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Located directly above Farrer Park MRT station, our team focuses on o�ering patients prompt medical attention. The Ambulance drop-o� and Diagnostic Imaging Suite are designed in close proximity to the Clinic, enabling patients to transit quickly with immediate access to needed services.

Farrer Park Hospital 24-hour Walk-in Clinic

Farrer Park Hospital 24-hour Walk-in Clinic is open everyday throughout festive seasons and Public Holidays.

Level 2, Farrer Park Hospital, 1 Farrer Park Station RoadSingapore 217562 | Tel: +65 6705 2999

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COMFORT. FAIRNESS. VALUE.

10president’s forumLost in transLation Dr Wong Tien Hua

Vol. 48 No. 1 2016

5editoriaLfighting for the good of humanityA/Prof Daniel Fung

6featurenew psychoactive substances: high index of suspicion needed in cLinicaL servicesDr Lambert Low, Dr Melvyn Zhang and Dr Christopher Cheok

16insighta gLimpse into the past — medicine in singapore (part 5)A/Prof Cuthbert Teo

28exec seriesthe singapore medicaL counciL discipLinary process Lek Siang Pheng and Mar Seow Hwei

19euLogyin memory of prof feng pao hsiiProf Fong Kok Yong

13eventwhen the force awakensMellissa Ang

22opinionon caLL and feeLing stressedDr Tan Yia Swam

33from the heartan evening with snoopy and charLie brownDr Jade Kua

38aic saysguiding you through chas audit: a Quick reference (part 2)

20gp matterssetting the pace aheadDr Leong Choon Kit

24professionaLismprofessionaLism in risk managementDr Seow Wan Tew and Dr T Thirumoorthy

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.

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4editoriaLthe editor’s musingsDr Tan Yia Swam

34induLgemuch ado about dracuLa!Dr Juliana Poh

8featuremarijuana demystifiedDr Melvyn Zhang and Dr Christopher Cheok

32sma charity fundnew onLine giving pLatform!

caLendarsma events mar – apr 2016

12counciL newssma offers programmes to heLp foreign doctors assimiLate here

14interviewmarijuana: yes or no?Dr Ravindran Kanesvaran, Dr Adrian Wang and Dr Alex Yeo

Located directly above Farrer Park MRT station, our team focuses on o�ering patients prompt medical attention. The Ambulance drop-o� and Diagnostic Imaging Suite are designed in close proximity to the Clinic, enabling patients to transit quickly with immediate access to needed services.

Farrer Park Hospital 24-hour Walk-in Clinic

Farrer Park Hospital 24-hour Walk-in Clinic is open everyday throughout festive seasons and Public Holidays.

Level 2, Farrer Park Hospital, 1 Farrer Park Station RoadSingapore 217562 | Tel: +65 6705 2999

Outpatient Consultations

Medical/Surgical Emergencies

Medical Screening

Vaccination

Chronic Disease Management

Other Services Include:

COMFORT. FAIRNESS. VALUE.

Personally speaking, 2015 was a good year for me. I started building up a practice, made some new friends and renewed several old friendships. My family remains in good health and most significantly, we welcomed a new baby. For the country, joy at 50 years of independence was tempered with grief at the passing of MM Lee Kuan Yew. I was saddened and alarmed by the many natural disasters and man-made tragedies worldwide — earthquakes, floods, plane crashes, wars, refugees, mass gun shootings, Ebola and acts of terrorism.

The birth of my second son has perhaps strengthened my maternal instincts to nurture and protect. There’s also a strong urge to leave behind a better world for the children (and of course, raise them up well to be deserving of it!).

Following this train of thought, I am reminded of the Chinese saying “医者父母心” (doctors with parental hearts) — it means that doctors should love and care for their patients as they do their children. This would also mean appropriate chastisement when necessary and not pandering to their every whim and demand, which can only lead to a spoilt child. There is now an attitudinal trend towards referring to patients as “customers” and doctors as “healthcare providers”, which is detrimental to the doctor-patient relationship in the long run. This is a global shift that has been derided by many. Whether or not this trend can be reversed remains to be seen.

SMA’s slogan, “For Doctors, For Patients”, succinctly sums up the role of this professional body. We play a delicate part in protecting and nurturing doctors, so that they can better look after their patients. The profile of our membership is changing, and SMA News will keep on evolving with the times to meet the expectations of our members. Some things will stay the same — we will always carry articles on professionalism, patient anecdotes, volunteerism and personal reflections. To spice things up, the “Indulge” column will be expanded to include other interesting hobbies that doctors pursue, though its mainstay will still be food and travel. So far, we have covered diving, flying and cooking. I’ve heard of doctors attending sommelier, barista or pole-dancing classes!

We will also have themed issues in the coming year, to be announced as the dates approach. There will be one soon on “Physician Health”, where we will cover stories on how doctors keep themselves healthy as well as cope when they or their loved ones fall ill. We would also like to revisit “Families in Medicine”, a spin-off from a Siblings in Medicine series from some years ago.

Do keep writing in and if you ever receive an invitation from my team to write, I hope you will agree to share your experience with us! Don’t be shy. We wish you all good health and happiness in 2016.

Dr Tan Yia Swam is an associate consultant at the Breast Department of KK Women’s and Children’s Hospital. She continues to juggle the commitments of being a doctor, a mother, a wife and the increased duties of SMA News Editor. She also tries to keep time aside for herself and friends, both old and new.

EditorYia Swam

4 editorial

SMA News / jan 2016

Doctors have always been on the forefront of social change and there is a long and venerable list of medical doctors who fought and are fighting for the problems they see in society. While advocacy for patients’ rights is often seen as part of a doctor’s duties, advocating for social injustice is not as clear-cut. Dobson and colleagues1 described the two forms of advocacy. One is that of advocating for individual patients, a role that we are all familiar and comfortable with. This was termed agency. Many doctors advocate for their patients in terms of better treatments and subsidised care. It is not hard to voice out on areas which we are comfortable to speak of, such as healthcare-related advocacy. One example is when we need to provide for medications which are expensive yet critical for helping patients with a disease like cancer. This form of advocacy comes naturally for doctors.

Dobson et al speaks of another form of advocacy which they termed activism. This form is described by the American Medical Association as advocating for “social, economic, educational and political change”. This is far less common and some may tell us that we should enter politics to achieve it. I beg to differ. There are many issues that politicians and governments cannot address. I

would like to think that because doctors are often held in high regard, what we say and do can have social, economic, educational and even political impact. The Singapore Medical Council Ethical Code and Ethical Guidelines2 state that we should “participate in activities contributing to the good of the community, including public health education”. In Singapore, we have doctors who advocate for specific causes and also doctors who enter politics and by default act as social activists. But these are not many. In order to be good advocates, doctors must be kept abreast of what is happening in the world and not just in knowledge and science of the work we do in treatment of illness. The World Health Organisation stated elegantly in its constitution in 1948 that health is not just absence of illness but the maintenance of social, mental and physical well-being. The medical motto of “Not pride of knowledge but humility of wisdom” certainly implies the need to exercise wisdom and to advocate this to the world at large. The future of medicine lies in preventing illness and maintaining well-being and it will require a population health approach and doctors will have to be more than just experts in treating illness. Social activism to improve lifestyles and reduce risks and harmful behaviours will be critical for new medical practitioners.

In this issue, we discuss the importance of doctors being aware of substance abuse and dependence, as well as the physician’s role in managing this growing problem. Like smoking, marijuana is sometimes thought of as a harmless social activity but the evidence suggests that it may be a gateway to a whole host of social problems. Whether it is in woman’s rights, medical students’ welfare, bringing out the best of GPs, managing stress or critical incidents, the concept is the same; we as doctors can do so much more if we see the big picture and lend a hand in making the world a better place.

References1. Dobson S, Voyer S, Regehr G. Agency and activism: rethinking health advocacy in the medical profession. Acad Med 2012; 87:1161–4.2. Singapore Medical Council. SMC Ethical Code and Ethical Guidelines. Available at: http://www.healthprofessionals.gov.sg/content/hprof/smc/en/topnav/guidelines/ethical_code_and_ethical_guidelines.html.

Fighting for the Good

Daniel volunteers with the Singapore Association for Mental Health, Singapore Children's Society and Paya Lebar Methodist Girls' School, and hopes to see more doctors involved in social advocacy.

Guest EditorA/Prof Daniel Fung

editorial 5

Jan 2016 / SMA News

This article is an edited version of an article published on the NAMS website (http://goo.gl/WIQWJT).

New psychoactive substances (NPS), commonly marketed as “bath salts” or “plant food”, are chemical compounds designed by chemists to circumvent the current legislation against drugs of abuse. They have been touted as “legal” highs, as many of these synthetic compounds do not fall under the scheduled controlled substances list in many nations. This has prompted many countries to take legislative action against these new substances. These drugs are synthetic derivatives from many drug classes, including phenethylamines, cannabinoids, cathinones and piperazines. However, they frequently escape detection from the immunoassay kits commonly used in routine laboratories. The Central Narcotics Bureau website reports that heroin and methamphetamine are the two most commonly abused drugs in Singapore, but little is known about the prevalence and problems associated with NPS use in the local context. While NPS is currently not a problem in Singapore, given the growing incidences of abuse of these psychoactive substances in European countries, it is important

for clinicians to be cognisant of these substances. Only when clinicians are aware of these substances would they have a high index of suspicion when they encounter patients presenting with specific clinical manifestations.

Gamma-hydroxybutyric acid (GHB), a metabolite of gamma-aminobutyric acid that has its origins as early as the 1960s and later became notoriously known as a date-rape drug, was one of the first NPS to be synthesised. GHB has since been scheduled as a controlled drug in many countries, including Singapore. Thereafter, the market saw the emergence of other types of NPS such as synthetic cathinones, eg, mephredone and synthetic cannabinoids (also known as spice). Perhaps an inherent difficulty in classifying these substances as illegal based on class of drugs stems from the fact that some members in the same class may have already been used for their therapeutic properties, eg, the synthetic cathinone, bupropion, is commonly used as an anti-depressant and smoking cessation agent. Therefore, it is difficult, if not impossible, to have a blanket ban on whole classes of chemicals. This belies the fact that new NPS are hitting the market as the older ones get outlawed and enter the controlled drugs registry. Hence, it is difficult to ascertain whether a clinical syndrome is due to NPS or the myriad of such chemicals present. However, an index of suspicion based on certain recurring clinical patterns can possibly lead to an expedient diagnosis and treatment, after other acute medical conditions have been ruled out.

CLINICAL PRESENTATIONWhile there have been disturbing news reported in the Sun, of a man tearing off his scrotum after using “meow meow” (mephedrone) due to hallucinations, as well as other similar horrid news related to NPS, the presentation is often less conspicuous. Patients may not disclose their use of an NPS during history-taking, or they may not perceive NPS to be drugs, as these substances are marketed as supplements, “plant food” or “bath salts”. In the absence of clinical tests, clinicians should have a high index of suspicion that patients

New Psychoactive Substances:

High Index of Suspicion Needed in

Clinical Services

Dr Lambert Low is an associate consultant with the National Addictions Management Service but is currently away on HMDP pursuing further subspecialty training in the field of addictions. He is a house tutor with the LKC School of Medicine and is also a certified acupuncturist. He is producer of the IMH play “8-5”.

PROFILE

DR lambert low

TexT by

6 feature

SMA News / jan 2016

presenting with brief delirium with no other organic cause may in reality be labouring from the effects of an NPS. In particular, the Crime Survey of England and Wales (CSEW) 2013/14 found that young persons between 16 and 24 years old have about a three times greater propensity of using an NPS such as mephredone and salvia than the general adult population. The CSEW report also suggested that there may be a significant association between the nightlife economy and the use of NPS, with a greater frequency of use among those who visit nightclubs more frequently.

Synthetic cathinones such as mephredrone are stimulants that resemble amphetamines in their action. The clinical syndrome is, therefore, one of cardiovascular, central nervous system and sympathetic overdrive, manifested as agitation, tachycardia, raised arterial blood pressure, dilated pupils, hyperthermia, muscle clonus and sialorrhoea. As the syndrome worsens, confusion, seizures, arrhythmias and respiratory arrest may ensue. Biochemical abnormalities reported include renal impairment with elevated potassium and creatinine, as well as elevated liver enzymes and creatine kinase. The group of phenethylamine compounds produce sympathomimetic effects such as agitation, raised blood pressure, tachycardia, dilated pupils, clonus and seizures, as seen with synthetic cathinones. Hallucinations due to 5-HT2A agonism, however, are more prominent in this group of compounds. Biochemical abnormalities reported include elevated creatine kinase, deranged liver enzymes, and renal impairment with consequent increased creatinine and serum potassium.

Besides cathinones and phenethylamine compounds, which have stimulant properties, the piperazine family of drugs such as benzylpiperazine (BZP) and trifluoromethylphenylpiperazine (TFMPP), which have been branded as safer choices in lieu of ice and ecstasy, also produce stimulant effects. Caution must be exercised, as not all piperazine derivatives exhibit such stimulant properties. MT-45, an NPS from the same family that has recently appeared on the market, has demonstrated

opioid-like symptoms such as respiratory depression and decreased levels of consciousness. Some of these patients have responded well with the competitive opioid receptor antagonist Naloxone. Patients who have taken synthetic cannabinoids such as spice/K2 have also been known to demonstrate symptoms of sympathetic overdrive such as elevated heart rate, agitation, excessive sweating, high blood pressure and muscle twitches. Confusion, hallucinations, paranoia and cognitive impairment can also follow.

MANAGEMENT OF NPS OVERDOSE AND TOXICITyHaving a high index of suspicion based on the pattern of common presenting complaints mentioned above would help clinicians to decide on the appropriate management. While many treatments involve supportive measures such as hydration and monitoring, there is at present no specific antidote for most of the NPS. Thus far, the evidence suggests that benzodiazepines may be helpful in ameliorating the sympathomimetic overdrive effects associated with the ingestion of NPS. Benzodiazepines can be given intravenously to counteract the sympathomimetic effects on the heart, reducing the chance of arrhythmias and heart attack, as well as preventing seizures. The use of antipsychotics is controversial, and some have suggested that drug interactions with NPS may render them unsafe.

Given that NPS usually come in various combinations of chemicals and the labelled preparation may not be the actual constituents, it is very important for clinicians to first focus more on immediate and supportive management.

The use of NPS is a new and emerging problem in the drug abuse landscape in Singapore. Clinicians need to be aware of the use of such substances in Singapore and to have a high index of suspicion of possible NPS abuse when young people present with agitation, psychosis or confused states.

PROFILE

Dr Melvyn Zhang is currently a senior resident (Year5) in psychiatry with the National Healthcare Group. He has a special interest in addictions and E-health. To date, he has 33 publications, with major publications in the British Medical Journal, Lancet Psychiatry as well as the Journal of Internet Medical Research (JIMR).

Dr Christopher Cheok is currently the Vice-Chairman, Medical Board (National Addictions Management Service) of the Institute of Mental Health. He is a visiting consultant to the Singapore Armed Forces and a member of the medical board of the Civil Aviation Authority of Singapore. He has a special interest in child and adolescent psychiatry, psychological trauma and research.

