news VOL. 48 NO. 4 | APRIL 2016 | MCI (P) 052/01/2016

Doctor, Do You Need Vol. 48 No. 4 2016 4 5 29

Editorial feature SMA CMEP Physician, Heal Thyself Doctors, Your Health SMA CMEP Appreciation Dr Tina Tan Matters Too Dinner 2016 Dr Chong Yeh Woei Denise Tan Vol. 48 No. 4 2016

EDITORIAL 31 BOARD Editor 7 9 SMA CHARITY FUND Dr Tan Yia Swam Let’s Run to the Moon! PRESIDENT’S FORUM COUNCIL NEWS Deputy Editors Home isn’t the Highlights from the Dr Tina Tan Best Clinic Honorary Secretary 32 Dr Tan Tze Lee Dr Wong Tien Hua Dr Daniel Lee FROM THE HEART Editorial Advisors Project Yangon: Love, A/Prof Daniel Fung Live, Learn A/Prof Cuthbert Teo Ralene Sim Dr Toh Han Chong 11 14 Members Dr Chie Zhi Ying INSIGHT INSIGHT Dr Jayant V Iyer Substance Addiction The Depressed Doctor: 34 Dr Leong Choon Kit Dealing with Difficult among Physicians INDULGE Dr Jipson Quah Decisions Dr Gomathinayagam STAY FIT, BE ACTIVE! Dr Jonathan Tan Kandasami Dr Tor Phern Chern Dr Jimmy Teo Dr Jeanne Ong, Dr Foo Chek Siang and EX-OFFICIOS Dr Magdalene Liau Dr Wong Tien Hua Dr Daniel Lee Hsien Chieh 16 18

EDITORIAL INSIGHT OPINION OFFICE A Glimpse into the An Update on the Senior Manager Past — Medicine in Zika Virus Sarah Lim Singapore (Part 6) Dr Hsu Li Yang Senior Executive Sylvia Thay A/Prof Cuthbert Teo Editorial Executive Jo-Ann Teo

ADVERTISING AND PARTNERSHIP 20 22 Li Li Loy OPINION OPINION Denise Jia Being in a Convivial When a Doctor Tel: (65) 6223 1264 Email: [email protected] Learning Compact Becomes a Patient A/Prof Cheong Pak Yean Dr Tan Yia Swam 37

Publisher CALENDAR Singapore Medical SMA EVENTS Association MAY – JUN 2016 2 College Road Level 2, Alumni Medical 24 26 Centre GP MATTERS SMA CMEP - PROFESSIONALISM Singapore 169850 A Helping Hand Professional 38 Tel: (65) 6223 1264 Fax: (65) 6224 7827 for GPs Responsibilities AIC SAYS Email: [email protected] Dr Leong Choon Kit of the THANK YOU, OUR URL: http://www.sma.org.sg Anaesthesiologists GP PARTNERS, FOR UEN No.: S61SS0168E Dr Hairil Rizal Abdullah SUPPORTING CHAS! DESIGN agency Oxygen Studio Designs Pte Ltd CORRECTION In the March 2016 issue Interview article on page 12, the list of medical officers in the pioneer batch should have been PRINTER “Drs Lo Hong Ling, Richard Hin Yung (Obstetrics and Gynaecology), Lim Kuang Hui, Arthur Lim (Ophthalmology), Cheong San Thau (Surgery), William Chew Loy Soong, Chan Swan Tong, Richard Chin Keng Huat, Wong Yuen Poh, Sun Rise Printing & Lee Soo Choo, Chew Chin Hin, Moses and myself [Jerry Lim].” We apologise for the error. Supplies Pte Ltd

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Physician, Heal Thyself

A while back, a doctor I knew committed us that altruism may well be the medicine Dr Tina Tan is a psychiatry senior suicide. It was sudden and tragic. There that we need. resident with National Healthcare were no warning signs; everything Group. She obtained her medical seemed to be going perfectly for this So what happens when a doctor does degree from Duke-NUS Graduate Medical School (Class of 2011). She colleague. Yet, on hindsight, there fall sick? No doubt that stigma exists. also has a bachelor’s degree from probably were clues that things weren’t Doctors who are willing to share the University of California, Berkeley. as rosy as they seemed. their perspective of needing medical treatment are few and far between. The truth is that we are as human Beyond the worry of time taken away as the patients who consult us. The from our busy work schedules, is the same qualities that make a good doctor worry that news of our ailments will increase the likelihood of mental illness get around. So much is at stake — our — we can be perfectionists with high careers, our livelihoods. It is little wonder expectations of ourselves and others, that doctors don’t seek help when they Tina Tan with a correspondingly low tolerance for need it, nor do they want to talk about it Deputy Editor uncertainty. That combined with work thereafter. Thus, it is with sincerity that factors, such as long hours or lack of our Editor, Dr Tan Yia Swam, shares her support, all increase the likelihood of heartfelt experiences as a patient to Dr Hsu Li Yang provides a timely and physical and mental illness in doctors. encourage our readers not to remain much needed commentary on the Zika silent but to seek help for their problems. virus, including a reminder of the key Psychiatric problems in doctors are In addition, our “GP Matters” column question to ask our patients — their complicated with no easy answers due to includes a call for the medical profession travel history. the ethical issues involved. Dr Tor Phern in Singapore to provide resources for Chern explains why doctors are prone to fellow physicians in need. We also report here the latest news depression and how to seek help for a from the SMA Centre for Medical colleague in need and Dr G Kandasami On the lighter side of things, A/Prof Ethics and Professionalism, and an covers an equally hushed-up topic — Cuthbert Teo continues his series on article by Dr Hairil that teases out the dependence and addiction in doctors. the history of medicine in Singapore, unique ethical issues anaesthetists showcasing humorous medical student face. They may be behind the screens Our "Feature" article, therefore, focuses memories from the 1930s and 40s. It but their responsibility as healthcare on how we can maintain our physical proves that even our oldest professors providers is as crucial as that of a and mental well-being. Dr Chong Yeh were once medical students who weren’t patient’s primary physician. Woei shares his insights about “walking always on their best behaviour. the talk” that we always like to nag our On a final note, I want to announce patients about. Our “Indulge” article In his article about scholarship, A/Prof that SMA News will be providing more looks at unique and healthy ways some Cheong Pak Yean shares his passion exclusive online content, such as articles doctors have found to unwind and stay for convivial learning and teaching. It’s ahead of print, videos and audio clips, fit at the same time. Still have a dearth the presence of that merry and mentally for our members. of ideas? Miss Ralene Sim shares her stimulating atmosphere that keeps us heart-warming experience of volunteering refreshed from the daily drudgeries of our Keep calm, and read your issue of SMA with Project Yangon last year, reminding work, both for the teacher and student. News!

SMA News / Apr 2016 feature 5

Doctors, Your

M a t t e r s To o

We always hear the old adage “Physician, heal thyself”! Personally, I think it to be true but with a caveat: it should not be “heal” but rather along the lines of “prevent”.

A doctor’s health Entering into our thirties, we often take lives. As we head in to the second half We are in the trade but we often take our our bodies for granted. We experience of our lives, we must remember that own health for granted. In the early parts a lot of stress and the reaction to that life expectancy is taking us into the of our career, we tend to push our body could be eating excessively, imbibing eighties. This to me is longevity and and mind to the limit. Those houseman lots of alcohol, smoking more than we the idea is then to have the best quality calls that start from 8 am and last till should and sometimes getting into of life, hopefully till the very end before the afternoon of the next day with little various forms of gambling. Gambling we make a quick and painless exit from or no time to rest are really punishing. could well be in the casinos, “punting” in this planet. What we really do not want One thing to note is that when one has the turf club or leveraging up in equities, or need is a premature event such as little or no rest, there is a potential risk derivatives and futures. a massive heart attack or a stroke. of making mistakes like prescribing a Such events that could leave us as a wrong drug, missing out a drug allergy In my experience in the private sector, cardiac cripple or bedridden for decades or giving an injection via the wrong quite a number of my colleagues ended before our eventual demise form a very route (intrathecal or intravenous). An up working long hours with little time to frightening prospect. interesting thing I learnt when renewing spare for family and friends. A handful my car insurance was that doctors are of them also ended up with visceral fat Measures to take classified as high-risk drivers. That is due to irregular meal times coupled with It is therefore important to make sure we because there have been a number of seeking solace in food. do not put ourselves at risk of chronic accidents, fatal or otherwise, where the diseases such as diabetes. We often doctors involved were sleep deprived. If Recognising the pitfalls and scenarios counsel our patients about their body you have relatives, friends or children who that cause us to get into difficulties is the mass index, whereas a number of us are doctors in training, please impress on first step. The second is to act on them have knowledge deficits about the them that sleep deprivation and driving by shifting ourselves out of a passive calories in the food that we consume. do not mix well. mode and actively taking charge of our The knowledge of the calories present

