine Soo Exec Series
26 Marketing Medical Practice for New
ADVERTISING AND
PARTNERSHIP SMA CMEP – Professionalism Private Specialists
Li Li Loy 16 Professionalism in Medical Dr Desmond Wai
Tel: [phone]
Email: [email protected] Education – What Makes for
an Effective Student-Faculty Reflections
PUBLISHER
Singapore Medical Association Relationship? 29 Don’t Wait
2 College Road Level 2, Dr T Thirumoorthy Dr Tan Su-Ming
Alumni Medical Centre
Singapore 169850
Tel: [phone] Opinion SMA Charity Fund
Fax: [phone] Extending a Doctor’s Reach 30 Legacy Gifts
Email: [email protected]
URL: https://www.sma.org.sg through Public Service Ho Li Shan
UEN No.: S61SS0168E Dr Roy Joseph
DESIGN AGENCY 20 The Power of Primary Care From the Heart
Oxygen Studio Designs Pte Ltd
Research to Innovate Care 32 The Pro Bono Physician

PRINTER Prof Helen Smith A/Prof Daniel Fung
Sun Rise Printing &
Supplies Pte Ltd
Indulge
34 The Newton Science Show
Opinions expressed in SMA News reflect the Dr Tan Yia Swam
views of the individual authors, and do not
necessarily represent those of the editorial
board of SMA News or the Singapore Medical
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More likely than not, each of us the Singapore Association for Mental
encounter individuals who stand out Health and recounts how he started
as exemplary upholders of the public volunteering. He also makes a case for
Dr Tina Tan is an associate
service ethos of our profession. This why doctors make great volunteers.
consultant at the Institute of
includes those who volunteer amid
I now move on to another subject Mental Health and has a special
their busy schedules, those we look up
featured in this issue: generalists. It’s interest in geriatric psychiatry.
to as our teachers and mentors, and
the latest new-old term being used She is also an alumnus of Duke-
those who serve in the community by the Ministry of Health and has, as NUS Medical School. Between
in various ways. No matter how expected, started a nice debate about work and family life, she squeezes
disillusioned or cynical we may be, it the roles of specialists versus that of time out for her favourite
can be argued that the vast majority of pastimes – reading a good
generalists. A/Prof Cheong Pak Yean
us are in this profession because there is (fiction) book and writing.
and his colleagues ask questions about
some part of us that wants to help those
whether such a distinction should even
who can’t help themselves. Remember
those medical school motherhood bgiev emna tdhee. TGhoisv eisr nemspeencti’asl rlye preelaetveadn ct alls Ti n a T a n
statements you used to say to yourself
for young doctors to choose generalist
before reality hit? disciplines, in response to changing Deputy Editor
Thus, this month, we bring you population needs.
an interview with Dr Marcus Tan, a
Prof Helen Smith writes about the
psychiatrist who runs a practice in the
importance of research in the primary
heartlands with two of his colleagues,
care setting and how it can help drive
Dr Thong Jiunn Yew and Dr Seng Kok
the development of primary care in
Han, the latter of whom I’ve had the
Singapore. Dr Wong Tien Hua also adds
pleasure of working with some time ago
to the discussion in his monthly column,
as a resident. The goals of Dr Tan and his
about the increasingly crucial role of GPs
colleagues have been to increase the
in Singapore.
ease of access for mental health patients
As you can see, this month’s issue
and reduce the stigma of seeking help.
covers a variety of topics, touching
We also feature an article by Dr Roy
mainly on public service and primary
Joseph, who is no stranger to many of us
care, including the Government’s hottest
in the field of medical ethics. He relates
new topic on generalists. As for the latter,
his experience in public service and his
I hope that the articles featured will spur
journey towards serving as Chairman of
further conversation and submissions
the National Medical Ethics Committee.
from my fellow SMA Members. Keep
A/Prof Daniel Fung shares his calm and please write in. We’d love to
enriching experience volunteering with hear from you.