DR Melvyn Zhang

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Christopher Cheok

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feature 7

Jan 2016 / SMA News

INTRODuCTIONMarijuana has recently been legalised for medical use in Canada and the United States. The legalisation of marijuana is a hotly contested issue globally. In Singapore, marijuana, also known as cannabis, was included as a Schedule I drug in the 1961 Single Convention on Narcotic Drugs. Currently, grave punishments are meted out to individuals who abuse or possess the drug, with a fine of up to $20,000 or imprisonment of up to ten years. In addition, individuals are liable to the death sentence if they import or export more than 500 g of cannabis or 200 g of its resin, or more than 1,000 g of the two combined.1

In 2015, the Central Narcotics Bureau noted an increase in the absolute number of cannabis users locally. More importantly, the media has reported a changing profile of these abusers. Instead of the dated perception of drug users being less educated and of a lower socio-economic status, cannabis abusers

these days are young and well-educated. Many abusers, however, have the perception that cannabis is not addictive. Clearly, such myths surrounding cannabis can be attributed in part to the legalisation efforts for its therapeutic use overseas. In this article, we will look at the current therapeutic applications of medical cannabis and the issues associated with cannabis abuse.

MEDICAL uSE OF CANNAbISMedically, cannabis has been proposed for use in the treatment of paediatric developmental and behavioural disorders such as autistic disorder.2 However, evidence of its effectiveness to date is limited only to single case studies and reports. Cannabis has also been purported to be of use for cancer treatment.3 Studies have advocated that cannabis might help in the inhibition of cancer-related growth as well as curb the spread of cancer cells. These are largely initial findings that need to be validated by more

rigorous clinical trials. Cannabis has also been reported to aid in the treatment of neurological conditions such as epilepsy and headache.4 It has also been advocated as a treatment modality for multiple sclerosis-associated spasticity. Despite these initial findings, more rigorous clinical trials are needed to prove its clinical efficacy before the drug can be integrated as part of a recommended treatment.

Cannabis has also been reported to be helpful for individuals experiencing digestive-related issues (eg, nausea and vomiting) arising from chemotherapy.5 One of the main reasons for the legalisation of cannabis overseas is its purported usefulness in patients with terminal conditions. Thus, despite the problem of addiction associated with its use, therapeutic usage for this group of patients clearly outweighs the risks, due to the potential improvement in quality of life that this group of individuals will experience.

MARIJUANA

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SMA News / jan 2016

It is important for medical professionals to be cognisant that, while cannabis does have its therapeutic purpose, there are inherent risks associated with its use. This is especially important given the growing incidence of cannabis abuse locally and the changing perception of the young and educated towards this drug of abuse. It is pertinent for clinicians to be updated and informed, so that they can provide their patients with the latest information and the appropriate education.

CANNAbIS-INDuCED PRObLEMS There is a multitude of psychiatric manifestations that could arise from the use of cannabis, apart from the addiction itself. Cannabis use may predispose individuals to depressive and anxiety disorders,6 in addition to heightening the chance of them developing psychosis.7

Cannabis usage might result in a twofold increment in the risk of acquiring schizophrenia and a corresponding fourfold increase in the risk of psychosis. However, there are ethnic and genetic variants. It should be noted that individuals who are homozygous for the VAL/VAL alleles in the catechol-O-methyltransferase (COMT) genotype tend to be at enhanced risk. Those individuals who are homozygous for the MET/MET alleles in the COMT genotype tend to be not at enhanced risk. In addition, the usage of cannabis has been linked with an earlier age of onset of psychosis. Individuals who use cannabis tend

References1. Central Narcotics Bureau. Drugs and inhalants. Available at:   http://www.cnb.gov.sg/drugs/bannedsubstance/cannabis.aspx. Assessed 2 December 2015. 2. Kurz R, Blass K. Use of dronabinol (delta-9-THC) in autism: a prospective single-case-study with an early infantile autistic child. Cannabinoids 2010; 5(4):4–6.3. Caffarel MM, Andradas C, Pérez-Gómez E, Guzmán M, Sánchez C. Cannabinoids: a new hope for breast cancer therapy? Cancer Treat Rev 2012; 38(7):911–8. 4. Benbadis SR, Sanchez-Ramos J, Bozorg A, et al. Medical marijuana in neurology. Expert Rev Neurother 2014; 14(12):1453–65.5. Tramèr MR, Carroll D, Campbell FA, et al. Cannabinoids for control of chemotherapy induced nausea and vomiting: quantitative systematic review. BMJ 2001; 323(7303):16–21.6. Kedzior KK, Laeber LT. A positive association between anxiety disorders and cannabis use or cannabis use disorders in the general population—a meta-analysis of 31 studies. BMC Psychiatry 2014; 14:136. 7. Arseneault L, Cannon M, Witton J, Murray RM. Causal association between cannabis and psychosis: examination of the evidence. Br J Psychiatry 2004; 184:110-7.8. Large M, Sharma S, Compton MT, Slade T, Nielssen O. Cannabis use and earlier onset of psychosis: a systematic meta-analysis. Arch Gen Psychiatry 2011; 68(6):555-61.9. Serafini G, Pompili M, Innamorati M, et al. Can cannabis increase the suicide risk in psychosis? A critical review. Curr Pharm Des 2012; 18(32): 5165–87. 10. Duchene C, Olindo S, Chausson N, et al. [Cannabis-induced cerebral and myocardial infarction in a young woman]. Rev Neurol (Paris) 2010; 166(4):438–42. French.

to develop psychosis earlier as compared to the norms in the general population. Prior meta-analyses have reported that these individuals develop psychosis three years earlier than the general population.8 More recent research has highlighted the association between cannabis use and suicide, although it does predispose one to an increased risk of suicide.9

The use of cannabis can result in adverse medical complications such as cannabis-induced arteritis, cannabis-induced posterior circulation stroke and even myocardial infarction.10 It can also lead to respiratory issues such as bullous emphysema and chronic obstructive lung disorder. Developmentally, youths who start using cannabis at a younger age may suffer from neurological complications and executive functioning deficits.

CONCLuSIONWhile there is some evidence supporting the clinical efficacy of medical cannabis, the evidence needs to be carefully considered. Medical cannabis may be safe for a special subgroup of patients. However, for medical professionals at large, it is important to recognise not only the changing trend of drug usage, but also the worrying trend of cannabis abuse among young, educated individuals. As medical professionals, it is essential for us to be aware of the adverse effects of cannabis abuse and to counsel patients whom we suspect are at risk.

PROFILE

Dr Melvyn Zhang is currently a senior resident (Year5) in psychiatry with the National Healthcare Group. He has a special interest in addictions and E-health. To date, he has 33 publications, with major publications in the British Medical Journal, Lancet Psychiatry as well as the Journal of Internet Medical Research (JIMR).

Dr Christopher Cheok is currently the Vice-Chairman, Medical Board (National Addictions Management Service) of the Institute of Mental Health. He is a visiting consultant to the Singapore Armed Forces and a member of the medical board of the Civil Aviation Authority of Singapore. He has a special interest in child and adolescent psychiatry, psychological trauma and research.

DR Melvyn Zhang

TexT by

Christopher Cheok

TexT by

feature 9

Jan 2016 / SMA News

PROFILE

TexT by

Dr Wong Tien Hua

Dr Wong Tien Hua is President of the 56th SMA Council. He is a family medicine physician practising in Sengkang. Dr Wong has an interest in primary care, patient communication and medical ethics.

The local newspapers recently reported on the increasing number of foreign practising doctors in Singapore, citing a figure of more than 2,100 currently employed in public hospitals and polyclinics. The influx was to meet the increasing demand for medical services here, especially with the inevitable ageing of our population and the rise in incidence of chronic diseases. The gap in supply of doctors has not yet been met by our three medical schools, which enrol about 460 students a year, a figure that has doubled since a decade ago. It will be some time before these medical undergraduates become full-fledged practising physicians.

Regarding the integration of foreign doctors into our healthcare system, a reporter commented that it matters not where a doctor was born or what languages he speaks. What is important is that he is knowledgeable, experienced and caring. While this is certainly true, there are nevertheless problems associated with foreign doctors practising in an unfamiliar healthcare system.

Reports from the UK have highlighted concerns that doctors who were qualified outside the UK were proportionally more likely to be subjected to an investigation by the General Medical Council about issues such as poor clinical skills and knowledge, lack of knowledge of the law or codes, and inadequate participation in medical education.1

I wrote to the Straits Times Forum in November 2015 (reprinted on page 12) to point out that foreign-trained doctors include both foreign doctors and Singaporean doctors trained overseas. Although the percentage of foreign-trained doctors in Singapore has grown slightly from 36.45 per cent in 2011 to 41.42 per cent last year, the total proportion is not an insignificant number.

SMA is of the opinion that this group of overseas-trained doctors requires some form of assimilation into the local medical practice environment. For foreign doctors, the need is greater because of language and communication barriers and

lost in translationlost in translation— Integrating Foreign-Trained Doctorslost in translation

Illus

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ion:

Dr K

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Loy

10 president’s forum

SMA News / jan 2016

difficulties in understanding the local culture. For Singaporeans trained overseas, they will also need to understand our healthcare system, health financing policies and health laws in detail, and ultimately adapt to the way medicine is practised here. Both groups are at risk of culture shock if they were thrown head first into the wards and clinics. Our highly stressful work environment is like the deep end of a learning pool, and trying to stay afloat will be a huge struggle for any foreign-trained doctor who joins the system. The stress and anxieties, along with the risk of medical error from trying to quickly assimilate should be minimised, even if it cannot be entirely avoided.

INDETERMINACy OF TRANSLATIONGood communication is a critical component in any relationship, and this is especially true in the doctor-patient relationship, which is based on trust and mutual understanding. If predominantly English-speaking foreign-trained doctors had difficulty with communication in an English-speaking country such as the UK, there would doubtlessly be language barriers in a multi-ethnic country such as Singapore.

Doctors who speak a foreign language have the option to use translators to help them overcome barriers in communication. Unfortunately, translators are far from ideal and cannot replace the intimacy of a direct exchange. We know that the presence of a third party in a confidential setting such as a medical consultation will alter the dynamics of the encounter. Patients are less willing to speak up, especially regarding their personal problems, or raise questions that they perceive to be embarrassing.

American philosopher Willard van Orman Quine coined the term “indeterminacy of translation” and argued that it is impossible to communicate the full extent of one’s intended meaning in another language. This is because an individual’s understanding of language is dependent on his or her native language, which is in turn shaped by that individual’s cultural and societal upbringing. The presence of a translator makes communication one step removed

from the original intended meaning, as the final message communicated is dependent on the translator’s own understanding, subjective interpretation and emotional response. It is like the game of Chinese Whispers, where one person whispers a message to the next in line, through a row of players. The resultant message often becomes modified far beyond its original composition and meaning as the message gets passed on.

Even though more Singaporeans are now able to converse in English and doctors can often do without a translator, communicating with Singaporeans can still be a colourful affair.

uNIquELy SINGAPOREOur language is both a source of national pride and academic scorn among Singaporeans. On the surface, a native English speaker will find it easy enough to navigate our streets and buildings due to the universal use of English in our signs and notice boards. The spoken language, however, often presents a challenge. Not only do we speak Singlish, which can be challenging to figure out by itself, but we often speak it at a rapid rate, which makes it even less comprehensible. On top of the four official languages, dialects such as Cantonese, Teochew and Hokkien are also frequently used among Chinese speakers.

The practice of medicine in our local context is subject to cultural and religious norms among our population. Traditional Chinese Medicine (TCM) is widely available in Singapore and many patients, both Chinese and non-Chinese, regularly see TCM practitioners or take traditional medicines for relief of symptoms. The philosophy of TCM is very different from that of Western medicine, and is based on the principle of yin and yang. For example, patients often relate their symptoms to the notion of internal balance, and may ask doctors if their symptoms are due to “heat” or “cold”. Use of over-the-counter traditional medication, such as pi pa gao for cough and po chai pills for gastrointestinal ailments, is also widespread. Doctors practising in Singapore need to have a good knowledge of local alternatives

to better understand the patient’s health beliefs.

Muslims observing the fasting month of Ramadan is a good example of how local medical practice needs to consider religious practices. As fasting patients are not able to take oral medication during the day, doctors need to adjust their prescriptions to allow a twice daily dosage.

Foreign-trained doctors would also need to brush up on their knowledge of our healthcare system, finance and regulatory framework. The legislative requirements that apply to doctors include the Medical Registration Act, the Private Hospitals and Medical Clinics Act, Infectious Diseases Act, Poisons Act, to name just a few. The “3M” of healthcare financing, Medisave, MediShield Life and Medifund, are constantly evolving and can be confusing even for medical professionals.

ROLE OF SMASince 2011, SMA has been organising seminars for foreign-trained doctors to provide insights into the Singapore healthcare system and help our colleagues assimilate into our society. The problem is that these doctors enter our system at different times and have varying needs. While a half-day seminar is useful as an introduction to local culture, it is difficult to reach out to the vast majority of foreign-trained doctors. A more formalised approach, with courses on health law, ethics and professionalism held at regular intervals, would be better placed to serve the needs of this group of doctors.

The process of assimilation takes personal time and effort. Foreign-trained doctors should join a voluntary professional organisation such as the SMA and make use of the many educational seminars and social events to establish connections with our local doctors, who are very willing to help them navigate the intricacies of our local culture and healthcare landscape.

Reference1. National Clinical Assessment Service. Concerns about professional practice and associations with age, gender, place of qualification and ethnicity - 2009/10 data. Available at: http://www.ncas.nhs.uk/publications/.

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Jan 2016 / SMA News

56th SMA AnnuAl

GenerAl MeetinG

E-Annual Report: The SMA Annual Report 2015-2016 and audited Financial Statements ending 31 December 2015 will move from print to electronic platform as part of SMA’s ongoing efforts to support environmentally sustainable practices by reducing our carbon footprint. Members can access and read the Annual Report and Audited Financial Statements from the SMA website. A downloadable PDF version will be made available online, for members who wish to print a hardcopy for your own reference.

Members who prefer to receive a printed copy may submit your request by returning the AGM Response Slip to the SMA Secretariat via fax: 6224 7827 or email: gekeng@sma.org.sg, or respond online: https://www.sma.org.sg/agm by 1 March 2016. A limited quantity will be printed for mailing to members upon request.

In summary, please submit the following documents to the Honorary Secretary by 12 noon on 1 March 2016 (Tuesday):1. Your letter, if you wish to propose Resolutions and

Constitution Amendments [Article XI Section 1(iii) and Article XII Section 2, SMA Constitution]

2. The Nomination Form if you wish to nominate candidates to fill the ten vacancies in the 57th SMA Council [Article VIII Section 3a, SMA Constitution]. The Form is circulated with the Notice of AGM in the January mailbag.

3. The Response Slip (which is also circulated with the Notice of AGM in the January mailbag) to

(a) Request for a printed copy of the Annual Report (b) Confirm your attendance for AGM and to sign up

for AGM lunch.

DR DANIEL LEE HSIEN CHIEHHonorary Secretary56th SMA Council

Date : Sunday, 17 April 2016Time : 2 pm–4 pm (buffet lunch

will be served from 1 pm)Venue : Alumni Auditorium, Level

2 Alumni Medical Centre, Singapore 169850

Pleasemark your

calendar

We refer to the article, "Number of foreign doctors rising in public sector" (23 November 2015).

The growth in the number of people residing in Singapore and its ageing population has had a far-reaching impact on the medical institutions and its fraternity, including the pressing need for more doctors.

We agree with the Ministry of Health that there is a need to assimilate the medical professionals from abroad into the local environment.

Foreign-trained doctors include both foreign doctors and Singapore doctors trained overseas.

The percentage of foreign-trained doctors in Singapore has grown slightly, from 36.45 per cent in 2011 to 41.42 per cent last year.

The SMA started organising seminars for foreign-trained doctors in 2011, as Singapore is unique in its customs and practices.