APR 2016 / SMA News 6 feature

in hawker food is particularly important muscles that you cannot see are those Keeping in touch with fellow doctors helps as the majority of our patients do eat in your back, glutes and thighs; these to foster friendships, trigger discussions out. Over the years, I have noticed that are the biggest muscles in your body. on difficult cases and also provides the all the endocrinologists whom I know To work these muscles and to get them opportunity to learn from each other in private practice have lost weight and to ache is not easy. Yet it is the aching on matters outside of medicine, from attained their ideal body mass index. I muscles that burn your calories and managing businesses to investment think it is because they make it a point you can work them hard with Pilates, decisions. Sometimes, running a solo to talk to their patients, especially those yoga and ballroom dancing. Besides, practice can be insular and it allows with diabetes and hyperlipidaemia, about pumping iron can lead to injuries that will withdrawal from society to creep up on food intake and they have ended up take seemingly forever to heal when you us without us even realising it. “walking the talk”. I wonder if that is the are at a certain age. One more benefit case for endocrinologists in the public is that strengthening the core muscles Strong relationships with your spouse, sector as well! Sending your patient to a can lead to good posture and stability, friends, family, children and colleagues dietician or nutritionist is a good idea but translating to fall prevention. are important and remember to invest better yet, educate yourself about food in friendships with people a whole intake, glycaemic indices and calories Finally, please avail yourself to medical generation younger. It can be really sad of common foods to effect a change in technology and have your blood work to reach longevity when all your friends your own diet. done regularly. I do mine annually in your cohort have perished. Finally, how around the time of my birthday, as we cope with challenges in a mature Having lost quite a bit of weight myself your birthday is always a good reminder way and maybe even through creative over the years, I would say that exercise of mortality. Please don’t forget your expression (eg, art, music, dancing or has a role to play but your eating habits colonoscopy when you reach 50 years writing) is paramount to attaining that remain as the main driver. Nevertheless, of age! There are prominent members elusive better quality of life. I wish all a brisk walk thrice weekly with a decent of our profession who have not followed my readers success in their journey heart rate pounding away is effective. this important guideline only to find to reach that holy grail of happiness, Having a wearable device on your wrist advanced metastatic colorectal cancer longevity and contentment. and clocking ten thousand steps daily a few years later. Cardiac imaging is yet another possibility for the long or functional cardiac testing is also haul. I tell my patients who take public important to prevent premature cardiac PROFILE transport to alight a train stop earlier or events. For my female colleagues, please forego the feeder bus and take a brisk find a good radiographer that does your walk home. That would be the exercise mammogram with little or no pain! Do needed for the day! My personal take is ask your female radiologist colleagues that a slow but long jog is very effective for the heads-up. for weight loss. Concluding words Yet another aspect to think about is If you have to take your statin, so be it. If text BY the loss of muscle mass. It has been you want to do your MRI stroke screen or estimated that upon hitting our forties, carotid imaging, please go ahead. I would we lose a pound of muscle annually. like to leave you with the lessons learnt Dr Chong Yeh Woei At this age, testosterone levels in men from the Harvard study on happiness. slowly decline at a rate of one percent Some of you may be aware that this Dr Chong was SMA annually, while for women, there’s the study was ongoing for 75 years and the President from 2009 dreaded menopause and its associated cohort included a US president, several to 2012 and is a symptoms. That is why muscle work is senators, and captains of industry. The member of the 56th important; but I am not about to ask you first lesson gleaned is that love is the SMA Council. He to pump iron at the gym. The reality is key and it is important to cope with life has been in private that gym work is mostly through mechanisms that do not push practice since 1993 about the muscles that love away. What this means is that it you can see and look is important not to be negative, prickly and has seen his fair good on the outside: and nasty; and not to be labelled as a share of the human in your chest and curmudgeon. Finding contentment in condition. He pines arms. The your work is critical and as doctors, we for a good pinot noir, are way ahead of the curve in terms of loves the FT Weekend goodwill and gratitude from our patients. and of course, wishes for world peace… It is important to have a group of professional colleagues to fall back on.

SMA News / APR 2016 president’s forum 7

Home isn’t the Best Clinic Why Doctors Should Avoid Treating Family Members and Themselves

During festive gatherings, the doctor and advice given, any follow-up affects the two parties, but involves in the family is often faced with the would not be possible until the next the other family members as well. prospect of being asked to dispense social gathering, typically a year all sorts of medical advice. Once later. These conditions set the doctor Double-edged sword that distant uncle whom you have up for misunderstanding, providing There are more complex issues at not seen in ages starts the inevitable inappropriate advice and, worse of all, play when treating family members. line of questioning, a small circle giving false reassurances leading to a The doctor is emotionally involved soon forms and various ailments missed diagnosis. with family and this will inevitably and alarming symptoms are pitched affect professional judgement, which at the family’s doctor — you. A Downside risk often demands a certain amount growing lump, a painful bump, from Some years ago, I met a senior of detached objectivity. Obligation acne to Zika; nothing seems to neurologist at a social event and is a double-edged sword that cuts be off limits. On one occasion, I asked her about my son’s frequent both ways. Sometimes, doctors was personally asked to advise a headaches. I was seeking the may feel obliged to advise and treat relative who had a roaring cardiac same reassurance that headaches immediate family members well murmur which I could hear just in children was a common beyond their own field of expertise. by placing my ear on his chest. phenomenon and that there was Family members who are being nothing to worry about. However, treated will also feel a sense of They come to us for quick advice in she refused to offer any comfort obligation towards the doctor, and the hopes of reassurance; oftentimes and instead advised that I bring my this can interfere with health-seeking they want to hear comforting son in for an assessment in case of behaviour. For example, a persistent words such as “it is benign” or serious pathology. I wasn't too happy symptom such as chronic cough “there’s nothing to worry about”. with that conversation then but on could be downplayed because Unfortunately, bar the most obvious hindsight, I realised that the doctor the patient is unwilling to seek spot diagnosis, the setting and had much wisdom in her years of assistance early for fear of causing context of such social consultations practice. I was a parent asking about undue trouble to the busy doctor are far from ideal. vague symptoms for a child who and preferring to wait for the next was not even present at the time opportune family gathering. This Firstly, the fact that the “patient” is and I wanted the doctor to give me may result in delayed diagnosis relating his history in a room with reassurance, a responsibility that the and treatment of progressing other people listening means that the doctor should not have been asked to pneumonia. Patient autonomy is also account is likely to be condensed, bear. If things went well, there would compromised because the sense lacking in details and incomplete. be little thanks to the doctor for of obligation and fear of offending Intimate information that may be giving charitable advice, but what if the doctor in the family restrict their crucial in some cases cannot possibly an insidious pathology was missed? choice to see other doctors and to be conveyed. Secondly, there is a Therefore, in such a scenario, the seek a second opinion. lack of proper equipment at hand. wisest option for the doctor is to Additionally, lighting is suboptimal insist that the patient be brought in Ethical guidelines are quite clear and the physical examination that for a proper assessment. in advising against the treatment we rely on to exclude relevant of family members except during conditions cannot be performed. In the context of treating family an emergency (American Medical Finally, there is also the lack of proper members in social settings, missing a Association Code of Medical Ethics documentation. Once the doctor is diagnosis or giving the wrong advice Opinion 8.19 - Self-Treatment or unable to record the problem, findings would be a painful affair that not only Treatment of Immediate Family

APR 2016 / SMA News 8 president’s forum

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. Illustration: Dr Kevin Loy DrIllustration: Kevin