04 NOV 2017 SMA News
E
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Bringing Affordable E
F
Psychiatric Care
Heartlands
TO THE
Interview with Dr Marcus Tan
Introduction
Drs Marcus Tan, Thong Jiunn Yew
and Seng Kok Han run a community-
based psychiatric practice, operating
out of two clinics. The three of them
got to know each other during their
National Service days more than a
decade ago, where they served in
succession at the Singapore Armed
Forces Ward, Alexandra Hospital.
There, they ran both the inpatient
psychiatric ward and day centre for
distressed servicemen. We are glad to
speak with Dr Marcus Tan to find out
more about their vision of bringing
psychiatric care to the heartlands.
1
Legend
1. L to R: Dr Seng Kok Han, Dr Marcus Tan and
Dr Thong Jiunn Yew
NOV 2017 SMA News 05
Could you tell us more about your What motivated you to go into the polyclinics, but waiting times for
psychiatric practice? heartlands? appointments can be long.
Jiunn Yew and I started the practice The phenomenon of hidden The opportunity came along
in 2010, while Kok Han joined us in morbidity is well recognised in when we were approached to join
our fifth year of practice. Each of us psychiatry. Through the course of private practice. At that time, we
our work in public institutions, we were offered several locations in
brings to our practice some 18 to 20
came to know of the need for greater private hospitals to choose from
years of clinical experience.
accessibility to psychiatric services. for our clinic. We managed to state
Despite us having rather different Apart from the unfortunate stigma our case for a community-based,
personalities, we became close friends attached to being diagnosed with heartland practice to serve the needs
and discovered that we share the a psychiatric illness and seeing of the local population.
same vision and passion for the work a psychiatrist, persons afflicted And here we have been, for the last
we do. Understanding each other on a with psychiatric conditions can be eight years.
personal level has been really helpful apprehensive to seeking treatment
in allowing us to anticipate each due to the perceived costs involved in Could you share with us the
the private sector. working model of your practice?
other’s practice requirements, needs
and goals. I think this understanding I recall that in the year 2007 or Our practice is focused on providing
affordable, financially sustainable and
is essential to form the stable 2008, I had the opportunity to see
accessible psychiatric care at a one-
foundation necessary for a working a pair of parents who were in acute
stop location. To do so, we try to keep
partnership that endures, much as grief after losing their child to suicide.
consultation rates as low as possible.
we are still a relatively young practice Part of their anguish was that while
We also take care to practise judicious
they knew that their child needed
compared to our seniors in more
prescribing and avoid polypharmacy
help, they were unsure of how to go
established practices. as far as we can. The latter helps
about doing so. They had not been
Our flagship clinic is situated at Ang keen to approach public institutions contain treatment cost.
Mo Kio Avenue 10, nestled in an aged as they feared that their child would The main challenge we face, like any
neighbourhood precinct populated be left with having “an official record” other private clinic in Singapore, is that
by a mix of old- and new-school hair that would affect his future. While the cost of medications are significantly
salons, hardware stores, itinerant this fear is really quite unfounded higher than what public institutions
fortune tellers on makeshift tables, given strict guidelines on medical obtain them for. The other challenge is
mom and pop Chinese grocery shops, confidentiality, this is a worry that is rental which, I believe for other clinics
real and continues to be present for too, is an escalating cost over time.
a wet market and food centre, a Taoist
shrine, traditional Chinese medicine many. Over the course of my work We do what we can to minimise
physicians and several GP clinics. with them, it became apparent that the cost of goods and overheads.
we can do more to provide timely We source for the most affordable
This location holds personal access to psychiatric services for those alternatives for medications, order in
meaning to me. I grew up in Ang in the community who are in need. bulk to leverage on the economics of
Mo Kio and this was one of those scale and constantly review our work
Instead of waiting for patients
places my friends and I hung out at processes to reduce wastage. Office
to show up at the doorsteps of
in our teens. The neighbourhood psychiatric departments of general products are “recycled” and at times
has changed a lot, obviously, but hospitals and the Institute of Mental “repurposed”. Savings are then passed
this remains a place that most locally Health (IMH), we decided that the on to patients.