These seminars were organised to provide insights into the Singapore healthcare system, including the intricacies of Singaporean culture and customs, and help foreign doctors better understand and assimilate into our society.

We hope that foreign-trained doctors who currently do not voluntarily join medically related professional bodies, which can help them understand local contextual issues and interact with the local medical fraternity better, will find the SMA and our educational outreach and development programmes helpful in understanding the local culture and clinical practice environment.

Dr Wong Tien HuaPresidentSingapore Medical Association

SMA OfferS PrOgrAMMeS TO HELP FOREIgN DOCTORS ASSiMilAte HereThis letter was first published in the Straits Times Forum page on 28 November 2015.

SMA News / jan 2016

12 COUNCIL NEWS

PROFILE

Mellissa Ang

Senior Executive, Membership Services

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1. Complimentary popcorn and drink combo sets ready for collection2. The Force is strong with this one!3. Star Wars figurines greeted guests at the registration counter

Legend

For the past three years, SMA has been organising annual Members’ Appreciation Nite events that aim to give recognition to individuals who have contributed to the Association’s work throughout the respective year. From 2012 to 2014, SMA Members were able to catch up with old friends from various specialties and institutions at the premiere movie screenings of the Hobbit trilogy. The Association also hosted our committee members, volunteers and SMA Charity Fund's donors at these events, in appreciation of their time and dedication to the work of SMA. Since the Hobbit film series ended its run in 2014, we chose a movie of the more long-running, intergalactic sort for 2015.

The SMA Members’ Appreciation Nite 2015 was held with the premiere screening of the long-awaited Star Wars: The Force Awakens movie on 17 December at 6:30 pm, at Shaw Theatres Balestier. All SMA members were entitled to purchase a pair of tickets at a discounted rate from our website, approximately two months before the event. Each pair of tickets also included a complimentary

popcorn and drink combo set. Tickets to the premiere screening were sold out within three days after registration was opened to our members.

Over 510 guests attended this year’s movie screening. Some guests arrived as early as 5 pm to secure better seats within their allocated section of the theatre. Everyone was hyped up to be the first few in Asia to catch the premiere of what was easily the most talked about movie for the year. Amid excited chatter among our guests at the cosy ticketing area at Shaw Theatres Balestier, we spotted a few Darth Vaders and plenty of light sabers among the enthusiastic crowd!

We are pleased to say that SMA now represents more than 7,500 doctors and medical students in Singapore as well as overseas. Together, we look forward to advocating for a better healthcare environment, for doctors, for patients. If you have any exciting new ideas for next year’s Members’ Appreciation Event, do share them with us at membership@sma.org.sg. And may the Force be with you in 2016!

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Jan 2016 / SMA News

EVENT 13

Dr Ravindran Kanesvaran

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Dr Ravindran Kanesvaran is a medical oncologist at the National Cancer Centre Singapore who specialises in GU oncology and has an interest in Geriatric Oncology. He is currently the President of the SSO (not the great Singapore Symphony Orchestra but the lesser known Singapore Society of Oncology).

PROFILEY

E S o r N O ?

M

AR I J U A NA

DR RAVINDRAN KANESVARAN (ONCOLOGIST)Marijuana (also known as cannabis) is a plant grown in some parts of the world for its medicinal value and oftentimes, consumed recreationally for its psychotropic effects. Its use for medicinal purposes dates back more than 3,000 years. The cannabis plant produces a resin containing psychoactive compounds called cannabinoids. The highest concentration of cannabinoids is found in the female flowers of the plant. Clinical trials conducted on medicinal cannabis are limited. The US Food and Drug Administration (FDA) has not approved the use of cannabis as a treatment for any medical condition. However, FDA has approved two cannabinoids (dronabinol and nabilone) for use in chemotherapy-induced nausea and vomiting (CINV).

Marijuana has been found to have a number of medicinal uses. In oncology, its main indication overseas has been in CINV. There have been three small studies using cannabis for this purpose and only one of the three showed any benefit when compared to placebo. As far as I know, there is no data to support its use for other cancer-related symptoms such as pain or poor appetite.

I believe that there are better ways to cope with the stressful living in Singapore than to resort to the recreational use of marijuana.There are very few pros to medical marijuana. We have so many good antiemetics for CINV that there is little reason to consider using marijuana or cannabinoids. I can only see housing agents benefitting from this, because if it is approved, it may boost the rental market as people rent spaces to grow the plant. My main concern is that marijuana may become the drug of choice for abuse even if it’s strictly regulated.

As mentioned above, with the new generation of antiemetics for CINV, there is little role for medical marijuana use for the patients I treat in oncology. There is also limited data for its use to treat other cancer-related complications.

DR ADRIAN WANG (PSyCHIATRIST)I think the evidence base for the medical use of marijuana remains limited. While it may help in pain control and nausea, its effects remain unpredictable and it's difficult to decide if the benefits outweigh the risks. The risks are that it can trigger psychotic reactions and may cause cognitive and memory impairments. There is also a possible link between

With the legalisation of medical marijuana overseas, the use of this drug has been hotly debated globally. We interview three specialists for their personal take on the potential benefits of marijuana use in their respective specialties.

SMA News / jan 2016

14 interview

PROFILE

Dr Adrian Wang

Dr Adrian Wang received his MBBS from the National University of Singapore in 1990 and Master of Medicine (Psychiatry) in 1996. He has also received training in the treatment of bipolar disorders at Stanford University. Before commencing private practice at Gleneagles Medical Centre in 2005, he was Chief of the Department of General Psychiatry at the Institute of Mental Health, and the Chief CARE Officer of the National CARE Management System. His main area of specialty is the treatment of mood and anxiety disorders.

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Dr ALEX YEO

Dr Yeo Sow Nam is Director of The Pain Specialist, Mount Elizabeth Hospital. He was trained at the Prince of Wales Hospital, Sydney and was the first in Singapore to obtain accreditation in the pain management specialty, awarded by the Australian and New Zealand Faculty of Pain Medicine. He was the first Fellow of Interventional Pain Practice (USA) in Singapore.

My special thanks to Ms Mabel Poon Lee Shin, my clinic manager, for her kind assistance in preparing this article.

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I feel that evidence of the benefits of medical marijuana, even in the areas of pain management, remain limited.

The most prominent effects of marijuana are mediated by receptors in the brain. Acute intoxication is characterised by euphoria, loss of short-term memory, stimulation of the senses and impaired linear thinking. Adverse effects include depersonalisation and panic attacks, while common physical effects include increased heart rate and reddened conjunctivae. Use of marijuana in chronic, high doses may cause subtle cognitive impairments that appear to be long-term, though the duration of impairment is unknown. Marijuana use may be a risk factor for the development of cognitive impairments in individuals with underlying mental illness. Although marijuana causes dependence, the addictive power and withdrawal symptoms produced are mild compared to cocaine, alcohol, heroin and nicotine.

With relevance to my practice and as evidenced in animal testing, cannabinoids reduce hyperalgesia and allodynia associated with formalin, capsaicin, carrageenan, nerve injury and visceral persistent pain. Two obvious targets are spasms in multiple sclerosis and resistant neuropathic pain. The dose administered should be the minimum quantity, repeated four or six hourly and gradually increased until relief is attained.

According to FA Campbell’s study on the effectiveness of cannabinoids in pain management, the best analgesia achievable with single-dose cannabis in nociceptive pain is equivalent to single-dose codeine 60 mg, which rates poorly on relative efficacy compared with non-steroidal anti-inflammatory drugs or simple analgesics. However, raising the cannabinoid dose to increase the analgesia would result in more adverse effects. Compared with the relatively negative analgesic results in nociceptive pain, the suggestions of cannabinoids’ efficacy in spasticity and neuropathic pain are perhaps more intriguing, as the therapeutic need in these areas is greater than in postoperative pain. To date, there is insufficient evidence to support the introduction of cannabinoids into widespread clinical practice for pain management, although the absence of evidence of effect is not the same as the evidence of absence of effect.

cannabis use and schizophrenia in young people.

I am also worried that some people may use medical marijuana as an excuse for recreational use. Some people may think that recreational use of marijuana is harmless, but its long-term effects have not been fully evaluated. In addition to the adverse effects I have mentioned, there is some evidence that long-term use can lead to dependency, chronic states of intoxication, and cardiac and respiratory problems. There is also the possibility that marijuana may be a "gateway drug" that can lead people to experiment with harder drugs such as cocaine and amphetamines.

The pros of medical marijuana are that for a selected group of patients, such as those with cancer or chronic pain conditions, it may alleviate suffering. We will also need a new set of prescribing guidelines to provide doctors with a framework on prescribing it safely.

Although there are some evidence that marijuana may help with depression, anxiety and bipolar disorder, these are not strong evidence. The risks may outweigh any potential benefits. Thus for now, I cannot think of any strong compelling reason to use it in the patients I treat.

DR ALEX yEO (PAIN SPECIALIST)The recent interest for wider access to cannabis or cannabinoids as analgesic in chronic painful conditions seems to be logical. It is true that the human body contains cannabinoid receptors in the central and peripheral nervous system, although the functions of these receptors and their endogenous ligands may still be unclear. The debate on legitimising the use of both the natural chemicals that act on cannabinoids receptors and synthetic cannabinoids has been ongoing for many years. In Britain, doctors used to prescribe cannabis. In a survey conducted in 1994, 74% of UK doctors indicated that cannabis ought to be available on prescription. To date, the synthetic, nabilone, is the only legally available cannabis preparation in the UK. It is licensed solely for use in nausea and vomiting induced by chemotherapy. Recreational smoking of cannabis in the 20th century and the consequential restrictive federal legislation have functionally ended all medical use of marijuana. Overall,

Jan 2016 / SMA News

Interview 15

into the PastA Glimpse

Medicine in Singapore (Part 5) 1920 to 1933: A New College Building, Students’ Club, School of Pharmacy

This is the fifth instalment of a series on the history of medicine in Singapore.

In 1920, approval was given to build a new College building, designed by Major PH Keys. The foundation stone was laid on 6 September 1923 and the new building was opened officially on 15 February 1926 by the Governor of the Straits Settlements (SS), Sir Laurence Nunns Guillemard. After the completion of the College of Medicine Building (COMB) in 1926, the Tan Teck Guan Building was then occupied by the Department

of Anatomy and an extension of the building housed the dissection room.

The first floor of the COMB housed the Council Chamber, the Principal’s Chambers, administrative and department offices, the Keith Museum (which later housed the Medical Library located in the centre of the first floor, in an 80 ft by 26 ft room) with courtyards on either side (one courtyard was near where the pond at Singapore

Medical Council is now situated), the Department of Biochemistry, a student laboratory and the Department of Materia Medica (pharmaceutics and pharmacy). The mezzanine floor was part of the library. Services provided by the library were rather limited, and students were allowed to take out certain books on long-term loan as personal textbooks, for books were a rare commodity in those days. On the second floor, there was a main lecture

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SMA News / jan 2016

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standing was acquired for the Central Expressway and the association moved temporarily to Houseman’s Quarters. On 3 August 1988, Dr Kwa Soon Bee (then Permanent Secretary for Health and Director of Medical Services, appointed 1984, retired 1996) assisted the association with obtaining the use of the old Department of Scientific Services Building at the junction of College and Outram Roads. The Alumni Association building was renovated and occupied in December 1989, and officially opened by Dr Kwa on 21 July 1990. Later, the Association Alumni and the Gordon Arthur Ransome Memorial Fund Committee (of which Dr Chee Phui Hung was chairman), presented the Ministry of Health with two large oil paintings, which now hang at the COMB. When the Alumni moved out of its building in 1988, Dr Chen’s billiard table was transferred to the Singapore General Hospital Recreational Club (doctors’) lounge, while the first table was transferred to the Pathology Department’s Recreational Club. The first table was eventually refurbished to its original state in 1994 and restored to its rightful place in the billiard room of the Alumni building, courtesy of Tun Dr Mahathir.

In 1924, the College was apparently briefly closed.2 The closure partly reflected the anti-colonial attitude in Malaya, grouses between European staff of the College and GH and the principal Dr GH MacAlister, as well as a lack of dialogue between the European administrative staff of the College and the students. The precipitating event was a trivial one. One night, a student violinist and saxophonist of the Federated Malay States (FMS) Hostela at Sepoy Lines started playing tunes, attracting the attention of the European sisters staying at the nearby Sister’s Quarters, who lined up and cheered. Someone (who was probably opposed to fraternisation with the natives) informed Dr MacAlister. He put up a notice that such un-gentlemanly behaviour should cease and the notice was slashed. This led to the student representatives of the FMS Hostel and the Medical College Union being summoned and told off by the principal. The following week, the students decided to boycott a social event in which the Governor would be giving away sports prizes. The College Council, however, took the view that the students, in absenting

hall (later the New Lecture Theatre), two lecture rooms (later Allen and Farris Lecture Theatres), the Department of Biology and the Department of Bacteriology with its Bacteriology Student Laboratory. Level three housed the Department of Physiology. There was no central staircase; instead a pair of staircases led to the mezzanine floor.

The building’s design, the work of architects Keys and Dowdeswell, is reminiscent of classical Greek monuments such as the Acropolis of Athens. Allegorical bas-relief sculptures and moulding on both sides of the facade depict the teaching and practice of medicine. These were conceived by the Italian artist, Cavaliere Rudolfo Nolli (who also designed similar ornamentation on the facade of the Old Supreme Court building), and executed by Mr J Sharpe Elliot. The sculptures are surrounded by moulded plastered architraves with a circular motif. The building is fronted by eleven sculptured timber doors. These doors stand behind the fluted columns of the Doric colonnades. Over the central doorway is a bas-relief of a Roman eagle, which classically signifies a civil or official building.

In 1920, the Medical Student’s Recreation Club began publishing a student magazine, The Medico, for a period of four years. In one issue, Prof CJ Smith had this to say about the local medical students: “The students here, compared with those at home, were too gentle and timid, and their manners were too good for medical students.” Around 1921, there was a first attempt to form a corporate medical body, and the Graduates Association was founded with Dr EW de Cruz as president. However, it became defunct.1

The Students Medical College Graduates Association was inaugurated on 5 September 1923 by a group of graduates of the medical school at a meeting of the fifth Congress of the Far Eastern Association of Tropical Medicine in the Victoria Memorial Hall. It was managed by a committee of 12 with Dr Chen Su Lan as the president. The main aim of the association was to make the College a University and to elevate the status of its graduates from assistant surgeons to medical officers. On 27 December 1930, at a meeting held at the Europe Hotel, the name of the association was changed

to the Alumni Association of King Edward VII College of Medicine. (The name was further changed to Alumni Association of King Edward VII College of Medicine and Faculty of Medicine, University of Malaya, in 1952.) In 1948, the association formed a building subcommittee to look into the building of a clubhouse. An application was made to the Government, in 1952, for the lease of a site in the General Hospital (GH) compound. The application was approved and a 99-year lease on the site was granted at an annual rent of $1. On 3 April 1954, the foundation stone for the association’s building given by the Government was laid by the Director of Medical Services, Dr WJ Vickers. On 10 October 1955, the Medical Centre at GH on 4A College Road was officially opened by the Vice-Chancellor, Sir Sydney Caine. In the early years, the activities were limited because graduates were scattered all around Malaya.

In January 1957, the Constitution was changed and the association was reconstituted with three branches: Northern, Central and Southern. In the 1960s, the centre was renovated, and housed the Singapore Medical Association (with Dr Arthur Lim as President), the Academy of Medicine, the College of General Practitioners, the Singapore Dental Association, the Pharmaceutical Society of Singapore, and the Singapore Government Medical and Dental Officers’ Association. The Centre had a lecture theatrette, swimming pool and dining facilities (the caterer, Ah Foo, was said to have been curt to everyone in his broken English). The lecture theatrette’s slide projector and sound system were under the charge of a Malay man named Bakri, who was remembered as being very quiet. Doctors who attended talks at the theatrette called him MOHD (most observant house doctor), because he sat through all the meetings and lectures.