Members). The doctor should with its expected role in the doctor- Studies have identified personality certainly not provide chronic care patient relationship. When a doctor traits that make doctors resistant for immediate family members over falls ill and requires treatment, it is to seeking help early. Doctors an extended period of time. Disease no wonder that he will feel intense can be perfectionists, obsessive- progression can be very subtle and conflict. The same problems with compulsive and may have a fear of even clinically astute physicians will regard to treating family members failure. Many of us practise various miss these changes occurring in front would apply if the doctor is unable to forms of self-denial, where the of their eyes in their daily encounters exercise detached objectivity when he patient’s needs override our own with family. attempts self-treatment. needs. It is not easy to accept the notion that we will one day fall ill just Self-treatment Doctors make bad patients like any other human being. Physician self-treatment and It has been said that doctors make treatment of family members are the worst patients. Delay in seeking Finally, there is the stigma attached usually addressed together in ethical treatment is often the norm and the to illness among the medical guidance. This reflects the duality opportunity to treat diseases that fraternity, especially with regard to of psychological roles that a doctor may benefit from early intervention mental health issues. The medical plays when he attempts to treat may be lost. This could be due to the community in Singapore is small and himself: there is tension between his embedded “medical self” and doctor’s heavy schedule and clinical concerns of maintaining medical the unfamiliar role of being sick. demands as the long hours spent in confidentiality may prevent early Their professional roles are deeply the wards leave little time for self- treatment of mental health problems. ingrained in doctors from the time care. It seems ironical that medical they enter medical school. They learn services can be hard to access even Doctors need to be reminded that to look after and treat "the patient", though doctors work in a hospital. we can claim no special status in who is someone sitting on the other I suspect that many doctors do not our own susceptibility to illness side of the consultation table, lying even know where the hospital staff and disease; we are not immune to on the hospital bed or undergoing clinic is located, much less make use affliction or addiction and we too will a procedure on the operation table. of its services when they are ill. When one day fall sick and require help. We The patient and the doctor are two symptoms of illness appear, they should not walk this path alone. We entirely separate entities, each tend to be ignored or downplayed. should seek help early.

SMA News / APR 2016 COUNCIL NEWS 9 Highlights PROFILE from the Honorary Secretary

Report by Meeting with MPS to allow for an upgrade of the SMA President, Dr Wong Tien stethoscopes used by our Dr Daniel Lee Hua and several SMA council members. Members will get to enjoy discounted prices from the members met with the CEO Dr Daniel Lee of Medical Protection Society trade-in, as well as a 3M goodie Hsien Chieh (MBBS (MPS), Mr Simon Kayll, and its bag arranged exclusively for SMA [S’pore], GDFM representatives on 1 March members for this exercise. [S’pore], MPH 2016. Issues pertinent to medical [Harvard], FAMS) indemnity were discussed. In conjunction with the visit, MPS is Honorary Change of SMA CMEP Secretary of the organised several workshops Executive Director on informed consent for MPS 56th SMA Council. Dr T Thirumoorthy, who members in Singapore. He is a public completed a second term as health specialist the Executive Director of the and Deputy SMA Centre for Medical Ethics Director of Clinical Meeting with NTUC Income and Professionalism (CMEP), Services at Changi SMA President, Dr Wong Tien stepped down on 31 March 2016. General Hospital. Hua, met with Mr Soon Gud Voon, A/Prof Gerald Chua, previously Senior Manager & Head, Property Designate Director, CMEP, has & Casualty, NTUC Income, to Legend taken on the reins from 1 April 1. Group photo of SMA and discuss various medical indemnity 2016. The SMA Council thanks issues. Ideas were discussed with MPS representatives at the Dr Thirumoorthy for his stellar meeting on 1 March 2016 a view to reinforce the partnership contributions and valuable efforts between the organisations, and to as the Executive Director and improve and expand the benefits Board Member of the SMA CMEP to our members. since its formation in 2002. Under the leadership of A/Prof Gerald Chua, SMA CMEP will continue to Tie up with 3M to offer support the profession to, in the stethoscope trade-in words of Dr Thirumoorthy, “Stay In collaboration with 3M Littmann competent, stay compassionate, Stethoscopes, SMA will be stay service-ful”. facilitating a trade-in exercise

1 Introductory Course in Health Law In collaboration with JurongHealth

Ng Teng Fong General Hospital, Tower A, Level 1, Auditorium 2 pm to 5 pm, Max 2 CME Points/Session

This course will cover the basic concepts of health law. It is relevant for all practising doctors and of greater value to medical leaders and teachers, especially for those who have had no previous education in this area. The faculty consists of both lawyers and doctors. The sessions will be held on the first Saturday of each month from June to September 2016.

4 Jun Introduction to Health Law and Legal Responsibilities of Medical Practitioners

2 Jul Understanding the Elements of Medical Negligence

6 Aug Professional Accountability and Misconduct

3 Sep Medical Experts and Report Writing

Please return this slip for SMA Introductory Health Law Education Series to Carina Lee, Singapore Medical Association, 2 College Road, Level 2, Alumni Medical Centre, Singapore 169850. Tel: 62231264, fax: 62247827 or email: carinalee@ sma.org.sg. A confirmation email will be issued to all applicants.

Name: MCR no.: Specialty: Contact no.: Email: Mailing address:

Please tick in the corresponding boxes A. SMA Member: Yes No B. JurongHealth Employee: Yes No C. I will like to register for: 4 June 2 July 6 August 3 September Registration (inclusive of GST): $120 per session (Inclusive of GST) Complimentary for SMA Members and JHS Employees Mode of Payment Credit Card VISA/ Master Card no.: Expiry date: / CVV2/CVC2 no.: Cheque (payable to Singapore Medical Association) Bank: Cheque no:

Signature: Date:

By 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. insight 11 Substance Addiction Among Physicians

Generally, the problems physicians face because of addiction to substances are not well reported in the media or widely known to public. Many may perceive that physicians are immune to addictions but on the contrary, the prevalence of addiction among physicians is similar or even higher than the rate that is seen in the general population. One US study reports the lifetime prevalence of addictions among physicians to be as high as between 10% to 12%. In the West, the number of physicians from specialties such as anaesthesiology, emergency medicine and psychiatry who seek help for their addictions is slightly higher than those from other specialties. However, this could be due to an over-representation relative to their numbers in the overall physician pool. Work-related stress, ready access to narcotics and other psychotropic drugs in the workplace, and also a possible selection bias in the type of physicians who choose these specialties are reported to be some of the other contributing risk factors. Alcohol dependence is the most common presentation, followed by dependence on opioids. Abuse of stimulants and other substances is also reported and among those who seek help, more than half are reported to be abusing multiple substances. There is no scientific data available in Singapore on addiction among physicians. 12 INSIGHT

Factors affecting their staff and patients. They may show of samples, diverting medicines from help-seeking behaviour irregularities in their prescribing patients, colluding with patients The problems caused by their practices and may not promptly to share prescriptions, writing substance abuse may first attend to their calls during their fraudulent prescriptions or seeking appear at home or in their social on-call duty hours. The presence of internet-based prescriptions must circumstances before becoming these signs should raise suspicion be thoroughly investigated. Consent obvious in their workplace. By the for addiction issues and warrant should be sought from the physician time the symptoms appear in the further investigation. However, under investigation to gather more hospital setting, their substance these warning signs alone are not collateral information from friends, abuse would often have been active sufficient to confirm the presence of family, co-workers and pharmacies for a long period of time. One study a substance use disorder. to support the diagnostic evaluation, found that the mean duration which while careful steps should be taken physicians took to seek treatment Assessment to protect confidentiality. for substance-related problems was Once a suspicion of addiction is six to seven years. It is not surprising raised, the relevant authorities The positive signs elicited in the that physicians seek treatment in the workplace should review history should be supported with very late during the course of their policies and notify the appropriate laboratory investigations such as substance use disorder and by people in the management to urine tests for drugs and blood that time, the symptoms are likely proceed with further investigation. alcohol levels or breathalyser tests to be in an advanced stage. The If a discreet investigation is for alcohol. The results of the key reason for the delay in seeking carried out and enough evidence investigations should be thoroughly treatment may be due to their efforts is available to confirm the initial scrutinised as they can act as a to keep workplace performance and suspicion, the physician should be means for helping the clinician to reputation intact. Physicians fear asked to undergo a proper clinical refute the false allegations or claims. that the disclosure of addiction will assessment. Evaluation of addiction Therefore, extreme care should affect their affluent social status and issues in physicians would require be taken to avoid false positives they may risk losing their licence a multidisciplinary team with as physicians may face serious to practise medicine. Lastly, it has experience in working with this professional and legal sanctions if a also been commonly observed that population. The assessment could test result indicates drug use. the help-seeking process can be become very difficult because the delayed due to the physician's family physicians may show exceptional Treatment members and co-workers’ efforts to rationalisation, denial and resistance Once there is reasonable clinical hide the addiction, in order to protect to cover their substance use evidence to establish a substance use disorder, an intervention should the family, the medical practice and habits. In the US, physician health be provided staff who are employed by it. programmes, which are available in most states, would provide such Signs and symptoms expertise to facilitate independent The earliest signs of addiction assessments and support for the may include: neglect of physical struggling physicians and offer appearance, weight changes, guidance to hospital administrators sleep impairment, lethargy in work on treatment and monitoring. or tiredness, smelling of alcohol while at work, or skin changes Routine clinical assessment of such as bruises and needle marks. addiction should involve eliciting Physicians are reported to be good in a thorough history suggestive concealing their substance use and of loss of control over the use thus, these signs might be subtle of substances, development of and not easily detectable. tolerance and/or withdrawal symptoms, cravings and the When the symptoms become physician’s own attempts to reduce severe, one might see significant or stop using substances. The deterioration in the quality of their physical, psychological, legal, social work. They may repeatedly come and interpersonal complications that late for meetings and appointments, might be substance-related should show long-term absences at work, be explored in detail. Any information seek special considerations, or may on observed negative changes at have poor working relationships with work such as allegations of stealing