born Singaporeans can relate to. We way forward in combatting mental To further help defray the cost of
wanted our practice to be situated in illness is to bring our services to the running the clinics, we also take on
the community, in a place where we heartlands, where most of us live and teaching assignments and involve
live and work, and I could not think of work. In addition, a presence in the ourselves in employee assistance
a more ideal spot. With the occasional community will likely go some way to programmes and external contracts
wafts of fried salted fish mixed help our efforts in de-stigmatisation. for on-site consultation.
with the buttery aroma of kopitiam Doing so also avails us opportunities We are proud to note that the
coffee, and strains of Hokkien songs to link up with GP clinics, as well as average cost of care at the practice
community mental health and social is contained below $10 per day –
playing from the HDB flats above our
resources – all of which are important around the price of a meal from
shophouse clinic, it does not get more
components of a comprehensive the food court – for the majority of
heartland-like than this.
mental wellness service. our clients. This also gives us some
Our other clinic operates out of bandwidth for pro bono work with
The concept of establishing a
Novena Medical Centre, which is more selected cases.
psychiatric service in the heartlands
centrally located to serve our patients is not new; some of our seniors have To ensure that quality of care is not
working near or in town. They visit also done so, mostly on an ad-hoc compromised by the patient volume
us on their way to or from work, and basis, before we did. IMH has also we manage, we cap the maximum
sometimes during their lunch hours. established outpatient clinics in number of patients seen per session to
06 NOV 2017 SMA News
promote early intervention has made from all walks of life. Over the past
“When lost or in
a difference, especially for those who eight years, we have had some really
are in crises. interesting cases. We have diagnosed
doubt, always
clusters of folie à deux or delusional
Administratively, we look after
disorder by proxy, treated cases
different aspects of the practice. Jiunn
remember to
of psychosis initially attributed to
Yew takes charge of the day-to-day
paranormal causes, and exposed
operational and logistical issues, Kok
do right by your doctor-hopping benzodiazepine
Han manages the staffing, while I look
into our liaison with the community abusers – in one case, a patient tried
patients. The and professional partners. I also work to impersonate her twin!
on charting the practice’s focus and Being in the heartlands also allows
rest will follow.” overall direction. Having said so, most us to leverage on our surroundings
issues that arise are discussed, with a for therapy. I recall how I used to take
consensus reached before decisions buses with patients to help them
ensure that sufficient time is allocated are made. habituate the anxiety they feel. I have
for each consultation. To enhance
also utilised coffee shop toilets for
accessibility, we also have to ensure What keeps you going when dealt
exposure and response prevention
that our clinics open long enough to with challenges/difficulties?
therapy for some of my patients with
minimise first appointment waiting Being in the community, we do not obsessive-compulsive disorder. Some
time. To accommodate patients who have the benefit of support from years back, I had a young patient who
prefer to see us after work or during a multi-disciplinary team that can had a phobia of trees after seeing
weekends, we run evening clinics on help to share the workload. Some his family home get demolished
most weekday evenings till late and cases can be rather difficult – not just by a falling tree during a typhoon.
back-to-back sessions on Saturdays from a biological point of view, but a
He would get really nauseous and
into the afternoon. This in turn has psychosocial one as well. When faced
throw up while on his way to school.
translated to rather long working hours. with challenging cases, we confer
To overcome his fear, we took to
Apart from ward rounds which are done mini “grand ward rounds”, or peer
climbing trees at one point. Although
before and/or after clinic hours, we review learning as it is called now, to
that helped his condition, it did not
run as many as 13 sessions per week. discuss the case and bounce ideas for
end well for me.