In the basement, there were two billiard tables. One table was bought from the UK with funds donated by two doctors from Penang, Dr Mahathir from Kedah and Dr Tow Siang Yew. The second table was later donated by Dr Chen Su Lan. The billiards room had an attendant, Ah Poh, who demonstrated snooker tricks. Annual reunions began in 1963. In 1985, the land on which the Centre was

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Jan 2016 / SMA News

References1. Soh CS. The Alumni Story. In: Lim KH, ed. At the Dawn of the Millennium: 75 Years of Our Alumni. Singapore: Singapore University Press, 2000:49-522. Sandosham AA. Old Times at King Edward VII College of Medicine. In: Lim KH, ed. At the Dawn of the Millennium: 75 Years of Our Alumni. Singapore: Singapore University Press, 2000:218-24.3. Taylor MB, Chow VTK. The Evolution of Teaching and Learning Medical Microbiology and Infectious Diseases at NUS. Annals Acad Med 2005; 34(6): 98C-101C.

PROFILE

A/Prof Cuthbert Teo

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A/Prof Cuthbert Teo is trained as a forensic pathologist. The views expressed in the above article are his personal opinions, and do not represent those of his employer.

Editorial Advisor

Photos by SGH Museum

Notea. The FMS Hostel or Federated Malay States Hostel at Sepoy Lines was so named because a Sultan had donated the money for building it. It was the predecessor of King Edward VII Hall at that site. The FMS Hall had been built in 1916, during which time TTSH Student’s Hostel for 50 students also opened. The FMS Hostel was built at the expense of b. the Governor Sir Arthur Henderson Young (Governor 2 September 1911 to 17 February 1920), and was said to have been an imposing 4-storey building overlooking the GH. It housed 72 male students, and before the Club House was built, its only social life was said to have been a billiards table, which was sold by the College to pay the debts of students who had been suspended in 1924. The playing field behind the hostel was opened on 14 December 1932 by Sir Cecil Clementi (Governor 5 February 1930 to 9 November 1934). Female students lived in the YMCA at Fort Canning (and later in bungalows at Mt. Rosie and Holne Chase in Grange Road, and later at Eusoff College in Evans Road). The Holne Chase Bungalow was later used by the Singapore Anti-Narcotics Association to house addicts undergoing treatment.

themselves from the function, had insulted the Governor and, in turn, His Majesty the King. The College was thus closed and the students expelled from the hostel. Later, some non-hostelite students apologised to the principal and the College was re-opened. A Commission of Enquiry set up by the College maintained that the students had indeed insulted the King, and meted out severe punishment to the students involved. One student was expelled from the College, some were suspended for one year, many for six months, and all those due to sit for their examinations were prevented from doing so.

The Department of Bacteriology was established in 1925, led by Prof A Neave Kingsbury.3 Besides activities such as teaching, routine bacteriological diagnosis and vaccines production, research work was also performed on viral diseases and leprosy.

In 1926, the College and its hospitals were inspected by Sir Richard Needham, Inspector of the General Medical Council (GMC). In his report, Sir Needham told the GMC that, in his opinion, the graduates should be awarded the MBBS because of the high standard of the College. He wrote: “In as much as the Singapore diploma is in no way inferior to the recognised MBBS degree, the letters ‘LMS Singapore’ frequently give the wrong impression, at all events to the public, of the professional status of the holder. In course of time no doubt a university will be established in Singapore which will provide for the students of the College an MBBS degree.”

In 1926, Dr JC Tull succeeded Dr Finlayson as the next Government Pathologist. He was also the honorary physician to the Governor of Singapore. A chair in Pathology was created at King Edward VII College of Medicine, and Dr Tull concurrently held the Chair in Pathology until his retirement in 1936.

In 1928, the SS Government appointed its first pharmacist, Mr T Roebuck, at the GH, and the Medical College appointed him as its lecturer in pharmacy. In 1929, the School of Dentistry was established in the College and produced its first dental graduates in 1933.

The 1929 class of medical students was the first batch to undergo the six-year medical course initiated at the recommendations of the GMC. Among the graduating students were Drs ES Monteiro, Benjamin Sheares (born 12 Aug 1907, Dr Sheares became Malaya's first local professor of obstetrics and gynaecology in 1951, and Singapore's second President on 2 January 1971, an office he held until his death on 12 May 1981), N Amad, RG Gunatilika, Lim Eng Cheang, Benjamin Chew (founder of the Singapore Anti-tuberculosis Association) and AW Moreira.

In 1933, Sir Richard Needham inspected the College, and again he reported its high standards to the GMC. In 1934, the Registration of Pharmacists Ordinance was passed, establishing a Pharmacy Board. When the Ordinance was enforced in 1935, 42 persons were registered as pharmacists. In October 1935, the College introduced a Diploma in Pharmacy course, and in the same year, the School of Pharmacy was established.

1. Lecture room, College of Medicine2. Council Chamber, College of Medicine

Legend

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SMA News / jan 2016

On the morning of 19 December came the sad and sudden news that Prof Feng Pao Hsii, illustrious rheumatologist (and nephrologist and infectious disease pioneer) had passed on peacefully in his sleep. He left behind a legacy of having nurtured and mentored generations of rheumatologists from Singapore and beyond. Respect for Prof Feng is so high that in July 2000, the Singapore Society of Rheumatology inaugurated the first Feng Pao Hsii Lecture in his honour. How do we even start to describe such a man?

In 1969, he went to Israel for further training under the auspices of the World Health Organization Research Fellowship and is still well remembered by friends there. Prof Yehuda Shoenfeld wrote, “I am so sorry to hear about the demise of Prof Feng, a great and long-time friend who not only did so much together with us but was a real friend of Israel, having been trained in our country. The world without Prof Feng will be different. I will cherish him in my heart.”

Indeed the rheumatology world will be different without Prof Feng. He was a man of few words, but when he spoke, we listened. When he had a vision, he brought it to fruition. That was how rheumatology started as a new discipline in 1986 — advancing from aches and pains to one dealing with the diverse nature of autoimmunity like lupus. In the same year, the National University of Singapore awarded Prof Feng with an MD for his work, Systemic Lupus Erythematosus (SLE) in Singapore — A Clinical Study.

Text by Prof Fong Kok Yong, Senior Consultant Rheumatologist, Department of Rheumatology and Immunology and Chairman, Medical Board, Singapore General Hospital

In Memory of Prof Feng Pao Hsii:Rheumatologist Extraordinaire

Prof Feng is indeed the Father of Rheumatology and SLE in Singapore.

While he was a high achiever, he also paid attention to individuals under his charge. Dr Chew Li Ching vividly remembers, “Prof was also a gentleman with a caring heart. I recall when I first set foot in Singapore, he frequently enquired if I had settled in and was happy in my work during the early days. And in the latter years, when the kids came along, he would often ask how they were doing and even remembered their names. He was a great man who had a big heart.”

In the last two years, frail health hindered his mobility, but his mind was just as sharp and seeking. I recall

my last conversation with him on 28 November 2015; we talked about family, kids, our Singapore society and politics, overseas friends, his health and yes, the training of younger rheumatologists. On 24 December, the sky opened and poured for more than half an hour before the sea burial could proceed. Prof Feng will be remembered as a visionary, an academic, a mentor, a caring boss, a family man and a great friend to all.

Prof Feng Pao Hsii was an SMA Honorary Member and served as the Editor-in-Chief of Singapore Medical Journal from 1978 to 1987.

Jan 2016 / SMA News

EULOGY 19

2015 has been an exciting year for me. I have had the joy of hosting Dr Eugene Chua, a FM resident attached to my clinic during his third year in medical school. I am also beginning to see a bountiful harvest from my years of advocating for FM among the pre-med and medical students, trainees and residents. It is especially comforting when I receive texts from students who enquire about FM residency or ask me to be their referees for their residency application. Even my son, who dreams of a medical career, wants to be a GP!

OPTIMISINg THE gP POTENTIAL Before I get too carried away, I was reminded that Singapore GPs have much to do before we can be on par with our contemporaries overseas.

At the time of this writing, our very motivated counterparts up north were having their annual primary care research conference in Kuala Lumpur. It is their belief that, through sharpening their research skills, they can bring out the best in primary care. We face similar challenges as our Malaysian colleagues — many are solo GPs in private practice, while some work in government-funded clinics where long waiting time is not

uncommon. Yet, their passion for research is undaunted. This passion is contagious.

In November, I spent a week Down Under, giving my full attention to my family, especially the children. After watching sunsets for the third day in a row, we got bored. I decided to drive 300 km to the Wheat Belt in Bruce Rock to have lunch with my classmate, Dr Caleb Chow, who moved to Australia not long after we completed our bond. Caleb will share his story in another instalment of this column, so that we may draw lessons from his experiences.

Visiting Caleb in the Wheat Belt opened my eyes to what a GP’s work is like there. I also saw real integrated care in action. Caleb is the only GP in town, and his clinic caters to everyone, from the youngest to the oldest. He performs minor surgeries, manages the hospital ward, looks after patients with dementia in the nursing home and counsels those who are stressed out. He does preventive medicine, conducts health talks to the residents of the town and administers vaccination. He exemplifies a healthy lifestyle.

Interestingly, he also started a cafe to encourage social interaction. He plants vegetables and rears chickens and fish in his backyard.

“Hi, Dr Leong, I have applied for family medicine residency. Could you be my character referee?”– Victoria, my first LPE student

“Dr Leong, I have decided to apply for family medicine residency.”– Fei yee, my student from family

medicine (FM) elective student

“Oh, Dr Leong, just wondering, have you submitted the referee documents for my residency application?”– Ken, my Graduate Diploma in

FM trainee

“Dr Leong, I am thinking of switching my residency from internal medicine to family medicine, what do you think?”

– Shy Xian

Setting thePace Ahead

Family Medicine

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SMA News / jan 2016

PROFILE

Dr Leong Choon Kit

Dr Leong Choon Kit is a GP in the private sector. He is an advocate of the ideal doctor which is exemplified by one who is good at his clinical practice, teaching, research and leadership in the society. His idea of social leadership includes contributing back to society and lending a voice to the silent.

Disclaimer: The names listed in the messages are not the real names of the students.

Editorial Board Member

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His staff even help to look after an orphaned baby kangaroo! “Is Uncle Caleb a doctor or a vet? ” my daughter quipped at the sight.

REFLECTINg AND gIvINg THANKS FOR 2015 So, what have we GPs done for ourselves, the fraternity and the public?

As we start a new year, it is timely for us to reflect on and give thanks for our accomplishments in 2015, and plan on what to achieve for ourselves, our family, our colleagues and the public in the year ahead.

COLLAbORATING WITH REGIONAL HEALTH SySTEMS (RHS)Our polyclinics and hospitals are bursting at the seams. GPs in private practice can definitely help offload their patients. Many hospitals and their respective departments are exploring and experimenting with shared care models. While it can be frustrating and slow in getting these schemes to work, it is important for us to play our part. It also gives us the chance to understand the challenges our colleagues encounter in the public institutions.

REACHING OuT TO FOREIGN COLLEAGuESIt has been reported that Singapore faces a shortage of doctors and that an increasing pool of foreign doctors are among us. It might be a good idea for us to reach out to them and help them assimilate into our society and healthcare system in the year ahead.

MAKING FM ATTRACTIVE It is a sad fact that many parents prefer their doctor children to become specialists. I have even heard of colleagues whose spouses refused to talk to them after they had chosen FM as their specialty. It is really up to the GPs to make our specialty more appealing.

In my opinion, contributing more to our society may improve the public’s perception of GPs. We can chip in to help at various voluntary welfare

organisations (VWOs), schools and even resident committees. My good friend, Dr Ang Seng Bin, is a fine example for us to emulate. He is the vice-president of the National Council for Social Services and chairs the Ang Mo Kio Family Service centre.

Besides VWOs, we can also consider volunteering our services at Singapore Medical Council or professional bodies such as the SMA, Academy of Medicine and College of Family Medicine.

ESTAbLISHING PRIMARy CARE RESEARCHResearch in primary care is an unexplored field, with many gems waiting to be uncovered. The results will help shape better management plans for the public. Private GPs are sitting on these gold mines.

I concede that research is the last thing on my mind as a solo private GP. However, we can always collaborate with polyclinics and the RHS to achieve this. I often dream of emulating Dr Tan Ngiap Chuan, a GP who also focuses on primary care research.

TEACHING FM FROM yOuNGAchieving the abovementioned will certainly help to bolster the standing of the fraternity and increase the public’s confidence in their GPs. However, the most important thing is replicating this reality.

Primary care is crucial in improving our healthcare system. Besides supporting the public sector in serving the population and aiding our foreign doctors to adapt, we should also challenge the younger generation to take up FM as their lifelong career.

To do that, we must teach, shape and inspire the next generation of doctors, like my friend, Dr Teo Boon See, a GP in private practice and a professor in FM.

Hopefully, by this time next year, we can reflect and be thankful that we have inched forward and upward a tiny bit.

gp matters 21

Jan 2016 / SMA News

Dr tan yia swam

TexT by

Dr Tan Yia Swam is an associate consultant at the Breast Department of KK Women’s and Children’s Hospital. She continues to juggle the commitments of being a doctor, a mother, a wife and the increased duties of SMA News Editor. She also tries to keep time aside for herself and friends, both old and new.

PROFILE

oN Call

STRESSStress comes in many forms, and manifests in many ways. I broadly classify them into happy and upsetting stressors, and will be discussing only the latter in this article. Each group can be further divided into three main categories: personal, people and events. Examples of upsetting stressors include: 1. Personal: mental and physical

ailments — eg, a minor illness like an upper respiratory tract infection (URTI), or something more serious like a stroke/cancer. Doctors are just as prone (maybe even more so?) to some forms of mental illness, for a multitude of reasons.

Major disclaimer — this article is my personal opinion; and comprises many anecdotes collated from my own experience, and also from friends and acquaintances over the past ten years. I think bits and pieces will resonate with you, but rest assured, you are not the one I got the idea from. Apologies, I didn’t have time to reference some of my comments. Hopefully this will make you laugh a bit, reflect a bit, and perhaps sigh in relief that you aren’t the only one!

2. People: relationships with partners, spouses, parents, children, neighbours, maids — all these are already stressful enough. In our line, we usually see people who are at a bad spot in their own lives (like illness or tragedy) and these frazzled individuals often need to vent their anger on someone, so it is no surprise that healthcare staff end up bearing the brunt of it sometimes.

3. Events: car accident, MRT

breakdown, air-con leaking, or being late for work. Anything can be a stressor, including major life events such as marriage, divorce, birth, death and travel.

AND FEELINg STRESSED!

22 Opinion

SMA News / jan 2016

FOOD TO EAT DuRING CALL

• Coke Light or Coke Zero (to reduce admissions)

• Green tea (for good luck)• Kopi-o kosong (ie, black coffee only with

NOTHING else)• In general, eat when you can because you

won’t know when the next meal will be

FOOD NEVER TO EAT DuRING CALL

• Chilli and spices (in case of diarrhoea)• Chinese bao (as it may mean for one to

“bao”[or “do”] everything, may also refer to a shroud)

• Beef (or “niu rou” in Mandarin, which sounds like “neuro” — heard this from neurology and neurosurgery colleagues)

• Pineapple tarts (as this brings in “prosperity” and “business”)

bEFORE THE CALL• Sleep early the night before• Post a little prayer/plea on

Facebook/Twitter for a good call• Check who your team

partners are, who the covering consultant is, and who the admitting senior doctor in the emergency department is

• Charge handphone battery!