SMA News / APR 2016 insight 13

without further delay to help both emergencies, to reduce the potential PROFILE the physician in question and his for wrong-doing or abuse. Physicians or her patients. Very few studies should be allowed to have their legal have been published on appropriate counsel handle various legal issues treatment methods for clinicians. that can arise during the entire Usually, residential treatment process, starting from the initial programmes which offer individual assessment period to the point when and group therapy, medications or they are deemed to be safe to return attendance at Alcoholics Anonymous to work. or Narcotics Anonymous meetings TEXT BY are recommended. The main focus is to achieve complete abstinence from Conclusion Dr Gomathinayagam drugs and alcohol. Early recognition of the substance Kandasami use disorder and prompt initiation Generally, treated physicians show of treatment is the key to very good recovery in the range of successful recovery. It is vital that Dr Kandasami 75% to 80%. The high success rates written policies and procedures is a consultant are attributed to very structured are in place throughout the whole psychiatrist, chief treatments offered in physician process, as faithful adherence to at the National health programmes that are available the policies can help to prevent Addictions in countries like the US. The high disastrous clinical and legal cost of failure such as loss of Management Service consequences to all the parties income and public embarrassment, at the Institute of and the positive influence of staying concerned. It is better to prevent Mental Health. He in the medical practice also helps substance misuse before it holds an academic to maintain sobriety. However, begins. Therefore, physicians appointment with there is also a high risk of relapse should engage in healthy lifestyle NUS Yong Loo Lin soon after treatment. Therefore, activities to reduce the risk of School of Medicine it is recommended to impose falling victim to psychoactive and Duke-NUS restrictions on employment with substances. They should seek Medical School. clear instructions to the recovering immediate help for their medical He has been a physician about the consequences or psychiatric problems. Healthy core faculty for the of a relapse or failure to comply with physicians create and maintain National Psychiatric any of the return-to-work conditions. better working environments for Residency Program themselves and those around for psychiatry. Ethical and legal them. In Singapore, the National considerations Addictions Management Service Healthcare organisations are at the Institute of Mental Health required to report a physician to the provides specialist addiction licensing board if there is reasonable treatment for the general suspicion that the physician is population and can offer expert struggling with a substance use advice and support for physicians disorder. Ethically, physicians who are concerned about their have a primary duty to respect alcohol or drug habits. the autonomy of others, but when a fellow clinician is suspected of abusing drugs for their psychoactive properties, he or she can potentially harm patients and family members. Further readings Therefore, it is advised to seek an opinion from the hospital ethical 1. Berge KH, Seppala MD, Schipper AM. Chemical dependency and the physician. committee if such dilemmas arise Mayo Clin Proc 2009; 84(7):625-31. when reporting the suspected abuse 2. Boyd JW, Knight JR. Chapter 46. Substance use disorders among physicians. In: to the authorities. In many parts of Galanter M, Kleber HD, Brady KT, eds. The American Psychiatric Publishing Textbook of the US, recovering physicians are Substance Abuse Treatment, Fifth Edition. American Psychiatric Publishing. 3. Flaherty JA, Richman JA. Substance use and addiction among medical not legally allowed to self-prescribe students, residents, and physicians. Psychiatr Clin North Am 1993; 16(1):189-97. or prescribe medications for their 4. Brooke D, Edwards G, Taylor C. Addiction as an occupational hazard: 144 other family members except in true doctors with drug and alcohol problems. Br J Addict 1991; 86(8):1011-6.

APR 2016 / SMA News 14 INSIGHT

Dealing with Difficult Decisions

“These are the duties of a physician: Doctors apparently endorse more nature of the job. This entails long First… to heal his mind and to give help to depressive feelings in response working hours, regular rapid and high himself before giving it to anyone else...” to personal and professional stake decision-making, while facing — Monument to Serapion circa 220AD stressors than even lawyers! Female unpleasant and taxing illnesses with doctors in particular appear to the constant requirement to keep up- Are doctors more likely have a higher rate of depression in to-date with increasing amounts of to be depressed? comparison to other females with information. The typical personality Depression is a psychiatric similar educational levels and are of a doctor may be a predisposing condition that afflicts up to 5.8% far in excess of population levels factor as well. It is believed that of the Singapore population. It is a of depression (39% vs 23.9%). the average doctor is smart, driven, syndrome that includes abnormally Higher rates of depression are competitive and has difficulty low mood, anhedonia and somatic apparent, even for students, with relaxing or acknowledging personal symptoms like insomnia and fatigue. up to 34% of medical students limits or vulnerabilities. Doctors appear to be at higher endorsing depressive symptoms risk of having depression than the that persist throughout training, There is also some evidence that average person. A landmark Harvard showing little accommodation people with a predisposition to study by Vaillant et al1 prospectively to the demands of training. illnesses like depression, self-select followed Harvard sophomores for into medicine. One study2 showed 30 years and found that doctors Why are doctors more that medical students, compared were consistently more likely to use depressed? to controls, were more likely than drugs and alcohol heavily, have poor One explanation for the high rates law students to have experienced a marriages and obtain psychotherapy. of depression is the high stress serious medical illness in their family

SMA News / APR 2016 insight 15

of origin and the fear of death at a are shared. If confirmed, the next Rounding up younger age. Selecting the medical step could be a private chat with the Medicine is a rapidly advancing field profession may be an unconscious affected doctor, to ask about the that has the potential to reduce reflection of the desire to combat recent changes in mood, behaviour suffering, extend life and improve fears of powerlessness from close and general situation. However if there our quality of life. The demands of contact with serious illness or obtain are issues of clinical competency, this profession are high and take a the care that was lacking due to ill a more expeditious approach toll on its members. We should be parents. Unfortunately, many doctors involving the programme director mindful of the first duty of doctors: who enter the profession to “conquer (for students) or head of department to heal thyself. illness” soon find that they are only may be warranted. Referral to the human and have little power over hospital staff support programme or many serious conditions. a certified mental health provider may PROFILE be useful at this stage. What is the problem with depressed doctors? Is it that simple? The American Medical Association Studies have shown that only one defines the impaired physician as one third of doctors who suspected a who is unable to fulfil professional colleague to be impaired reported or personal responsibilities due to them. Common reasons include psychiatric illness, alcoholism or drug uncertainty about actual impairment dependency. Many depressed doctors Text by or harm to patients, the general are likely to initially have personal reluctance to criticise colleagues problems, such as marital or familial Dr Tor Phern Chern and the lack of protection of whistle- interactional problems, which can blowers. These are very real and progress to the abuse of alcohol to practical issues when trying to get Dr Tor is a “manage” these problems. Eventually, our colleagues the appropriate help. psychiatrist working this can progress with difficulty in in the Mood Disorder coping with clinical duties that can A useful ethical framework should Unit in the Institute manifest in poor record-keeping, of Mental Health. He lapses in administrative duties, aim to prevent harm to patients, withdrawal from social activities execute our professional obligation has a special interest and compensatory behaviour like at self-regulation (as stated in the in treating patients rounding at odd hours. The most Singapore Medical Council [SMC] with electricity and serious outcome of depressed guidelines) and most importantly, help magnetism. In a doctors is suicide, which is four times our impaired colleague. The best way previous life, he spent more likely to occur in female doctors to do this will vary from institution his time treating than the general population. to institution but it is often wise to stressed young men avoid treating a colleague, unless in uniform. What can other doctors the relationship is purely clinical. The do to help? concerns about confidentiality and The first step is to recognise that loss of licence to practice are very something may be amiss. This is real for any impaired doctor. Locally, often reflected in problems related the SMC does not have a category to the personal life of the doctor and of licensing that allows doctors to if clinical performance is affected, practise with restrictions, making the situation is often quite severe. fitness to practise an all-or-nothing A useful first step is corroboration situation. This could potentially make with other colleagues to determine it more challenging to identify and if your concerns about the doctor treat impaired physicians.