Weekends are seldom protected time treatment off one another. I am glad
off and it is not uncommon for us to to note that the staunch peer support Of course, it is not always all rosy.
work some 70 hours per week. that we have cultivated in the practice We have had to contend with threats
One feature of our practice is that over the years has helped sustain us. and even some rather “colourful”
we work alongside our GP partners While we may differ in opinions at letters from anti-psychiatry
to co-manage stable patients on times over operational and clinical individuals. It’s all in a day’s work.
maintenance treatment. Once the decisions, we have always managed What matters is that we do our best
patients are stable, they are returned to resolve our differences. so we can go home and sleep easy.
to their GPs who continue care, until
On a personal level, we are also What lessons do you have to impart
the time when they are well enough
good friends who play well together. to our younger colleagues just
for treatment to be discontinued or
Despite our schedule, we make it a starting out?
when unwell. For the latter, we will
point to meet regularly for dinner to
take over management until the Private practice is not as easy as how
catch up. When possible, we also travel
patients are stable enough to be it may look from the other side. It
together for conferences and leisure.
returned to the GP or be discharged. comes with its own set of challenges.
Anytime an opinion or sounding I have to admit that the engaging Contrary to what some may think, the
board is needed, we are just a phone nature of the practice and the often main driver for most of us moving out
call away from our GP colleagues. hectic day-to-day routine takes a toll from the public sector is to have the
in more ways than one, at a cost to control to shape the practice we want.
Apart from attending to our
our personal lives. The people around
patients from referral and walk-in Some do hit the big time, but most
us may not always understand why
sources, we also offer what we of us just get by.
we do what we do. This is also when
term “transitional care” for patients
we turn to each other for support. No matter what, don’t lose yourself.
who already have appointments
Work for your passion for the art and
from the outpatient departments At this point, I am glad to say that
be prepared to work very hard. Take
to public hospitals, but are unable we are blessed to have understanding
time out when you need to. Don’t burn
to wait. For this group, we provide families and supportive partners who
out. While it may get lonely at times,
earlier assessments and initiation appreciate the nature of our work.
you know that support, in the form of
of treatment where we manage the
Are there any memorable patients/ colleagues, is always only a call away.
patients until they see our public
incidents in your years of practice?
sector counterparts. This helps to When lost or in doubt, always
moderate the cost of care for them The accessibility of our location, to remember to do right by your
too. I believe that this initiative to some extent, avails us to patients patients. The rest will follow.
NOV 2017 SMA News 07
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Text by Dr Wong Tien Hua
Deciding to go into general practice has well. It is like having the roles of the chief Roles of the family practitioner
never been an easy choice. In earlier executive officer, clinical services, human
The concept and practice of family
days, general practice was sometimes resources, legal, accounts, property
medicine, and the operations of general
a default vocation that doctors slipped management and IT departments all
practice that we see in Singapore today,
into when they could not specialise. rolled into one.
have indeed come a long way.
Family medicine was not well defined
All the extra tasks may sound
and the skill sets and competencies The clinical skills required to perform
daunting and will certainly take time
required were not adequately covered in in a primary care setting is now well
to master, but I suspect most GPs will
medical school. documented. The World Organization
not trade that away for the professional
of Family Doctors (WONCA) published
GPs were true generalists who had autonomy that they currently enjoy,
a good description of the special
to learn how to handle whatever cases and the ability to practise medicine in a
characteristics and roles of general
that came their way. They had to develop setting where they can make a difference
practice and family medicine (see page
the clinical skills and acumen to treat to the community. Running one’s own
10). It includes not only factors of good
patients spanning the demographics of practice allows the doctor absolute
clinical care but also takes into account
age, illness and social status – including freedom to do whatever he/she chooses
the social, psychological and even
patients from the very young to the within legal and ethical boundaries.
philosophical aspects of holistic care.