DuRING THE CALL• Don’t wear red underwear• Don’t ever brag about how

relaxed one is (“Wah! EOT no cases ah?)

• Abide by food restrictions (the list is as extensive as confinement practices and merits its own table given below)

• Bathe early (to wash away bad luck) versus…

• Don’t bathe (so as not to give the impression that one is free)

• Don’t take the “last” lift, ie, the one furthest down the corridor

• Bring an extra battery and charger

• Don’t lose your piece of paper with changes and admissions!

AFTER THE CALL• Hand over on time and go off

post-call in a timely fashion (if your department has such a culture)

• Enjoy a facial/massage• Enjoy a movie• Enjoy a good meal• Go back and sleep• Go exercise • Make requests never to be on

call with xxx ever again!

MANIFESTATIONSWe all show stress differently. The trick is to recognise it in ourselves, and in each other. Try not to be too smug when telling your stressed-out, burned-out colleague: “Oh, just relax lah, what’s there to be stressed about?” You may not know the full circumstances of that person’s stressors. It’s also difficult to recognise when you are the main stressor for someone else! But the situation should become obvious when the other person tries to avoid you because you scold him/her too much. A much more sinister type of stressful colleague is the one who pretends to be concerned for you, but is secretly prying your secrets out and feeding them to the boss (ie, backstabber or sh*t-stirrer). What’s scary is that he/she is not even aware of the harm he/she is causing! Here are the various manifestations of stress:

1. Psychosomatic: this one no need to explain right? Diagnosis of exclusion. But fellow doctors, be mindful not to UNDER-diagnose yourself, ie, brush off symptoms until they blow up in your face!

2. Physical: stress ulcers! Classical. Frequent URTIs. Musculoskeletal aches and pains. Menstrual upsets. Erectile dysfunction?

3. Mental: anxiety, anger, depression, insomnia, hallucinations (eg, hearing phone ringing or patients crying in call room), thinking that colleagues are talking bad about you (but then, this COULD be true…).

COPINgI envy some people who seem to cope with stress very well. No anger, no sleep problems, no worries. One dear friend, who’s like that, tells me: “It’s easy, people who irritate me are all stupid and beneath me, so why stress? Things just happen, just go with the flow!” I was amazed to hear that, not just from him, but also from a few others who seem very chill and relaxed ALL the time! I won’t say I agree with their views but it sure is a refreshing perspective!

Gillian wrote a great article on stress and coping in the 2015 April issue (https://goo.gl/D0EVXR), so I would like to focus specifically on what’s unique to our field: what is more stressful than being on call? Being the solo warrior against heaps of changes to be done? (Or so it feels on most days!)

I have heard of so many practices and superstitions that doctors have devised to cope with a stressful call, some unique to certain disciplines/departments/hospitals — do write in (email: news@sma.org.sg) if you have more that weren’t mentioned!

Despite priding myself as a thinking, modern, scientific woman, I did start observing some of these customs after learning about them in the past… and the habits have lasted till today. Those of you who no longer do calls — do you find this nostalgic? Those still on call, do let us know how these work for you!

I hope this simple write-up was a wee bit helpful, and will inspire you to read up more relevant, scientific articles on stress and coping! Keep healthy, stay sane!

Opinion 23

Jan 2016 / SMA News

What are clinical incidents?A clinical incident is any unplanned event during the medical care of a patient, which causes, or has the potential to cause, unintended or unnecessary harm to a patient.1 The incident could be an adverse outcome where injury or harm is caused by medical management or complication instead of the underlying disease, or a near miss or sentinel event (an unexpected occurrence involving death, serious physical or psychological injury).

The following are the consequences and expectations of patients after a clinical incident:

SEEKING COMPENSATIONFollowing an adverse outcome, the duration of hospital stay may increase, incurring higher costs of hospitalisation and out-of-pocket expenses for the patient. The patient may be unable to return to work for a longer period of time, or worse, the adverse outcome may result in severe disability or death.

SEEKING INFORMATION AND CLOSuREThe patient and relatives will want to know how and why the event occurred.2,3 They will want the doctor-in-charge or a senior doctor (in contrast to a house or medical officer) to explain what had happened and to answer their questions.

SEEKING ACCOuNTAbILITyThey will want to know if the hospital has carried out any investigation(s) to prevent such incidents from happening again. The incident could be a serious reportable event, requiring the hospital to report to the health authorities and conduct a root cause analysis to prevent a recurrence.

MEDICO-LEGAL AND MALPRACTICE FALLOuTLegal suits claiming that the doctors involved were negligent and complaints to the medical council can arise following a serious clinical incident.

RISK OF bREACH IN DOCTOR-PATIENT RELATIONSHIPThe patient and the family would have lost their trust in the doctor and/

or the hospital after an unexpected adverse event.

What is Clinical Incident Management (CIM)?CIM is an open disclosure process that seeks to proactively help doctors communicate with patients and their relatives when clinical incidents happen. Studies have shown that about 10% of patients suffer an adverse event during hospital admissions; most are system issues rather than the result of the doctor’s negligence.4 Many hospitals may have a service quality department that oversees complaints about services and care, but most of these complaints, if they arise from adverse outcomes, are not proactively managed. One of the aims of CIM is to take immediate action after an adverse event, prevent or reduce future harm to patients/consumers, reduce the likelihood of negligence claims and restore the patients’ faith in the hospital. This is especially important, as the same studies have suggested that about 50% of adverse events may be preventable.

Clinical Incident Management

– Professionalism in Risk Management

24 professionalism

SMA News / jan 2016

CIM is activated when a clinical event is serious or has potential medico-legal implications. It works best when the CIM team (eg, from the clinicians, medical board or risk management office) is informed of the incident before the patient lodges a complaint. Hence, the medical or nursing staff should alert the CIM office when they encounter unexpected adverse outcomes or complications during the care of a patient.

An example would be a laparoscopic procedure ending up as a laparotomy due to bleeding from a vessel injury during the intended procedure. The CIM process is organised to allow the doctors involved to take charge of the problems themselves, with assistance from the hospital’s legal department, clinical governance, business office and other departments. One common request is for the business office to stop billing the patient until the situation improves, as a patient who has just suffered an adverse outcome is likely to be angry and unhappy when presented with a bill.

Many patients who have experienced serious adverse outcomes, commonly request for medical reports and these should be vetted by the hospital’s lawyers. Requests for medical reports must be addressed in a timely manner, as any delay may be viewed as a lack of respect for the patient and may raise concerns of cover-up. From a risk management point of view, the hospital’s insurers and the doctors’ medical indemnity provider will have to be informed.

CIM aims to reduce litigation and undue publicity while attempting to meet the needs of patients and their relatives who want answers. It bridges the communication gap between the patients and hospital by creating a comprehensive solution to ensure prompt, effective and consistent conversations. Most CIM programmes train senior doctors in communication skills to help the primary doctors involved handle the difficult conversations that are often encountered after adverse outcomes.

Comprehensive preparation When CIM is activated, the CIM office staff and doctors involved typically

meet to discuss the case and make preparations to meet with the patient and family as soon as possible. Careful preparations are required, and include open discussions about the incident, whether there is liability on the part of the doctors involved (hence the need to involve independent medical experts and legal counsel, if necessary), whether to admit liability if deemed present, and the wording of an apology or expression of regret to be extended to the patient.

The discussions will include information about the patient’s condition, such as the seriousness of the current illness, further treatments if needed, treatment duration, duration of disability to work, as well as further follow-up and care. Finally, there is the issue of cost and whether the hospital and doctor (through the doctor’s medical indemnity insurance) will waive some or all of the fees. The hospital may also separately conduct an internal medical review of the incident to ensure an unbiased and accurate review. The findings of this review may be passed on to the patient.

Steps in CIMACKNOWLEDGEMENT AND TAKING RESPONSIbILITyThe steps in a CIM meeting with the patients, with or without their family members, involve acknowledging the seriousness of the incident, followed by an apology or expression of regret. The apology would have been carefully crafted before the meeting because of its medico-legal implications, since an apology may mean admitting liability or responsibility. When no admission of liability is offered, the apology would be an expression of regret on the sufferings that the patient has undergone.

ACTIVE EMPATHIC LISTENINGAnother important aspect involves listening to the unhappiness and difficulties the patient and family have encountered since the incident. Not uncommonly, they tend to experience frustrations with doctors or nursing staff and the care rendered during and following the incident. There may also be accusations against particular doctors and/or nurses.

PROFILE

Dr Seow Wan Tew

Dr Seow is a neurosurgeon practising at the KK Women’s & Children’s Hospital and at the National Neuroscience Institute. He has had some legal training and had been actively involved in medical risk management at KKH and the NNI. He facilitates some of the MPS risk management workshops and has been a member of the SMA CMEP for several years.

Teaching Faculty, SMA Centre for Medical Ethics & Professionalism

TexT by

Dr T Thirumoorthy

Dr Thirumoorthy has been involved in the SMA CMEP for the last 15 years and has been Faculty at Duke-NUS Medical School since 2007. His teaching responsibilities include subjects on clinical skills, professionalism, medical ethics, communications and healthcare law. He has been practising medical dermatology at Singapore General Hospital since 2002.

Executive Director, SMA Centre for Medical Ethics & Professionalism

TexT by

professionalism 25

Jan 2016 / SMA News

1. Department of Health, Western Australia. Clinical Incident Management Policy. Perth: Patient Safety Surveillance Unit, 2015.

2. Stephen F, Melville A, Krause T. A study of medical negligence claiming in Scotland. Available at: www.scotland.gov.uk/Resource/0039/00394482.pdf. Assessed 10 December 2015.

3. Vincent C, Phillips A, Young M. Why do people sue doctors? A study of patients and relatives taking legal action. Lancet 2004; 343:1609.

4. De Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The Incidence and Nature of in-Hospital Adverse Events: A Systematic Review. Quality and Safety in Health Care 2008; 17(3):216 –23.

References

Questions about the incident itself often need to be answered. These may include questions that have been asked and answered before. New information will have to be given, especially if a medical review was conducted.

REbuILDING THE RELATIONSHIPAfter the disclosure, the future care and follow-up of the patient will be discussed to avoid dis-abandonment. In many situations, the patient may not want any further association with the doctor or hospital, preferring to be cared for by another doctor and hospital. The CIM team can help facilitate this by contacting the requested doctor and hospital, providing medical reports and making the transfer arrangements.

Finally, there is the discussion about waivers. If the hospital offers a waiver, it is “without prejudice”, given out of goodwill and does not constitute an admission of liability. The question of whether to offer a waiver is always a difficult one; while a waiver may help patients financially through a difficult time, they may assume that the hospital is admitting liability by offering the waiver. Hence, this should be discussed and agreed upon with both the hospital’s and doctor’s lawyers. Further, patients who accept the waiver have to sign a final settlement agreement.

In many instances, more than one conversation session with the patient and relatives may be required. Each meeting should be planned as thoroughly as the first one. When promises are made during the CIM session (eg, to provide a report within a certain time period), they should be followed up and honoured. It is important that the CIM team is seen to be honest, transparent, truthful, empathic, sincere, and having the interest of the patient in mind. This also means the team must be easily contactable and accessible. Hence, it is crucial that a reliable staff is appointed to be the contact person for the team and hospital.

ConclusionCIM is a process that aims to reduce complaints and legal claims against doctors and hospitals following an adverse outcome, by proactively initiating an open

disclosure conversation between the doctor, hospital and the patient and relatives. It is important to ascertain as complete a picture of the adverse event as possible, in a timely manner and to reaffirm the patient’s trust in the hospital by acknowledging the patient’s difficulties following the event. Expressing regret or apologising for the situation, responding to the patient’s questions and demands, and reiterating the hospital’s commitment to care for the patient, help to rebuild strained relationships. An offer of financial aid through a goodwill waiver may reduce the risk of an acrimonious dispute resolution at a later time.

When conducted skilfully, CIM can help to re-establish the patient’s trust in the doctor and hospital, facilitate the physical and psychological recovery of the patient, and preserve the sacred doctor-patient relationship that is lost when things go wrong.

Looking for potential clients and business partners?Advertise with

Contact Li Li Loy / Denise Jia at6223 1264 or adv@sma.org.sg to book an advertising space now!

news

26 professionalism

SMA News / jan 2016

Please return this slip for Medico-Legal Seminar on Mental Capacity to Carina Lee, Singapore Medical Association, 2 College Road, Level 2, Alumni Medical Centre, Singapore 169850. Tel: 6223 1264, fax: 6224 7827 or email: carinalee@sma.org.sg. A confirmation email will be issued to all applicants.

Name: Handphone no.:

Email: Profession/Specialty:

MCR no.: SMA Member: YES / NO (please circle accordingly)

This seminar aims to provide the knowledge and application skills for the medical practitioner to be able to write confidently a good medical report on mental capacity assessment that meets the professional standard for medical and legal use. Doctors are expected to prepare and submit medical reports that meet requirements of the Court, patients and their families. In addition, the participants would be given an opportunity to engage leading expert lawyers, officials of the family courts and doctors on all aspects of mental capacity.

Medico-Legal Seminar on

Mental Capacity – Assessment & Report

Writing for Doctors

30 April 2016, Saturday1.30 pm – 4.30 pm, Academia

Number of CME Points: 2

Time Programme

1.30 pm Registration (Lunch will be provided)

2.00 pm Introduction

2.10 pm Patients lacking Capacity (Temporary/Fluctuating) - Dr Nagaendran Kandiah, Programme Director, National Neuroscience Institute Dementia Programme

2.30 pm Overview of Mental Capacity Assessment for Doctors- Prof Goh Lee Gan, Senior Consultant, Division of Family Medicine, National University Hospital & Member, Public Guardian Board, Mental Capacity Act, Ministry of Social & Family Development, Singapore

2.50 pm The Medical Reports — Discerning the Good, bad and the ugly - Ms Lim Hui Min, Director of Legal Aid, Legal Aid Bureau

3.50 pm Panel Discussion: MCA, LPA Certification and Mental Capacity Testing - Dr Colin Tan, District Judge, Family Justice Courts- Dr T Thirumoorthy, Executive Director, SMA CMEP- Prof Goh Lee Gan- Ms Lim Hui Min- Dr Nagaendran Kandiah

4.20 pm Closing

4.30 pm End of Session

Registration (inclusive of GST):

Complimentary for all doctorsBy registering for this event, you consent to the collection, usage and disclosure of personal data provided for the purpose of this event, as well as having your photographs and/or videos taken by SMA and its appointed agents for the purpose of publicity and reporting of the event.

professionalism 27

THE SINgAPORE MEDICAL COUNCIL DISCIPLINARY PROCESS

– a Study of a ReCeNt CaSeThis article was first published in the Rodyk Reporter (July 2015 issue), and is reproduced in this publication with the consent of the authors and Rodyk Academy.

PROFILE

Lek siang phengmar seow hwei

TexT by

Lek Siang Pheng and Mar Seow Hwei are partners in Rodyk & Davidson LLP, which is a panel law firm for The Medical Protection Society Ltd and NTUC Income Insurance Co-operative Ltd.