References

1. Vaillant GE, Sobowale NC, McArthur C. Some psychologic vulnerabilities of physicians. N Engl J Med 1972; 287:372-5. 2. Paris J, Frank H. Psychological determinants of a medical career. Can J Psychiatry 1983; 28:354-7.

APR 2016 / SMA News 16 INSIGHT A Glimpse

intoMedicine the in Singapore (PartPast 6) 1930s to 1940s: More student antics and memories This is the sixth instalment of a series on the history of medicine in Singapore.

In 1936, Dr JC Tull was succeeded In 1936, Col (Dr) John William fellow students. One fine day, I came as Professor of Pathology by Dr Scharff was appointed Lecturer in upon a final year medical student JA Cowan, who held the position Public Health and he introduced a whom I shall not identify for obvious briefly until 1937. Dr HO Hopkins health and sanitary survey of rural reasons. Mournfully, he told me that was the next Professor, and he held villages as part of the curriculum. In another capable final year student the position from 1937 to 1941. 1937, doctors were just beginning to had kindly done a circumcision for In 1938, the Dental Clinic Building understand the aetiology of cardiac him, but that septicaemia had set in. was completed at the present site beriberi (a vitamin B1 deficiency). Hence, despite the loss of face, he of the Singapore General Hospital Prof ES Monteiro described how had to make a clean breast of things (SGH) and served as a teaching thiamine chloride was first used in to the professor, who had ordered department. At around the same Singapore as a cure and as proof of hospitalisation to avoid possible time, the Dental School comprised the aetiology.1 amputation. This unfortunate student one professor (EK Tratman), was a very old friend of mine, against one lecturer (JW Softley), two Dr Ng Ek Khiam described some whom I had played in inter-school tutors in dental surgery (Henley of his fellow students in the late games in North Malaya. Our schools Wong and Tay Teck Eng) and one 1930s.2 “I remember a string of were ‘enemies’ but personally, we instructor in dental mechanics names: Baptist, Ding Ee, Siew Choh, were good friends. How could I leave (GH Stephens). Tan Sri Dr Tay later Oon Teik, Danasamy, Parampalam, him alone to let fearful self-pity eat became Chairman of the Council Lum Choon, Duriaretnam and Frank into his very soul? So filled with love of the University of Singapore and Dourado, who played the funeral and charity, I used to pay him regular the Singapore Cancer Society. march on his flute when conducted visits to cheer him up with funny In preparation for the war, a to the bath tub for the immersion stories. But even Bob Hope would maxillofacial unit was set up at the ceremony in scented water. I was have run out of funny stories, so my Kandang Kerbau Hospital (KKH). quartered at Room 33 of the then stories graduated to the sublime. I Federated Malay States Hostel showed him pin-ups and debauched (FMS Hostel) on top of a hill, facing him with ‘nice’ stories. You can the sisters’ quarters. Japanese picture a man tensed with passion. telescopes were selling at ten You can picture a man tensed with cents apiece and most students pain. But can you picture a man were equipped with one. I came tensed with both?” to the College with a reputation as a sportsman, but could not Based on a tongue-in-cheek do much because I had a knee account3 given by Dr Chee Phui injury, which took me in and out Hung (who was among the first of hospital. During one of these batch of MBBS graduands from the hospital episodes, just before I was University of Malaya, Singapore), put under traction for a year, I loved medical and dental students were to wander from room to room to a rambunctious lot in the 1930s: visit the other patients, especially “We remember the good old days

SMA News / APR 2016 insight 17 when we sang songs to ‘dirty’ lyrics, for “northerners” who came to the with different backgrounds, got drunk on a potent cocktail of College of Medicine in Singapore in outlooks and eccentricities. There gin, whisky, brandy and beer from the late 1930s.5 “The first pioneers were people who had come from the Kay-Mouat cup after an inter- from the north were Salma and the wilderness and there were city college victory, smelled the nurses Sutan. Through no fault of his folks who thought that padi grew when we advanced from morbid own, (Sutan) took the slow boat to on trees. There were people with anatomy classes to clinics, gambled graduation, and if the College had plenty of dollars and other[s] with the night away in hostel corridors issued any decorations, he certainly plenty of sense. There were sloppy and suffered ‘air raids’ when our would have been awarded the Long students and those who dressed rooms were turned upside down. Service Medal. Bakar was another with sartorial correctness. There We recall too, getting pelted by stalwart at games, but whenever were clowns and fuddy-duddies, and rotten eggs in the former FMS he scored wide off the goal, he there were paragons of virtue and Hostel’s quadrangle, hopping on to would swear as angrily as he would others who were a little salacious, goucho’s cowboy lorry to ‘barrack’ throw a rotten mah-jong card. In and there were adventurers, at our Raffles College counterparts academic studies, these boys took ideologists, romanticists and throughout the year; conducting things easy. Why worry! They had a students. This motley crowd melted panty raids at Eusoff Hall, the good scholarship and there was a in the Medical College Union (which ladies hostel; dowsing the chief whole year to relax, and they could was re-formed in 1922 from the medical officer when he dared always do some frantic reading just Student’s Recreation Club) pot, out to invade the hostel and defying before the exam. But to satisfy their of which emerged the good Alumni the police with bugle calls.” Upon conscience, they carried Jamieson we all are today.” graduation, Dr Chee worked briefly with them to the picture hall or in the Department of Bacteriology whenever they patronised the mee PROFILE of the Faculty of Medicine before stall behind the ronggeng stage at going into private practice. In his Happy World. Among themselves, later years, Dr Chee devoted his they formed the Radio Club. They time to the Alumni Association, just parked themselves around where he was known as “the Agong” the radiogram in Harrower Hall (apparently in reference to him after dinner with Gray’s or Samson being the “King of Raggers”). Wright’s on their laps ostensibly with the idea of doing some earnest Dr JJ Murugasu was in the second reading. Bakar and I were constant text BY batch of students after the war. He partners in the labs, just because entered Tan Tock Seng Hostel in nobody else wanted to partner us. October 1946 and later transferred Both of us occasionally slipped A/Prof to FMS Hostel. This was how Dr out of the gynaecology lectures Cuthbert Teo Murugasu described daily life as at KKH after the attendance had a student.4 “Every morning, the been taken, in order to go to the Editorial Advisor College provided transport in the pictures at the Rex Theatre close form of a military truck driven by a by. I also achieved the record of A/Prof Cuthbert Teo is fellow called [‘goucho’] because he being the only student in the history trained as a forensic had a big hat. It was the truck that of the College to be asked by Dr pathologist. The views took us first to Holne Chase to pick Balasingam to repeat the one- expressed in the above up the girls, then to Raffles College month post mortem course just article are his personal opinions, and do not for physics and chemistry lectures. because I was honest enough not to represent those of In the afternoon, we had biology copy the post mortem notes from his employer. at the College of Medicine Building the technician, Nalpon, as so many before returning to our hostel. When others did. The College was a real I came back to our third floor room, melting pot to which came students I would always announce my arrival by throwing my shoes up in the air References so that they landed noisily on the wooden floor. Seah Cheng Siang, 1. Monteiro ES. Excerpts from a personal perspective of medicine in Singapore in the past 50 who stayed in the room below, years til 1977. Singapore Med J 1977; 18(2):118-25. eventually got fed up and bought a 2. Ng EK. Down memory lane. In: Lim KH, ed. At the Dawn of the Millennium: 75 Years of Our big wooden pole. This, he banged on Alumni. Singapore: Singapore University Press, 2000:380-1. the ceiling to tell me to stop making 3. Chee PH. Commentary. In: Lim KH, ed. At the Dawn of the Millennium: 75 Years of Our Alumni. Singapore: Singapore University Press, 2000:444-5. so much noise.” 4. Murugasu JJ. On orientation during the FMS days. In: Lim KH, ed. At the Dawn of the Millennium: 75 Years of Our Alumni. Singapore: Singapore University Press, 2000:240-1. In 1964, Dr Omar bin Hamid wrote 5. Omar D. It’s great to be in College. In: Lim KH, ed. At the Dawn of the Millennium: 75 Years of an account of what life was like Our Alumni. Singapore: Singapore University Press, 2000:372-5.