very old, patients presenting with both “Being your own boss” means that there
physical and mental ailments, as well as is no one to report to and that you are The training of family medicine starts
patients suffering from both acute and able to be the captain of your own ship. from medical school with the necessary
chronic diseases. curriculum in family medicine, as well
The Straits Times recently ran a feature
The GP also has to contend with the on Dr George Khoo,1 possibly Singapore’s as exposure and attachment to primary
business and management aspects of oldest practising GP at the age of 89, care services. After graduation, residency
running his/her clinic. Most GP clinics are who has been practising at his solo for family medicine is available to train
run by solo practitioners who own their clinic at Rochor Centre since 1963. In doctors towards the Master of Medicine
practice, typically operating with long the article, he described his experience (Family Medicine) degree. Doctors can
opening hours. They have to hire and treating patients from the nearby also opt to sign up for the two-year
train their clinic assistants, manage the brothels and opium dens back in the Graduate Diploma in Family Medicine
logistics of a pharmacy, and attend to days. He has even treated not just three, course conducted by the College
accounts and legal matters. There is also but four generations of family members. of Family Physicians Singapore. The
the additional burden of handyman tasks One can imagine the immeasurable Register of Family Physicians was set
such as electrical work and plumbing, long-term impact Dr Khoo has made to up in July 2011 and serves to recognise
and nowadays with the increasing use the health of the community in Rochor, medical practitioners who have relevant
of computers, having to troubleshoot where his practice has been embedded qualifications and set the standards of
information technology (IT) matters as in for more than 50 years! practice for family medicine.
08 NOV 2017 SMA News
Solo but not silo look like private establishments, with Regardless of these external
modern furnishings and the latest pressures, I still believe that there is
Many commentators have long hailed
technology such as self-registration, a unique role for solo GPs despite
the demise of the solo practitioner,
given the rapid changes in Singapore’s electronic records and remote the rapid changes in our healthcare
healthcare landscape. The fact is that medication collection. system, and I also believe that solo GPs
the majority of private GP clinics are Family Medicine Clinics (FMCs) were are more resilient than most would
still operated by solo GPs today, the introduced in 2011 as a response to the estimate. Because the fundamental unit
percentage of GPs in group practices shifting need for team-based approaches of healthcare boils down to the doctor-
has not increased in the past decade.
in primary care. FMCs are managed by patient relationship, the solo GP who
The Ministry of Health’s Primary Care
a group of like-minded GPs who work provides personalised healthcare and
Survey 2014 showed that only 27% of GP
together to provide comprehensive who is accessible to the community will
clinics considered themselves in a group
team-based care for patients, especially continue to be sought after by patients
practice (two or more clinics).2 The figure
those with chronic diseases. and families. Patients seek that one
was 27% and 26% in 2010 and 2005
editions of the survey, respectively. The The business environment has family doctor whom they can relate to
difference is in the groups; the number also been getting harsher and more personally. If you look at the roles and
of clinics in group practices has grown, unforgiving. Gone are the days of competencies of the GP as described
with a significant increase in group cheap rental, low wages and low cost by WONCA, there is nothing listed that
practices that have 40 to 59 branches. supplies. Operating costs for clinics a solo GP cannot do, and nothing that
Because medicine is becoming have been on the rise, with rental and cannot be overcome with some support
more complex, no single doctor can staff salaries now accounting for a large and technology.
effectively manage the wide range percentage of expense. The cost of
The singleton GP today may be solo in
of cases that present in primary care. drugs and equipment has seen year-
makeup, but no longer silo in function.
Hence, there is now a bigger focus on a on-year increases; yet professional fees
team-based approach. have not changed much over the past Advances in technology mean
Government polyclinics are excellent decade. Because of smaller volume, solo that doctors can be well connected.
examples of multi-disciplinary primary GPs find it hard to take advantage of For example, doctors can join in a
care setups, providing high-quality economies of scale; they therefore need physician network to consult with
care and services all under one roof. to constantly operate under maximum other colleagues, use electronic records
The latest new generation polyclinics efficiency in order to survive. to access investigation results and
Dr Wong Tien
Hua (MBBS[S],
MRCGP[UK], FCFP[S],
FAMS[Fam Med])
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.