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SMA News / jan 2016

In November 2014, the High Court of Singapore (also known as the Court of Three Judges) overturned the verdict of the Singapore Medical Council (SMC) Disciplinary Committee (DC) that Dr Lawrence Ang, an obstetrician, was guilty of one charge of professional misconduct (in relation to the need to call for a neonatologist to attend or be on standby for a delivery) and that, among other penalties, he should be suspended from practice for three months. At the disciplinary committee inquiry, the DC had acquitted Dr Ang of three other charges relating to the obstetric management of his patient.

In doing so, the High Court found that the conviction of Dr Ang on that charge was unsafe, unreasonable and contrary to the evidence because the DC had: 1 failed to determine the standard

of conduct the doctor was to be judged by, or from which his departure could be sufficiently serious to amount to professional misconduct;

2 failed to explain its reasons for preferring certain medical opinions over others in the face of conflicting medical opinions on key issues;

3 taken into account facts that went beyond the ambit of the relevant charge; and

4 made at least two factual findings that were contrary to the evidence.

This decision came in the wake of highly publicised criticisms from the Singapore Court regarding two decisions that the SMC DC had made in 2012, and announcements regarding reforms to the disciplinary process that governs doctors, made in July 2014 by the SMC and Ministry of Health.

What might one glean from these cases?

Some, like the author of a forum letter to the Straits Times (10 December 2014), may think that perhaps the DCs are more stringent in applying medical standards than the courts. On the other hand, this

is precisely the point that the High Court in Dr Ang’s case, comprising Sundaresh Menon CJ, Andrew Phang Boon Leong JA and Judith Prakash J, found lacking in the analysis of the DC — there was no determination by the DC of what the standard of care was. In such a case, how does one conclude that Dr Ang had, so to speak, fallen short?

There is a lesson here for those interested in medico-legal matters. The issue of standard of care is crucial in the legal analysis of a complaint or suit brought against a doctor. As to what the standard of care for treatment should be, it does not mean the ideal practice. Instead, the relevant benchmark is what is known as the Bolam test. In other words, if the doctor’s actions are supported by a responsible body of medical opinion, he would not be negligent. Hence, the fact that a patient has obtained a medical view in support of his complaint or claim does not necessarily mean the doctor had fallen below the standard of care. Further, the fact that the patient eventually suffered harm does not necessarily mean that there was negligence and/or professional misconduct.

One must determine the standard of care and whether the doctor has fallen below that standard. In addition, in SMC disciplinary cases, professional misconduct has to be made out. Professional misconduct is made out in at least two scenarios: first, where there is an intentional, deliberate departure from standards observed or approved by members of the profession of good repute and competency; and second, where there has been such serious negligence that it objectively portrays an abuse of the privileges that accompany registration as a medical practitioner.

In Dr Ang’s case, the DC relied on the two SMC prosecution expert witnesses’ views to conclude that Dr Ang should have acted differently. However, the High Court found that the factors relied upon by the

two prosecution experts could not have stood as legitimate bases for convicting Dr Ang on that charge. This is because the factors that the prosecution experts relied on were in respect of an earlier period (6.30 pm to 8.15 pm). However, since the DC did not take issue with the management during that earlier period (which was the subject of one of the acquitted charges), the DC should focus instead on the events that occurred after 8.15 pm. Besides, the DC did not explain why it preferred the evidence of the two prosecution expert witnesses to that of the defence expert witnesses.

The High Court also thought that it was important in this case for the DC to identify the point in time at which the duty to call for a neonatologist arose, because if that duty arose at, say, 8.30 pm, Dr Ang’s breach had to be assessed in light of the fact that, by about 8.45 pm, he had asked for a neonatologist to attend to a patient next door, and by around 8.50 pm, he had commenced the delivery of the complainant’s baby.

The High Court also commented that, while there may be significant practical difficulties in finding the precise answers to those issues, it was nevertheless the responsibility of the SMC to lead the evidence addressing these matters and the responsibility of the DC to evaluate the evidence before coming to the conclusion. Given the DC’s failure to analyse the charge in the aforesaid reasoned manner, that was a fatal flaw that in itself warranted the setting aside of the conviction.

Hence, for claimants contemplating legal action against doctors and for medical experts who are being asked to provide opinions that would be used in medical malpractice litigation or complaints, it is important to first establish what the standard of care applicable to that case would be.

Another significant aspect of the November 2014 judgement by the High Court was its order that the

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Jan 2016 / SMA News

SMC is to pay Dr Ang the costs of the appeal, as well as the costs of the inquiry proceedings that took place before the DC.

After the November 2014 judgement, the SMC wrote to the High Court to clarify this costs order, and the High Court invited both parties to tender submissions on whether the Court had the power to make such a costs order, and if so, whether it should be exercised against the SMC in this particular case.

In March 2015, the High Court released its decision on the costs order. The High Court affirmed its earlier costs order.

In doing so, the High Court held that: 1 the DC has the power to order

costs of the disciplinary committee inquiry against the SMC;

2 the High Court also has the power to order costs of the disciplinary committee inquiry against the SMC; and

3 there was ample justification in Dr Ang’s case to order the SMC to bear the costs of the disciplinary committee inquiry as well as the costs of the appeal.

This is a significant development on two counts. Firstly, it was hitherto believed that the DC does not have the power to order costs of the disciplinary committee inquiry against the SMC in the event of an acquittal of a charge. Secondly, before this case, the High Court had never ordered the SMC to pay a doctor the costs of the appeal even when the latter had succeeded in his appeal against a DC decision.

In relation to the power of the DC to order that the SMC pays the costs of the disciplinary committee inquiry, the High Court noted that, while the Medical Registration Act was silent on the issue of making a costs order against the SMC, the Court also said that it was difficult to imagine that the Parliament intended for the SMC to be immune from adverse costs orders. It noted that even the Public Prosecutor was not immune to adverse costs orders.

The High Court held that the DC would have an implied ancillary power to make costs orders against both parties and not just the doctor alone. Such an implied ancillary power to make a costs order against the SMC could not be easily displaced and indeed could not be displaced just because the Medical Registration Act was silent on the issue.

As for the power of the court, the High Court held that there was an implied ancillary power (the power to hear and determine appeals from a DC), as well as a power under the Supreme Court of Judicature Act (which vests in the High Court the same powers as that of the Court of Appeal in the exercise of its appellate jurisdiction), to make a costs order against the SMC.

In determining whether the power to order costs against the SMC should be exercised, the High Court in this case cautioned that excessive emphasis should not be placed on the consideration that a public or regulatory function is being exercised by the SMC. This is an important but not conclusive factor.

The High Court found that a multi-factorial approach should apply in deciding whether to order costs against a body exercising a public or regulatory function. Ultimately, what the Court seeks to do in each instance is to make an appropriate costs order that is just and reasonable in the circumstances of the case.

In finding that costs should be ordered against the SMC for Dr Ang’s case, the High Court considered the following points: 1 It could not be said that the

charges were brought against Dr Ang on grounds that appeared to be reasonably sound.

There was no available reason to explain the Minister of Health’s decision to require the disciplinary committee inquiry to proceed despite the findings of the Complaints Committee. The DC’s reasons for dismissing the first three charges and the High

Court’s reasons for reversing the DC’s conviction on the fourth charge (which was the subject of the appeal to the High Court) are largely similar to the reasons given by the Complaints Committee in dismissing the complaint in the first place.

2 The errors made by the DC in convicting Dr Ang were largely contributed to by the SMC.

The charges were not sufficiently particularised; the type of professional misconduct that Dr Ang was alleged to be guilty of was not specified, and this undermined the ability of the DC to properly evaluate the evidence. Further, the DC had considered extraneous facts, and presumably, this arose from the SMC’s submissions.

3 Dr Ang was initially cleared by the Complaints Committee but was then made to endure two tranches of proceedings, which he should never have been put through. He would have had to incur significant costs in his defence.

The legal principles above were stated by the High Court to also be applicable to disciplinary tribunal inquiries under the current regime of the Medical Registration Act. Dr Ang’s case was under the previous regime.

The High Court’s decision to order costs against the SMC was the first time the SMC had been asked to bear the acquitted doctor’s costs of the disciplinary committee inquiry. Given its relevance to disciplinary tribunal inquiries that may be on-going or are to be undertaken, the High Court’s November 2014 judgement, as well as its views set out in the March 2015 judgement on costs, would have to be considered carefully by the parties and counsel involved in such inquiries.

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SMA News / jan 2016

For more information, contact Jen / Huda / Shirong at 6223 1264 or healthcare@sma.org.sg. To register, download the registration form from http://goo.gl/Ry4NJH (URL is case-sensitive) and

return to Singapore Medical Association via fax: 6224 7827 or email: healthcare@sma.org.sg.

Looking for courses for your Clinic Assistants to upgrade their skills and knowledge? Hurry and register them now. This course will train your Clinic Assistant to provide quality service!

Participants will be trained in Health Screening and Laboratory Tests, First Aid and emergencies, Reception and Clerical Duties, Dispensing Medicine and Drug Management. A nationally-recognised ITE Skills Certificate will be awarded upon successful completion of the one-year programme.

Do sign up for the ITE Traineeship Scheme to equip existing and new clinic assistants with the necessary skills. You are eligible to claim from SkillsConnect Training Grant when you sign up for the Traineeship.

Applicable for Singaporeans and Permanent Residents only.

One-year Course Outline: Semester 1: • Module 1: Basic Healthcare [60 Hours]

Semester 2: • Module 2: Clinic Dispensing [40 Hours] • Module 3: Outpatient Care [20 Hours]

Lectures and practical sessions will be held on: • Saturdays, 2 pm – 6 pm; or • Sundays, 9 am – 3 pm

Venue: The Verge (Nearest MRT Station: Little India )

Registration closing date: 5 March 2016 Commencement of next course: 19 March 2016

SMA-ITE Skills Certificate in Healthcare (Outpatient)- ITE Traineeship SchemeOrganised by:Singapore Medical Association

The new giving platform, Giving.sg, has replaced the old platform, SG Gives. From 1 February 2016 onwards, all online donations to SMA Charity Fund can be made at this URL https://www.giving.sg/smacf or by scanning the QR code provided.

We will be able to have supporters involved directly in pushing for our cause through online campaigns such as running an upcoming marathon, giving up your daily Starbucks coffee, saving your loose change, doing yoga daily for a month, and the list goes on! Start your giving campaign online through Giving.sg and make an impact to healthcare, today! For further enquiries, please contact smacharity@sma.org.sg.

Online giving Platform!

SMA EVENTS MAR–APR 2016DATE EvENT vENUE CME POINTS WHO SHOULD ATTEND? CONTACT

CME Activities

19 MarchSaturday

Medical Expert Witness Training Academia TBC DoctorsDenise Tan 6223 1264denisetan@sma.org.sg

9 AprilSaturday

SMA Seminar: Tax Obligations on Medical Practice

M Hotel TBCDoctors and Healthcare Professionals

Carina Lee 6223 1264 carinalee@sma.org.sg

9 AprilSaturday

Medical Expert Witness Training State Courts TBC DoctorsDenise Tan 6223 1264denisetan@sma.org.sg

30 AprilSaturday

Medico-Legal Seminar on Mental Capacity

Academia TBCDoctors and Healthcare Professionals

Carina Lee 6223 1264 carinalee@sma.org.sg

N e w

SMA News / jan 2016

32 SMA CHARITY FUND

The Association of Women Doctors (Singapore) (AWDS), Singapore Film Society (SFS) and National University of Singapore Medical Society (NUS Medical Society) collaborated to raise funds at the charity premiere of “Snoopy And Charlie Brown: The Peanuts Movie” in aid of NUS Medical Society’s community involvement projects. The premiere was held on Thursday, 10 December 2015 at Golden Village GVmax, VivoCity.

The premiere was attended by almost 600 guests, including underprivileged children from various organisations, whose seats were sponsored by generous donors. Guests were treated to a series of activities prior to the movie, including photo opportunities with the Medical Society Bear mascot, and free popcorn.

Booths had also been set up by medical students to showcase their community projects. The three NUS Medical Society flagship events featured at the premiere were the Neighbourhood Health Service, Public Health Service and Project Lokun.

Leaders of the AWDS, SFS and NUS Medical Society also gamely posed with guests who requested for photographs and answered questions about their organisations.

When asked about the role of AWDS, Dr Karen Soh, President of the AWDS, replied that AWDS has been pivotal in promoting women’s rights in relation to health and career advancement in medical practice. Dr Soh also added that AWDS actively organises

1. Excited children mobbing the Medical Society Bear mascot.

PROFILE

Dr Jade Kua

Dr Jade Kua is a consultant paediatric emergency physician with KKH. She works closely with various ministries to helm community projects, particularly those that educate schoolchildren and the general public on basic resuscitation skills. She also contributes frequently on editorials about children's health aimed at young parents. She is passionate about travel, horology and music.

TexT ANDpHoToS by

seminars, forums and workshops relating to health concerns, particularly those pertaining to women and families.

In his welcome speech, Mr Kenneth Tan, Chairman of the SFS, explained that the film society is a non-profit organisation that promotes the appreciation of movies, as both an art form and a medium of popular entertainment. SFS curates and showcases a year-round programme of feature and short films from all over the world, many of which are otherwise not available to Singapore audiences.

Donors were thanked by Mr Wong Wen Kai, President of the NUS Medical Society, for their generosity. He described the society as Singapore's longest-lasting representative body for university students. He said that for 67 years, the NUS Medical Society has sought to create a learning community that supports the holistic growth of medical students, helping them to develop into ethical, empathetic and competent doctors. It does this through advocacy of student interests, administrative management of student activities and serving as the point of contact for external parties seeking to reach out to the medical students.

The evening ended on a high note as guests left the theatre chatting excitedly about the adventures of Charlie Brown while the movie's theme song, Meghan Trainor's "Better When I'm Dancing", played on.

Snoopy Charlie Brown – A CHArity MOvie eveNt

1

from the heart 33

Jan 2016 / SMA News

Mention Romania, and images of Dracula, world-class gymnastics and the Danube River are conjured, but planning for this trip made me realise that the country has so much more to offer. The most direct route from Singapore to Romania’s capital, Bucharest, is by Turkish Airlines via Istanbul. City express buses and the Henri Coanda Express train connect the airport to the main Piaţa Unirii (Union Square) or the North Railway Station. I strongly recommend staying in the Old Town, which is littered with century-old buildings such as the CEC Palace, the National History Museum, the Military Museum, the University, old churches and others. You get the picture of a city steeped in history.

Like any other metropolitan city, Bucharest has a modern metro network that brings tourists to most of the city sights. However, I must warn that some of the attractions are plain humongous, and it is a considerable walk to the entrances. (Do rent a bicycle if you are short of time.) It took us almost 45 minutes of brisk walking to cross the Constitution Square and Liberation Boulevard along the front facade of the Parliament Palace to get to the side entrance, which is another 10 minutes up a slope. On most days, ticketed guided tours are available at regular intervals.

The Parliament Palace is the second largest building in the world, after the Pentagon, and the one-hour tour showcases just ten per cent of the most elaborately decorated rooms and corridors in the twelve-storey complex of 1,100 rooms! Construction commenced five years before the Revolution in

1989 and continued under debate during democratic rule. Be wowed by chandeliers weighing tonnes, curtains with gold embroidery and tassels, endless marble columns and staircases, and state-of-the-art conferencing facilities. One cannot help but think that one man’s crazy idea of building such a palace indeed showcases the country’s best and proves that Romania can and will accomplish!

We were spoilt for choice when it came to alfresco dining in the Old Town. Activity builds up in the afternoon till late at night, with street performers entertaining the crowd as they enjoy local or international cuisines. Trip Advisor’s recommendation of The Artist was an adventure, I must say. The Spoon

1

PROFILE

Dr Juliana poh

Dr Poh is a part-time emergency physician and full-time mother, who dabbles in cooking experiments and clan work, leaving no time to spare.