APR 2016 / SMA News 18 Opinion ZIKAAn UpdateVIRUS on the The Zika virus epidemic in the Americas, and in particular its association with subsequent development of microcephaly in the newborn of infected pregnant women, has resulted in considerable public and medical interest. Will it come into Singapore and what are the implications if it does?

About the Zika virus an infected mosquito is “a few days” PROFILE First, a brief introduction to the virus (variously described as somewhere itself. The Zika virus is a member of between two and 12 days). Incubation the flavivirus family (“flavi” actually periods after blood transfusion or translates to “yellow” in Latin and the sexual transmission are unknown, but family is so named because of its likely to be just as brief, if not more so. most famous member in history: the yellow fever virus), which also includes As with dengue, up to 80% of infected dengue, Japanese encephalitis and persons will be asymptomatic. The clinical disease the virus causes is TEXT BY West Nile viruses. Scientists working at the Yellow Fever Research Institute Zika fever, which is often described (currently Uganda Virus Research as a “mild dengue”. This is an acute Dr Hsu Li Yang Institute) discovered the virus syndrome comprising fever with serendipitously in 1947, in a sentinel various combinations of other symptoms such as headache, joint Dr Hsu Li Yang is monkey set up in the Zika Forest near aches, muscle aches, maculopapular currently based in Entebbe, Uganda. Other than Africa, the Zika virus is also present in Asia, rash and non-purulent conjunctivitis. the private sector, having been described in orangutans Not many clinicians or researchers with part-time in Sabah as well as in travellers from were particularly interested in this appointments at Indonesia, Cambodia and Thailand. mild viral illness until the first ever the Singapore's epidemic of Zika occurred on the first school of It is maintained in its sylvatic cycle Micronesian island of Yap in 2007; public health as by primates and is transmitted and even after that, there was little well as the oldest primarily by a variety of Aedes mainstream interest. However, the medical school. mosquitoes, including the two virus spread inexorably eastward major strains of Aedes mosquitoes through Micronesia, French Polynesia in Singapore — Aedes aegypti and (2013), Cook Islands (2014) and Aedes albopictus. The virus can also Easter Island (2014), to finally reach be transmitted via blood transfusion the Americas in 2015. Brazil was and in a recent curious discovery, the first country in South America to via sexual intercourse (at this point, report the Zika epidemic in April 2015 although we are clear that men can and researchers have postulated transmit the virus to their partners, that the virus arrived during the 2014 as the virus can be found in semen, FIFA World Cup held in that country. it remains uncertain whether women Since May 2015, the virus has spread can transmit Zika through sex). The throughout most countries of tropical incubation period after being bitten by South America, Mexico and parts of

SMA News / APR 2016 Opinion 19

Central America. The virus has also had elected to abort the fetus after are based on the polymerase chain been exported episodically from the confirmation of microcephaly and reaction, detecting the presence of Americas as well as Asia since then. intrauterine growth retardation at absence of the virus directly (and Week 32. therefore will only be positive from Complications of the virus • Among nine pregnant travellers blood samples for the first few days of The huge number of infections in to the US, with evidence of Zika disease; although it might be positive Brazil and other South American infection, there were two fetal deaths for a longer duration in urine or semen, countries has unveiled two rare and one newborn with microcephaly. the latter might be difficult to collect but terrifying complications of • In a Brazilian cohort of 42 women in a clinic setting), and can be done the infection. The first is Guillain- infected between Weeks 6 and at either the National Public Health Barré syndrome (or, specifically for 35 of pregnancy, there were Laboratory or the Environmental neurology wonks, the acute motor two fetal deaths (4.8%) and 12 Health Institute. axonal neuropathy phenotype of with abnormal fetal ultrasound Guillain-Barré syndrome) — an scans (28.6%), including four What can we do about it here? It is immune-mediated neurological (9.5%) with microcephaly. obviously impossible to quarantine condition presenting as progressive all visitors and returning travellers paralysis over a period of days to These resulted in travel advisories from countries with ongoing Zika weeks. Researchers have since for countries with ongoing Zika transmission until they are tested uncovered strong evidence of its transmission: pregnant women and negative for the virus. On top of that, association with prior Zika infections those actively seeking to get pregnant the majority of Zika infections are even in the French Polynesian should not travel to these areas and asymptomatic but can potentially outbreak, although the mechanism by should either abstain from sex or get spread the disease if bitten by Aedes which it happens remains unknown, their male partners to use condoms if mosquitoes. The key question then is as the usual auto-antibodies have they are in these areas, in addition to whether a Zika outbreak in Singapore not been detected. A very small minimising the risk of mosquito bites. will behave like chikungunya (with less proportion of patients (up to 0.24 per Several South American governments than 200 cases a year and only 42 1,000 Zika-infected persons) may have urged women to delay cases in all of 2015) or dengue. Most be affected, which explains why the pregnancies until the Zika outbreak local experts currently believe it will be association was not made until fairly is over, a recommendation which is more like the former, partly because recently. It is important to note that unlikely to be helpful. This outbreak our vector control is good (some of asymptomatic infection may also has also refuelled the debate on legal us might find this difficult to believe, result in Guillain-Barré syndrome, abortions and contraception in these but it is true) and largely because Zika albeit at far lower rates compared to highly Catholic nations. — unlike dengue — is not rife in the symptomatic Zika disease, according surrounding countries. to current evidence. Zika in Singapore? Will Zika be imported into Singapore? There is no Zika vaccine available The second, and much worse, The answer is very likely yes. We commercially and the current vaccine complication is the association of have tourists and returning travellers candidates will take several years viral infection in pregnant women with from both South American and Asian more to be tested, licensed and grave outcomes for the pregnancy. countries where Zika is endemic. commercialised. There is also no Microcephaly in the newborn In addition, it is unlikely that the specific treatment for the infection. was the first and most obvious Zika epidemic in Brazil will be Better diagnostic tests, especially manifestation, leading to a sudden under control by the 2016 Summer more specific serological tests, may surge of public interest in Zika and Olympics in August, which a fairly be helpful in certain instances, such the enormous public pressure to large contingent of athletes and other as the testing of pregnant women who confirm the association, as well personnel will be attending. may have potentially been exposed as to “do something about it”. The to the virus (either in countries with subsequent studies and events have How can we diagnose Zika infections? ongoing Zika transmission or in the been depressing, demonstrating that A travel history is important here, as scenario where there is an outbreak in the association is likely true and Zika the disease manifestations are very Singapore). The only real way forward is a cause for fetal complications similar to dengue (with perhaps the is continued investment in improving including microcephaly: exception of conjunctivitis, which is vector control, which has the side • The Zika virus has been shown not always present) and can result benefit of reducing the transmission to infect and kill neural stem cells in false-positive dengue antibody of a number of other diseases such as in cell culture experiments (ie, tests (being a related member of the dengue and chikungunya. biological plausibility). flavivirus family). Of note, the dengue • The virus was found in the brain of antigen test (usually positive between an aborted fetus in Slovenia. The Days 2 to 9 of dengue infection) will mother had been infected with be negative. The only laboratory tests Zika at Week 13 of pregnancy and available locally at this point in time

APR 2016 / SMA News 20 Opinion

Being in a Convivial Learning Compact:

To Add Zest to Life, Teach

This article was triggered by a Medscape Journal article written by Dr Julian L Seifter after he attended a grand round in Brigham and Women's Hospital (BWH), Boston. Dr Seifter’s article titled “Don't Abandon the Case Report in the Race for Big Data”1 was highlighted in the National University Hospital System (NUHS) family medicine (FM) residency weekly bulletin of 4th December 2015, as the case studies approach he espoused is also valued in the residency teaching programme. This article was also inspired by the Ministry of Health’s (MOH) call to train more doctors in a letter to the Straits Times Forum on 7 December 2015.2 A/Prof Cheong recounts his inchoate passion for scholarship as a young doctor, his positive experience as a medical teacher and concludes with an exhortation to colleagues to add zest to life by teaching.