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NOV 2017 SMA News 09
procedures done, and enlist and refer The SMA eMarket seeks to become a Antifragility in general practice
patients to allied healthcare workers common procurement platform for
The concept of antifragility was
that are available in the community. The private medical clinics and healthcare
proposed by Nassim Nicholas Taleb in his
institutions to access basic medical
advent of the smartphone and mobile 2012 book, Antifragile: Things That Gain
supplies, equipment and services.
apps has allowed doctors to join virtual From Disorder. Fragile systems break
chat rooms where clinical conundrums The Ministry of Health announced the down under stress and tension while
scaling up of Primary Care Networks
are discussed. The National Electronic resilience allows systems to resist shocks
(PCN) at the Committee of Supply Debate
Health Record is being refined and will and to recover from failure. However,
2017. The PCN pilot had shown that
eventually be widely available to primary the opposite of fragility is not resilience,
private GPs could operate very effectively
care physicians, allowing them to tap because resilience maintains or returns
with good outcomes as long as there was
the system to the same/prior state.
into the public hospital database. adequate support that enabled them
Taleb coined the word “antifragility” to
Technology also enables solo GPs to handle complex diseases. In PCN, describe a system that goes beyond
solo GPs and small group practices will
to purchase drugs and equipment resilience or robustness. Antifragile
be organised into virtual networks to
through cooperatives and online systems not only recover but improve
deliver care through a multi-disciplinary
markets where collective bulk under stress. An example in biology is
team approach. Counsellors and diabetic
purchase can achieve lower costs. the necessity of constant exercise and
screening services will be provided
SMA just launched our SMA eMarket on-site at the GP clinics to assist in bearing of weights to stress and hence
at the recent FutureMed 2017 event. managing chronic diseases. strengthen bones and muscles; the
removal of which results in atrophy.
Based on the above description,
The European definition of General Practice/Family Medicine3 I think that general practice is
antifragile. In the face of rapid change
The role of the GP includes:
and constant challenges, general practice
• being the point of first medical contact within the healthcare system, providing
remains not only resilient but adaptive
open and unlimited access, for all health problems both acute and chronic;
as well. New policies and schemes have
• coordinating care within the healthcare system; come and gone. GPs have seen through
different partnerships, engagements,
• practising patient-centredness in the context of family and community;
funding plans and business practices, and
• enabling patient empowerment;
have continued to adapt, consolidate and
• focusing on a long-term doctor-patient relationship and continuity of care; thrive amid all these.
• making clinical decisions taking into consideration the prevalence of illness in Finally, to the solo GPs who
the community; sometimes feel that their existence is
• managing undifferentiated illnesses at presentation; being threatened, I quote the German
philosopher and existentialist Friedrich
• ensuring health promotion and community health; and
Nietzsche who so eloquently said:
• dealing with all aspects of health in their physical, psychological, social, “That which does not kill us, makes
cultural, and even existential dimensions. us stronger.”
WONCA also defined six core competencies that are essential for the GP.
References
These include:
1. Tan T. The Lives They Live: Doctor is still in, at age
1. Primary care management such as dealing with undifferentiated illness. 89, for Rochor residents. The Straits Times 28 Sep
2017. Available at: http://www.straitstimes.com/
2. Person-centred care including respecting patient autonomy. singapore/the-lives-they-live-doctor-is-still-in-at-
age-89-for-rochor-residents.
3. Specific problem-solving skills to guide decision-making in primary care
settings where sophisticated tools are not available. 2. Ministry of Health, Singapore. Primary
Care Survey 2014 Report. Available at: https://
4. Comprehensive approach to care including acute and chronic problems, www.moh.gov.sg/content/moh_web/home/
health promotion and preventive health. Publications/Reports/2017/primary-care-survey-
2014-report.html.
5. Community orientation emphasising on what the patient presents in the
context of family and social settings. 3. WONCA Europe. The European Definition
of General Practice / Family Medicine - Edition
6. Holistic approach. 2011 Short Version. Available at: http://www.
woncaeurope.org/gp-definitions.
10 NOV 2017 SMA News