TexT AND pHoToS by

1. The Parliament Palace, the second largest building in the world.2. Sarmale, traditional Romanian cuisine3. Palinka souvenirs from Dracula land 4. Sour soup at Restaurant Sergiana, Brasov5. Spoon Tasting Menu at The Artist, Old Town, Bucharest6. Traditional Trdelnik bread sold outside the zoo7. Panoramic view of the Vidaru Dam and Lake8. View from the Clock Tower in Sibiu9. Seas of sunflowers en route

Legend

Much Ado About

Dracula!

SMA News / jan 2016

34 INDULGE

Tasting menu (70 leu = S$24) scored in presentation, with its classic drink, also called The Artist (Prosecco with black pepper and lemon grass), complementing the food beautifully. I would be surprised if they are not awarded a Michelin star soon!

There was so much to see with the limited time we had, but we were repeatedly reminded by the locals to take time out for Herastrau Park and the adjacent Village Museum, an outdoor setup of village houses from all over Romania with a mind-boggling collection of ancient windmills, costumes and household artefacts. The boat ride on the stunning lake was truly relaxing; I wondered why they had to provide free Wi-Fi!

We were fortunate to experience the Transfagarasan Highway, which is only open from July to October. Crossing the Carpathian Mountains, this road is perfect for exploring the Transylvanian region, and was a big, costly project for strategic military access in the 1970s. The winding road with steep hairpin turns and long S-curves was nothing short of spectacular. Our seasoned driver had to make several stops along the way, as we couldn’t get enough pictures of the breathtaking scenery. With every turn, the scenery was just picture-perfect — there were para-gliders, avid cyclists, small streams,

melting glaciers, Vidaru Dam with its man-made lake and endless stretches of coniferous trees. We even drove head-on into a flock of sheep and watched them surround us! As Jeremy Clarkson of Top Gear exclaimed aloud as he drove along the highway in his Aston Martin in 2009: “This is the best road in the world”!

Approximately three hours away from Bucharest is Brasov city with its famous 14th century Black Church, so named because it was destroyed by

a big fire in 1689 and later restored, but it still retained its blackish facade. It houses the biggest bell in Romania and an impressive pipe organ. We stayed overnight in a pensiune in Brasov and had dinner at Sergiana, an authentic Romanian restaurant in a vault! You haven’t been to Romania if you haven’t tried the traditional Romanian dish, sarmale, minced meat rolls in cabbage leaves, and Transylvanian sour soup served with a huge green chili. We were absolutely stuffed after all that and a traditional

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INDULGE 35

Jan 2016 / SMA News

An hour’s drive away from Alba Iulia is the Turda Salt Mine of Cluj County. Mining equipment and machinery are displayed in the mine-turned-museum, which dates back to the 13th century. A jacket is recommended, as it gets pretty cold 13 storeys underground. The Terezia mine at the bottommost is the oldest chamber open to visitors and has a salt lake on which you can paddle a boat for a token fee (10 leu). How exciting to paddle in semi-darkness! One can also play kiddie golf, take a ferris wheel ride, play a game of table tennis, or buy salt mine souvenirs such as bath salts and salt bar deodorants and soaps. Or just sit, and admire the spectacular salt stalactites and efflorescence!

I had the privilege of visiting the Tirgu Mures County Hospital where emergency medicine first started in Romania – a truly modern facility with ICU beds, advanced technology for medical oversight of other emergency departments and an impressive helicopter evacuation service. It had the familiar sight of crowded corridors and harassed emergency physicians, same as back home!

After a week of scenic drives, endless sunflower and polenta fields, pine trees and historical buildings, we drove ten hours back to Bucharest along the Transalpina Highway, which in itself was another once-in-a-lifetime experience. Some say it surpasses the Transfagarasan with its beauty! I think my descriptions will not be able to do justice either way. You will just have to make this trip to decide for yourself.

stew with polenta. And take my word for it – the Romanians make the best lemonade on this planet.

We made the “compulsory” visit to Bran Castle, a fortress made famous by Vlad Dracula, more popularly known as “Dracula’s castle”. Despite being a touristy setup that Vlad himself never inhabited, it was still interesting to explore its spiral stairways and quaint furniture (and imagine how short people of that period were). I was more captivated by the beautifully-preserved medieval city of Sighisoara, a designated UNESCO World Heritage Site. Vlad’s birthplace (admission fee 5 leu only) at Citadel Square is now a café selling Dracula souvenirs and (ahem) one of the “reddest” wines of the region. A short but challenging climb up 176 steps on School’s Hill leads to the gothic Church on the Hill, the most important architectural monument of Sighisoara, which offers a viewpoint of the historic city of cobbled alleys and numerous turrets.

Our memorable road trip continued onwards to Sibiu, the European Capital of Culture 2007, and Alba Iulia, a city of historical significance even before the Middle Ages. It was here that the largest fortress in Romania, Alba Carolina, was built; the perimeter measures 12 km! After WWI, on 1 December 1918, the proclamation of the union of Transylvania with the Kingdom of Romania was conducted in The Unification Hall. The National Day (also known as Great Union Day) of Romania is still celebrated here every 1 December! We spent hours exploring the well-preserved hall, university, cathedral, Roman ruins and the six gates; good walking shoes are recommended!

7

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9

SMA News / jan 2016

36 INDULGE

Jan 2016 / SMA News

SMA CHARITY FUND 37

SMA Members can now pay your 2016 SMA membership fees online via PayPal or credit card through your membership portal*!

If payment for your 2016 membership subscription is made by 31 January 2016, you stand a chance to win one of the two 38-mm Stainless Steel Case Apple Watches with Milanese Loops (worth $948 inclusive of GST) up for grabs. All SMA Members in good standing by 31 January 2016 will also obtain an exclusive membership gift pack comprising an SMA lanyard and post-it pad, as well as offers from our promotional partners!

*Your Member ID for the membership portal at http://www.sma.org.sg is the email address you indicated upon your membership sign up. You can reset your password on the SMA website. Email membership@sma.org.sg if you have any queries.

PAy yOUr 2016 MeMBerSHiP feeS

Photo used is for illustrative purposes only

BY 31 JANUARY 2016AND StAND A CHANCe tO WiN1 OF 2 APPLE WATCHES!

Medication: Examples that are not claimable under CHAS

GUIDING YOU THROUGH CHAS AUDIT: A QUICK REFERENCE (PART 2)In SMA News Nov ‘15 issue, we have covered issues related to the Patient Consent Form and issuance of patient invoice. In this issue we will cover clinical documentation; general medication and investigation that are not claimable under CHAS.

Diagnosis in case notes must be consistent with the information submitted on CHAS Online. CHAS GP clinics are minimally required to keep the following set of documents:

If you have a question on CHAS which is not covered above, kindly contact AIC at gp@chas.sg or 6632 1199

Errata: Guiding You Through CHAS Audit: A Quick Reference (Nov 2015)

We shared that a parent/guardian must sign on the patient’s behalf if the patient is below 18 years old. The correct age should be below 21 years old.

clinical notes

notesFor Complex Chronic with complications, GP’s clinical notes must document the causal link between the chronic disease and its complications

Prescription or clinical notes detailing medication prescribed, if any

Records of laboratory tests carried out for diagnosis and follow-up, if any

Please note that for each patient, each clinic can only submit 1 acute claim or 1 chronic claim, but not both on the same visit date.

Non-compliant Claims

Should there be non-compliant claims discovered during audit e.g. claims for items not allowed, your Administrator (NHG Polyclinic/ Singhealth Polyclinic) will proceed to recover the claim. This is in accordance with Part III Clause 3.4 of the CHAS Agreement.

Traditional and complementary medicine (e.g. herbal medicine)

Vitamins and/or dietary supplements

relevant conditions)

Lifestyle modifying medications (e.g. to treat hair loss or for weight-loss)

Intra-articular viscosupplementation

Sedatives-hypnotics

Investigation: Examples that are not claimable under CHAS

Investigations prior to establishing the condition for a CDMP condition under chronic subsidy, e.g. OGTT for a pre-diabetic patient

Investigations unrelated to the management of the claimed condition

Screening tests included in lab packages, e.g. STD screen, hepatitis screen, and tumour markers

When in doubt, please refer to the Handbook for Healthcare Professionals 2015 for the general list of claimable and non-claimable items, which is available on CHAS Online and MOH Website.

CLINICAL DOCUMENTATION MEDICATION AND INVESTIGATION

38 aic says

After completing my Basic Specialist Training (BST) in Internal Medicine at the Singapore General Hospital and Advanced Specialist Training (AST) in Cardiology at the National Heart Centre Singapore, I attained membership with The Royal College of Physicians of the United Kingdom (MRCP UK). Today, I am a Fellow of the Academy of Medicine, Singapore (FAMS Cardiology), a Fellow of The Royal College of Physicians of Edinburgh (FRCP Edin), a Fellow of the European Society of Cardiology (FESC) and a Fellow of the Asian Pacific Society of Interventional Cardiology (FAPSIC). I am also an American College of Sports Medicine (ACSM) Certified Clinical Exercise Specialist.

Whilst in institution practice, I have been active in clinical research and have been Principal Investigator of a number of multinational interventional cardiology registries and randomized control trials (DELIVER study and DEB-Only Small Vessel Disease study, SIGNIFY study, REDUCE study, RESPECT-HF trial), and have also been Co-Investigator in several landmark international studies like the PLATO and CURRENT/OASIS 7, IMPROVE-IT and LEADERS FREE trials. I have numerous publications in peer-reviewed journals in the field of Interventional Cardiology, and have been invited as fac-ulty to lecture in regional and international Cardiology conferences like AsiaPCR, EuroPCR, TCTAP, HKSTENT-CICF, ECC, TOPIC, CCT.

Besides clinical research, I have been involved in the teaching and mentoring of medical students, residents, senior residents and nurse clinician trainees. I am a Clinical Senior Lecturer at the Yong Loo Lin School of Medicine, NUS and a Core Clinical Faculty Member of the NHG Cardiology Senior Residency Program and a Clinical Teacher at the Lee Kong Chian School of Medicine.

The Heart Specialist Clinic Pte Ltd3 Mount Elizabeth, #14-09/10 Mt Elizabeth Medical Centre Singapore 228510Tel: (65) 6235 8733 | Fax: (65) 6235 8955Email: thscpl@singnet.com.sg | doctor@juliantanheart.com

I was conferred the Ministry of Health’s Healthcare Manpower Development Plan (HMDP) scholarship to pursue fellowship training in Interventional Cardiology, at the Alfred Heart Centre and Epworth Hospital in Melbourne, Australia. In addition to percutaneous coronary interventions, I am trained to perform peripheral endovascular interventions like lower limb angioplasty and renal artery stenting and renal nerve denervation, as well as in structural heart interventions like transcatheter aortic valve replacements (TAVR), percutaneous patent foramen ovale (PFO) closures, percutaneous left atrial appendage (LAA) closures, balloon aortic and mitral valvuloplasties. I have a particular interest in complex coronary interventions, like bifurcation stenting and chronic total occlusions (CTO) interventions.

At The Heart Specialist Clinic, we provide comprehensive specialist care in heart health matters. The full suite of sub-specialty interests and facilities include:

General cardiology services• General cardiac screening• INR monitoring• ECG• Exercise stress test• Ambulatory blood pressure monitoring

Echocardiography• Echocardiography – 2D, 3D and cardiac

dyssnchrony studies• Transeophageal echocardiography• Dobutamine stress echocardiography

Arrhythmia and Cardiac Electrophysiology• Ambulatory Holter ECG Monitoring• Signal average ECG testing• Heart rate variability, Heart rate

turbulence and QT analysis• Event ECG recorders and monitoring• Pacemaker interrogation and program-

ming• ICD interrogation and programming• Cardiac resynchronisation interrogation

and programming• Cardiac Electrophysiological studies• Catheter ablation of cardiac arrhythmia• Device implantation (pacemakers, ICT,

CRT)• Lead and device extraction

Interventional Cardiology• Percutaneous Coronary Intervention

(“stenting”)• Structural heart interventions• Peripheral endovascular interventions• Renal Denervation

I look forward to your continued support and to partner you in providing the best possible specialist care in cardiovascular medicine to your patients.

Yours sincerely,

Dr Julian K.B. TanFRCP (Edin), FESC, FAPSIC, MBBS (Singapore), MMed (Internal Medicine), MRCP (UK), ACSM (Clinical Exercise Specialist), FAMS (Cardiology)

Consultant Interventional CardiologistThe Heart Specialist Clinic

Professional Announcement

Dear friends and colleagues,After 16 years of service in the public healthcare sector, I have com-menced private practice at The Heart Specialist Clinic in Mount Elizabeth Medical Centre, Singapore.

Besides holding a concurrent Visiting Consultant post at the following re-structured tertiary hospitals: Tan Tock Seng Hospital and Khoo Teck Puat Hospital, I am a fully accredited consultant interventional cardiologist, with admitting privileges, at the following private hospitals: Mount Eliza-beth Hospital, Mount Elizabeth Novena Hospital, Gleneagles Hospital, Parkway East Hospital, Mount Alvernia Hospital and Farrer Park Hospital.

SALE/RENTAL/TAKEOVERFor regular partner +/- takeover. Geylang clinic. 9674 0321.

Clinic for takeover at central location in Raffles Place. Approximately 1400 sq ft. Fully equipped (treadmill, sound proof room etc.) room for 2-3 doctors. Vacant April 2016. For enquiry, please call 9010 1133.

D19 ground-floor shop at Simon Plaza, 2-mins to Kovan MRT. 968 sq ft with water point, toilet and 3-phase wire. Within private condominium and landed property enclave. Immediate occupancy, carpark available. Suitable for GP/Specialist clinic. Please call 9635 5188 or email mariayktang@yahoo.com

Clinic for rent. Prime next to lift, #06-01 Gleneagles Medical Centre. Immediate. 656 sq ft. Renovated. SMS 9680 2200.

Newly renovated rooms for lease available at Gleneagles Medical Centre and 2 units for lease available at Mount Elizabeth Novena. Please call Miss Karen 6258 7965 if interested.

For Sale. An integrated medical suite at Novena Medical Center located at Square 2, linked to Novena MRT & TTSH. Selling with vacant possession. Size 904 sq ft. $4.2M. Call Truddy Tan at 9850 4876 for more information & to own a unit here.

Serviced clinic for rent at Mount Elizabeth Novena Hospital. Fully equipped and staffed with IT support. Immediate occupancy. Choice of sessional and long term lease. Suitable for all specialties. Please call 8668 6818 or email serviced.clinic@gmail.com

SCM: buy/sell clinics/premises. Takeovers: (1) D14, industrial & HDB; (2) Hougang, practice with shophouse; (3) D21, affluence catchment. Rental: (i) Holland HDB shophouse; (ii) Adelphi; (iii) D21, share with specialist, MRT. Sale: Bishan ctrl shophouse. Kok Yein 9671 9602.

Jurong East Street 31 clinic for rent. Near HS Rail Terminal, NTUC Mart behind. Sharing with Eye Surgeon. Call 9856 0386.

Mount Elizabeth Novena Hospital whole unit 581 sq ft for rent/2 separate rooms for rent. Per Room $2,000. Flexible arrangement. Call Adrian 9188 0684.

Ground floor clinic for takeover at Biopolis. 1003 sq ft. Modern, tastefully fitted with full interior design, immediate move-in condition. 3 consultation/procedure rooms, reception, pantry, private exclusive entrance, ample carpark. Must see to appreciate! Rent $5K neogotiable. Call 9789 2388 Angeline.