As an internal medicine (IM) handful of doctors present in that apology to use and the event ended resident (1976-1979), I studied the cavernous room that had hosted on the hour. No doubt, the scribe Clinico-Pathological Conference decades of scholarly discussions. The would then rush to write it up for (CPC) proceedings in the New stark room was ringed with wooden publication in one of the next editions England Journal of Medicine (NEJM) benches, once occupied by some of NEJM. What struck me was that religiously and honed my clinical whose names are immortalised by a handful of persons sitting in a reasoning skills from it. There was eponymous diseases. Even the 35 mm nondescript room had such a great no internet then and the costly slide projector was passé compared impact on the medical world — a subscription to this premier journal to those we had in Singapore at testament to the power of scholarship mailed weekly to my home kept me that time. There was an ungainly and publication. I was privileged to current for the IM examinations. lantern projector with a microscope witness one presentation before it attachment that was later used for was published! I decided to go on a grand tour of projecting pathology glass slides. It the United States after my chest made a lot of noise when switched on I gave up that weekly scholarly medicine posting and MRCP but the projection was bright and clear. ritual after a few years in practice. examination in Edinburgh. A high point The air was still, musty even, but it was It wasn’t until almost a decade after of the trip was my visit to Boston, autumn and comfortable. I took a seat that I published my first academic where I surreptitiously crept into the in the far corner. paper. A/Prof Goh Lee Gan, my co- amphitheater of Massachusetts author, will attest to the many nights General Hospital (a Harvard affiliate of I was quickly lost in the case spent in the old Department of BWH) one afternoon. I had expected presentation and discussion that Community Occupational and Family to be lost in a big crowd of learned followed, too enraptured to worry Medicine (COFM) offices in National doctors holding court in the CPC. about being discovered. Thankfully, University Hospital (NUH) revising To my surprise, there was only a I did not have to put my rehearsed and revisiting the drafts. With

SMA News / APR 2016 Opinion 21

his encouragement, I persevered and the two residents have written pursuits as a young doctor as well as sometimes past midnight — that is these insights as a portfolio-based positive experience learning from and the power of a learning compact. case record for our online FM teaching fellow doctors and medical tabletop companion. students thence. For colleagues who I am happy now to be in another feel jaded by the ennui of medical learning compact in the NUHS FM Doctors in practice do seek practice, I vouch that conviviality can residency. I see young enthusiastic conviviality in groups outside medical be found in scholarly and teaching doctors presenting interesting cases practice. Such groups develop from compacts within medicine too. and discussing them. In debrief kinship and revolve around mutual after clinical sessions, learning interests. I belong to an informal You can add zest to life. Teach. gems picked up are shared. Around group also called SMA (Singapore the patients’ beds in their inpatient Makan Association), whose members PROFILE postings, cases are discussed from are bound by a love for good food. both inpatient and FM perspectives. Doctors’ social lives also revolve In the FM grand rounds, residents around sports, hobbies or spiritual share cases, diligently documented pursuits. Involvement outside the and researched under the guidance confines of medicine adds spice of the FM faculty and invited to life and recursively, zest to our experts. Some cases are presented medical practice. in external medical conferences and a few even made it to prestigious Conviviality can flourish in healthy TEXT BY refereed medical journals. An academic and scholarly groups example is a report3 in Osteoporosis too. Looking at it from a family A/Prof International (impact factor 4.24). system approach, the health of However, it is the scholarship such groups is revealed by its Cheong Pak Yean process and learning camaraderie sub-systems viz. Relatedness, that really matter. Getting it to print is Order, Agency, Development and A/Prof Cheong just an external validation. Self-Identity (ROADS in short). How Pak Yean teaches diverse members reverently relate to medical students Best of all, the interactions are one another engenders collegiality. at the NUS Yong convivial, happening in a friendly, Having good administrative support Loo Lin School lively and enjoyable learning orders the learning milieu. Active of Medicine, atmosphere. As I happily teach, I agency drives intellectual pursuits FM residents in also joyfully learn. In an outpatient and scholarship. Road-maps to consultation, a resident was puzzled develop high academic standards the NUHS FM why post-prandial glucose (PPG) harness energies and the cultivation programme and sees home monitoring was ordered for of self-identity within the professional patients at his private the patient as he was accustomed to group identity opens common space. IM and FM clinic. He only ordering fasting and pre-prandial Conviviality naturally flourishes in a wishes to thank his glucose (FPG) monitoring during his healthy learning compact such as the learning compact, hospital postings. We discussed and NUHS FM Residency, just as positive in particular, Ong agreed that for our patient, PPG was emotions and joie de vivre effuse Chooi Peng (Core preferred because she had near- from a healthy mind and body. Faculty member) normal FPG but persistently high and Grace Chiang HbA1c. Moreover, a drug targeting The MOH made a clarion call for more (Chief Resident) for PPG was just added. A subsequent medical teachers in a letter to the shaping this essay. literature search supported our Straits Times on 7 December 2015. A/Prof Cheong is a clinical decision.4 We are wiser for it I connect that to my past scholarly past president of the Singapore Medical References Association, College 1. Seifter J. Don't abandon the case report in the race for big data. Available at: http://www. of Family Physicians medscape.com/viewarticle/850365. Accessed 4 December 2015. and chairman, 2. Ministry of Health. MOH committed to growing local core of doctors, nurses. The Straits Times Chapter of Family Forum 7 December 2015, A21. Medicine Physicians, 3. Grace CS, Kelvin KW, Wei CT, Yeow TB. Stress fracture of the ulna associated with Academy of bisphosphonate therapy and use of walking aid. Osteoporos Int 2014; 25(8):2151-4. 4. American Diabetes Association. Postprandial blood glucose (Consensus Statement). Diabetes Medicine Singapore. Care 2001; 24: 775-8.

APR 2016 / SMA News 22 Opinion When a doctor Pbecomesat ent a I have been to the doctor’s only a the little yellow flashcard that served the advice and thankful that I didn’t few times in my life. The childhood as my notes. Another fond memory need surgery. Once, I saw a polyclinic memories are somewhat blurred by was the sweet taste of the pink syrup, doctor for a pain in my right knee — I time; while recent memories are a mix the chemical bitterness of the pills was 19 years old and had just started of joy, fear, anger and sadness. If you and the reverence in which I held a medical school. I couldn’t describe watched the animated movie Inside medical certificate (MC), stamped and the symptoms and to me it was just Out, all my experiences with doctors signed for which a school absence “painful”; like there was something are those swirly balls of golden was permitted. moving inside my knee and that yellow, with specks of burning red and it would suddenly give way while streaks of blue and purple. At the Primary Six school health walking down the stairs. The doctor screening, I received a referral did quite a thorough examination I remember seeing my neighbourhood for scoliosis. I recall my parents (which I appreciated only a few years GP, Dr Chong Ah Lek, for chicken worrying about my “crooked” spine later) and concluded it was nothing pox and the occasional bad cough and parroting the doctor’s advice serious. I remember vaguely my during my childhood. He was always that I must stretch and swim, and feelings of dissatisfaction; while it kind and gentle. I also remember the carry my heavy schoolbag on was not serious, the pain did bother antiseptic smell of the clinic and how I alternate shoulders to even out the me. Anyway, the right knee is still a was fascinated by the tiny scrawls on imbalance. They were respectful of problem to this day.