POSITION AVAILABLE/PARTNERSHIPSeeking full-time and part-time general practitioner/family physician for our clinic. Please call or text 9367 6933 for a confidential discussion.

Seeking independent and motivated full-time partner doctors or associate doctors for GP practices. Attractive salaries with possible profit sharing partnerships. Plenty of local and overseas training opportunities provided for suitable candidates. Please email CV to puahbk4304@gmail.com

Established medical aesthetic group in CBD area is looking for motivated doctors who are looking for growth opportunity. Both part time and full time positions are available. Joined partnerships are welcomed as well. All applicants are required to have COCs. Candidates with prior experience and knowledge are preferred. Comprehensive skill development training programmes will be provided.If you’re keen in joining our winning team, kindly email your detailed resume to: gangnamlasersg@gmail.com

ONLy Group Pte Ltd is looking for doctors with passion and has an eye for aesthetics. Experience with application of lasers and medically certified to perform BOTOX/Fillers is preferred. Remuneration and working hours are negotiable. Send resumes to: info@onlyclinic.com

Very high volume Eye Surgeon Tanjong Pagar Hotel- looking for Eye Surgeons as Associates/Partners. Fully equipped OT and lasers. Fully Medisave accredited. Call 9856 0386 for discussion.

MISCELLANEOUSbrand new bREWER Patient Examination Couch, model #4000, with drawers opening to patient’s right. Retractable leg extension. Cocoa colour. 3-year warranty. Selling at $3000/-. Call Clinic at 6733 1856.

Are you a Family Physician who wishes to spend more time with your patients?

International Medical Clinic (IMC) operates family clinics with a clear focus on the international expatriate community, and offers a truly unique practising environment, which includes:

A very real focus on patient care and service;

Significantly lower patient numbers, based on our patients being prepared to pay for quality time with their doctor;

No panel contract arrangements,

enabling medicine to be practised without any third party interference;

A significant remuneration upside for those suited to our style of medicine;

Standard work week hours, with the possibility of flexibility with the number of sessions worked.

For more background, please view our website at www.imc-healthcare.com

Please send your CV together with a cover letter stating the reasons you are attracted to IMC, to hr@imc-healthcare.com

M E D I C A LC L I N I C

ADSPrunella

Parkway Shenton Pte Ltd, a subsidiary of Parkway Pantai Limited, is a private primary healthcare solutions provider. We invite dedicated individuals who are passionate and driven to join us as:

1. General Practitioner (Correctional Healthcare) 2. General Practitioner (Health Screening)At Parkway Shenton, we provide sponsored postgraduate training opportunities in addition to our comprehensive suite of benefits. Join us for a challenging career and opportunities for personal development.Based in Singapore, you will be part of team of dedicated doctors and paramedical staff rendering healthcare and providing comprehensive care to our patients. You will also play a key role in the maintenance of clinical standards and the delivery of a service experience for our patients.

Requirements: • Basic medical qualification registrable with Singapore

Medical Council • Postgraduate medical qualifications are an advantage • Possess a valid practicing certificate from the Singapore

Medical Council • Relevant experience is an advantage • Good oral and written communication skills • Good interpersonal skills • Good team player

For position 1, kindly email: koh_hau_tek@parkwayshenton.com or call 92346086 for a friendly discussion.For position 2, kindly email: kok_chuan@parkwayshenton.com or call 97827710 for a friendly discussion.Please state “Position — Your Name” in the subject header of your email application.

www.parkwayshenton.com

The Art Fellas is proud to present 2 award winning local artists at Art Stage Singapore 2016!

Ren Jian Hui & Yeo Chee Kiong

Ren Jianhui (b.1956) Born in Chengdu, China. Ren graduated from China Central College of Arts and Crafts, and was mentored by Prof. Wu Guanzhong.

Since 2000, Ren Jianhui became gradually known in the international art scene, and was invited to hold solo exhibitions in Singapore, Kuala Lumpur, Tokyo, New York and Jakarta, etc. He participated in the Biennale Chianciano, Italy, in 2009, and was awarded with an Honourable Mention for Painting, including an impending Leonardo Da Vinci Award. Ren’s art works have been collected by various art museums, private foundations and organisations around the world.

Ren’s style of painting is a unique fusion of chinese ink and western oil techniques. From his style to the way we see him paint what he feels he’s living, many refer him as a ‘Rebel Master’.

His painting are often infused with deep complex meaning, which serves to reflect the society and portrayal of human nature through careful observation of the world.

Yeo Chee Kiong (b.1970) is an award-winning professional sculptor known for his uniquely playful and unexpected juxtapositions.

An alumnus of the Nanyang Academy of Fine Arts (NAFA) and the Glasgow School of Art, U.K., Chee Kiong has garnered critical attention for his practice-winning awards such as First Prize, LTADTL Art Competition 2012, Expo Station, the regional Grand Prize for Asia-Pacific Breweries Foundation Signature Art Prize (2008), the National Art Council's Young Artist Award 2006 and the Grand Prize of the 2nd CDL Singapore Sculpture Award in 2005.

In 2010, his work, 'The Wind & Wings' has been awarded the Legacy Sculpture for Singapore 2010 Youth Olympic Game (Youth Olympic Village).

In Addition, 2 works by Chee Kiong titled, ‘Pedicure’ was displayed in the ground level of MBS Expo and Convention Centre's foyer.

The Art Fellas participated in one of the most prestigious art fair in Asia, Art Stage Singapore 2016. There we presented 2 of our highly established artists, Ren Jian Hui and Yeo Chee Kiong who were award winning artists.

The Art Fellas represents a diverse roster of artists who make up the tapestry of varied voices across the ever-expanding spectrum of both emerging and established art from Singapore, Indonesia and China.

Find out more about our artists and various tailored art programmes now!

REN JIAN HUI YEO CHEE KIONG

Enquiries, please contact us at: info@theartfellas.comTel: 6702 4001/6702 4003 FB: www.facebook.com/theartfellas46 Kim Yam Road, #02-25The Herencia, Singapore 239351

Opening Hours:Mon-Fri: 9 am - 6pmSat & Sun: 2pm - 6pm Public Holidays: By Appointments Only

兄弟 Brothers, 2009, Oil on Canvas180 x 160 cm

Black Banquet, 2011, 8m x 1.2m x 0.9m

ART STAGESINGAPORE21– 24 J AN’1 6

WE ARE AS IA

Be a part of Southeast Asia’s Flagship Art Fairwww.artstagesingapore.com

artstagesingapore artstagesg artstagesg artstagesingapore

The Art Fellas is proud to present 2 award winning local artists at Art Stage Singapore 2016!

Ren Jian Hui & Yeo Chee Kiong

Ren Jianhui (b.1956) Born in Chengdu, China. Ren graduated from China Central College of Arts and Crafts, and was mentored by Prof. Wu Guanzhong.

Since 2000, Ren Jianhui became gradually known in the international art scene, and was invited to hold solo exhibitions in Singapore, Kuala Lumpur, Tokyo, New York and Jakarta, etc. He participated in the Biennale Chianciano, Italy, in 2009, and was awarded with an Honourable Mention for Painting, including an impending Leonardo Da Vinci Award. Ren’s art works have been collected by various art museums, private foundations and organisations around the world.

Ren’s style of painting is a unique fusion of chinese ink and western oil techniques. From his style to the way we see him paint what he feels he’s living, many refer him as a ‘Rebel Master’.

His painting are often infused with deep complex meaning, which serves to reflect the society and portrayal of human nature through careful observation of the world.

Yeo Chee Kiong (b.1970) is an award-winning professional sculptor known for his uniquely playful and unexpected juxtapositions.

An alumnus of the Nanyang Academy of Fine Arts (NAFA) and the Glasgow School of Art, U.K., Chee Kiong has garnered critical attention for his practice-winning awards such as First Prize, LTADTL Art Competition 2012, Expo Station, the regional Grand Prize for Asia-Pacific Breweries Foundation Signature Art Prize (2008), the National Art Council's Young Artist Award 2006 and the Grand Prize of the 2nd CDL Singapore Sculpture Award in 2005.

In 2010, his work, 'The Wind & Wings' has been awarded the Legacy Sculpture for Singapore 2010 Youth Olympic Game (Youth Olympic Village).

In Addition, 2 works by Chee Kiong titled, ‘Pedicure’ was displayed in the ground level of MBS Expo and Convention Centre's foyer.

The Art Fellas participated in one of the most prestigious art fair in Asia, Art Stage Singapore 2016. There we presented 2 of our highly established artists, Ren Jian Hui and Yeo Chee Kiong who were award winning artists.

The Art Fellas represents a diverse roster of artists who make up the tapestry of varied voices across the ever-expanding spectrum of both emerging and established art from Singapore, Indonesia and China.

Find out more about our artists and various tailored art programmes now!

REN JIAN HUI YEO CHEE KIONG

Enquiries, please contact us at: info@theartfellas.comTel: 6702 4001/6702 4003 FB: www.facebook.com/theartfellas46 Kim Yam Road, #02-25The Herencia, Singapore 239351

Opening Hours:Mon-Fri: 9 am - 6pmSat & Sun: 2pm - 6pm Public Holidays: By Appointments Only

兄弟 Brothers, 2009, Oil on Canvas180 x 160 cm

Black Banquet, 2011, 8m x 1.2m x 0.9m

ART STAGESINGAPORE21– 24 J AN’1 6

WE ARE AS IA

Be a part of Southeast Asia’s Flagship Art Fairwww.artstagesingapore.com

artstagesingapore artstagesg artstagesg artstagesingapore

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Disclaimer:Buying a life insurance policy is a long-term commitment. An early termination of the policy usually involves high costs and the surrender value payable (if any) may be less than the total premiums paid. This promotional material is not a contract of insurance and is not intendedd as an offer or recommendation to the purchase of the plan. The specific details applicable to this insurance plan are set out in the policy contract. This promotional material is for general information only and does not have regard to your specific investment objectives, financial situation and any of your particular needs. You may wish to seek advice from a financial adviser before making a commitment to purchase the plan. In the event that you choose not to seek advice from a financial adviser, you should consider carefully whether this plan is suitable for you."

This plan is protected under the Policy Owners' Protection Scheme which is administered by the Singapore Deposit Insurance Corporation (SDIC). Coverage for the plan is automatic and no further action is required from you. For more information on the types of benefits that are covered under the scheme as well as the limits of coverage, where applicable, please contact us or visit the LIA or SDIC websites (www.lia.org.sg or www.sdic.org.sg).

Yona 月华MBA, FCHFP & AFC,Court of the Table, Top of the Table Representing Manulife Financial Advisers, part of Manulife (Singapore) Pte. Ltd.

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AsiaMedic is a leading healthcare provider in Singapore.To support our expansion plans and better serve our growingpresence, we invite you to be part of our team.

www.asiamedic.com.sg

We are recruiting full-time Clinicians for the following positions:

Interested applicants, please email your contact details andcurriculum vitae to bernardine@asiamedic.com.sg

▪ FRCR or equivalent with subspecialist in Musculoskeletal MRI▪ Fellowship trained & must be registrable with the Singapore Medical

Council

Radiologist

▪ FRCR, MRCP or equivalent▪ Must be registrable with the Specialist Accreditation Board in Nuclear

Medicine, Singapore

Consultant Nuclear Medicine Specialist

▪ MBBS or equivalent & is registrable with the Singapore Medical Council▪ Post-graduate Diploma in Aesthetic Medicine is an added advantage▪ Must be familiar with lasers, botox and fillers

Aesthetic Physician

Parkway Pantai Limited (PPL) is the largest private healthcare provider and operates Mount Elizabeth Novena Hospital, Mount Elizabeth Hospital, Gleneagles Hospital and Parkway East Hospital — all accredited by Joint Commission International (JCI).

Our Accident and Emergency department / 24 hour clinics provide first-line treatment for a full range of medical conditions, including management of critical and life-threatening emergencies, to the treatment of walk-in patients 24 hours a day.

All our medical and surgical specialists are well-trained and ever–ready to support the handling of emergencies effectively and efficiently. By adopting a team approach towards the management of emergencies, we ensure the smooth and expedient management of all patients.

We invite dedicated individuals who are passionate and drive to join us as:

Requirements:•BasicmedicalqualificationregistrablewithSingaporeMedicalCouncil•PossessavalidpractisingcertificatefromtheSingaporeMedicalCouncil•Atleast3yearsofclinicalexperiencepost-housemanship.•Postgraduatemedicalqualificationsandrelevantexperienceareadvantages•Goodoralandwrittencommunicationskills•Goodinterpersonalskills•Goodteamplayer

Kindly email: steve_tan@parkwayshenton.com or call 9670 0472 for a friendly discussion.

www.parkwaypantai.com

Based in Singapore, you will be part of a team of dedicated doctors andparamedical staff providing comprehensive care to our patients. You will also play a key role in the maintenance of clinical standards and the delivery of a Parkway service experience to our patients. At Parkway, we provide sponsored postgraduate training opportunities in addition to a comprehensive suite of benefits. Join us for a challenging career and opportunities for personal development.

Resident Physician (A&E/ 24 hours Walk-In Clinic)

The department will offers comprehensive perioperative assessment and optimization for both the inpatient and the outpatient. Pain services for both acute and chronic pain will be provided to the patients and life/critical care support services for patients with trauma, airway issues, and cardiac arrest will also be extended. There will be 18 operating theatres (including one hybrid operating suite) and two cardiovascular laboratories within the operating theatre complex.

We are currently looking for like-minded individuals to join us in pioneering the future of integrated healthcare.

If you share the same passion, have a heart to serve and dare to take bold steps to transform care, we want to hear from you!

We invite Consultants / Associate Consultants and Resident Physicians to join

our Anaesthesia Team

We o�er a competitive salary and comprehensive bene�ts package that will commensurate with your quali�cations and experience.

Please write in with your full resume together with names of 2 referees and medical testimonials to:

Chairman, Medical BoardNg Teng Fong General Hospital1 Jurong East Street 21 Singapore 609606

Candidates must possess a basic medical Degree registrablewith the Singapore Medical Council and/or a recognised post-graduate quali�cation such as MMED

•

For specialist positions, candidates must have completed specialist training, with recognised post-graduate quali�cation registrable with the Singapore Specialist Accreditation Board.

•

Possess leadership qualities, as well as excellent interpersonal relationship and communication skills

•

The department will offers comprehensive perioperative assessment and optimization for both the inpatient and the outpatient. Pain services for both acute and chronic pain will be provided to the patients and life/critical care support services for patients with trauma, airway issues, and cardiac arrest will also be extended. There will be 18 operating theatres (including one hybrid operating suite) and two cardiovascular laboratories within the operating theatre complex.

We are currently looking for like-minded individuals to join us in pioneering the future of integrated healthcare.

If you share the same passion, have a heart to serve and dare to take bold steps to transform care, we want to hear from you!

We invite Consultants / Associate Consultants and Resident Physicians to join

our Anaesthesia Team

We o�er a competitive salary and comprehensive bene�ts package that will commensurate with your quali�cations and experience.

Please write in with your full resume together with names of 2 referees and medical testimonials to:

Chairman, Medical BoardNg Teng Fong General Hospital1 Jurong East Street 21 Singapore 609606

Candidates must possess a basic medical Degree registrablewith the Singapore Medical Council and/or a recognised post-graduate quali�cation such as MMED

•

For specialist positions, candidates must have completed specialist training, with recognised post-graduate quali�cation registrable with the Singapore Specialist Accreditation Board.

•

Possess leadership qualities, as well as excellent interpersonal relationship and communication skills

•

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