SMA News / APR 2016 Opinion 23

After starting work as a doctor, Aye, Su Lin Lin, Lim Tian Jin, Ms eating too much but were just too my own health took a back seat. Jacqueline Kong and Nurse Diana. polite to comment. Early rounds, night calls, post-calls, I have thought long and hard about examinations… it just became an whether I should list down these Every time a new doctor came into endless merry-go-round of catching names — it doesn’t take a genius the ward, be it to draw blood or up with work and sleep. There were to figure out why we needed to see conduct a basic examination, the occasional visits to GPs or staff these particular doctors and I trust husband and I had our fun. The clinics to get an MC. By then, it had that readers will respect my privacy husband would point out which become something embarrassing and and not pry. In the end, I decided vein is better for venipuncture and shameful. How can a doctor be sick? that I needed to shout out, loud and helpfully apply the tourniquet while I What would my registrar/consultant clear, how much these people have would present my own history in the think of me? This lasted for years, until done for me. My apologies to all standard format and then pre-empt a few years ago when some major life the other doctors and nurses who them in the physical examination events happened. That was a wake- have looked after us; I might not steps. There was always a look up call for me to look after myself and remember you now, but at that point of surprise, followed by a look of my family first. in time, your presence and care was suspicion from the new doctors who deeply appreciated and you made didn’t know who I was… Without going into medical details, a difference. Too often, healthcare what I can share is: it s*cked to feel workers only get complaints and a Moral of the story: Read SMA News. so d**n helpless. bad rap in the press. There’s a lot of good work being done that should be PROFILE Family crises acknowledged as well. Another point Bad things often happen without of sharing is to hopefully encourage warning. There was a sense of more doctors to share their own unease when we looked at the scan patient journeys as we are uniquely images, followed by cold sweat, fear placed to appreciate our doctors. and the feeling of impending doom. The trained eye had seen what the On a lighter note heart refused to believe. A detached, In my most recent hospitalisation clinical part of me maintained a stint for delivery, the ward nurses TEXT BY calm and professional demeanour asked me how I wanted to be when discussing diagnosis and addressed. I responded with a Dr Tan Yia Swam management options, as if it was just confused “huh?” and they clarified: another grand ward round discussion “Shall we call you Dr Tan?” I told them: Editor (a tribute to years of training to be “No need! I’m not working. Just call “Dr Tan”). The real “me” was dazed me Yia Swam/Mdm Tan/Auntie/ Dr Tan Yia Swam and reeling in shock and disbelief. Miss… whatever you are used to.” is an associate Even close friends and the doctors Therefore, my ward’s label simply consultant at the managing our problems never quite stated “Yia Swam”. When passing Breast Department saw the depth of emotions we report, the nurses always mentioned of KK Women’s experienced. One commented: “How that I was a medical doctor. Among and Children’s are you feeling? You seem to be the medical staff, only my consultants Hospital. She taking this well.” My reply went along knew who I was. One of the junior continues to juggle the lines of: “We have to. Enough doctors was a student of mine and the commitments tears have been shed at home. No recognised me. He swore that he of being a doctor, a point crying now.” We knew we were would protect my confidentiality — I mother, a wife and in good hands and it was time to take reassured him that I trust him to be the increased duties on the role as a patient and trust the professional and not to ever discuss of SMA News Editor. doctor to do what’s best. ANY patient. Anyway, I hardly needed She also tries to keep to keep the birth a secret, people time aside for herself I wish to put on record my deepest knew I was pregnant! At least, I and friends, both old thanks to Drs Mary Rauff, Cindy Hia, assumed they did… or maybe they and new. Shankar Sriram, Winn Maung Maung thought I put on ten kilograms from

APR 2016 / SMA News 24 gp matters A Helping Hand for GPs

“Hey, Choon Kit, do you have a Looking beyond ministering to PROFILE moment? I’ve just received a letter from doctors in trouble, we will need to a management company and I am move into prevention mode. The disturbed by the new clauses they have organisation of courses or talks may added in. Can you help?” — SMA News, help doctors build up their arsenal to July 2015 withstand any stressors life throws at them, or even to help minister to “How many of us actually check our fellow colleagues who are suffering. TEXT BY blood sugar, blood pressure and cholesterol levels?” — A question I One-stop centre Dr Leong Choon Kit posed to fellow GPs in our WhatsApp Physician self-care is important to all chat group recently. doctors. It is not peculiar to GPs or to those of us in private practice. Editorial Board Member It has been half a year since I last wrote about this and I am With that in mind, I feel that the ideal Dr Leong Choon still receiving requests for help professional body to establish such a Kit is a GP in the from fellow doctors. The various system and run the one-stop centre private sector. He requests usually fall into a few broad should be the SMA. With a single feels strongly about hotline or email address, any physician doctors contributing categories: medical, social, financial, facing any trouble can get in touch back to society practice, patient complaints and and ministering to matters relating to health. with physician volunteers at the SMA. fellow doctors in trouble. As a result, It is commendable that the College It would be ideal if all doctors belong he tries to lend a of Family Physicians Singapore has to the SMA; however, membership is voice to the silent organised a skills course on physician purely voluntary. Despite having many majority in every self-care earlier this year. Looking at privileges that come along with SMA issue he has come the categories outlined above, it looks membership, some of us still prefer across, particularly like there is still a lot of work to be to stay out until we get into trouble. those in healthcare, done. Mental health and physician Maybe with the idea of a physician educational and other burnout is only a small portion of the self-care centre as the latest social concerns. many problems we face as doctors. incentive, more would be persuaded to take up SMA membership. We still do not have a framework or structure to administer care to Much like buying insurance, it would doctors who are suffering. We will be money we need to spend but need a point of contact, a hotline or a hopefully never have to utilise the one-stop centre for doctors to call — “payouts”. It is a paradox we must get one which is effective, efficient, timely used to; paying our annual dues to and confidential. our professional bodies.

SMA News / APR 2016 gp matters 25

Principle One example is in legal and business In areas where we cannot find any The main principle governing physician matters. For instance, a friend was experts among ourselves or in self-care should be that of cooperation approached by the police with regard situations when we should not rely on and self-support: one where to a patient he saw a while ago. As our amateurish experience, we could A Helping camaraderie is paramount. there was no official charge from the engage other professionals to help us. court, my friend was not clear what In the July 2015 issue of SMA News, his role and responsibility was at that I can think of two examples. One I shared in the “GP Matters” column time. Hence, I sought the help of my instance would be in the counselling about the fishermen’s cooperative I friend, a lawyer, for him. of fellow doctors. While we may know Hand chanced upon during my trip to Phillip a lot more about our own trade and Island in Melbourne a few years ago. In another instance, managed care stressors, we may also be too familiar They run a restaurant to earn money companies want to start charging with our colleagues for us to confide for fishermen who are too ill to go to a percentage of the fee charged our deepest thoughts and anxieties sea and offer job opportunities in the to patients by doctors in private with one another. Counsellors from restaurant. That is the type of model practice. Similarly, some mall non-medical organisations would we should aim for. Other important management also calculate the serve us well here. principles we should embrace are rental for clinic based on a fixed those of prevention, empowerment sum with an additional percentage Another instance would be in the area and strengthening. of the clinic’s gross takings. My of submitting income tax returns. friends were stressed out as they Some of us engage accountants Not only must we cater to those were unsure if it bordered on the for help, while others prefer to do colleagues in trouble, but we should organisation receiving kickbacks from it on their own. SMA has done well also help them with prevention. We the practitioners. It is obvious that in organising seminars touching must regularly pre-empt the possible my specialist friends would not like on income tax returns and related stressors and invite experts to share to run afoul of the Singapore Medical matters each year. I recall many of the their experiences with us. Council’s ethical code by unwittingly speakers being accountants, as well offering kickbacks. as senior tax officers from the Inland We should also keep a lookout for Revenue Authority of Singapore. one another. We can create social Structure groups to engage fellow doctors or be There are many things in our lives and I only serve in the SMA as an editorial whistle blowers to warn one another practices that can stress us out. We board member and I am neither privy of potential dangers. Often, we are not are only doctors and are certainly not nor able to influence any of the ideas I aware even when we are in trouble. specialists in life affairs. However, I outlined above. I pray that these ideas There is a Chinese saying: “ am confident that we can share best will come into fruition soon, so it can ”, which means that当局者迷， those practices and life lessons with one cater to many physicians who are who旁观者清 are amid trouble are clouded, another but we will need a structure facing ever increasing stressors from while bystanders are clear. to facilitate that. all quarters.

The SMA has the following platforms available for our members: Ethics consultation — request for opinion on practice issues you are faced with SMA forum — discuss issues and get suggestions from fellow forum users SMA CMEP resources and courses — access archived information on medical ethics, health law and professionalism or be updated through a seminar/conference Medical practice management courses — gain insight through our courses in 2016, including a tax seminar, a private practice seminar and a workplace and health seminar

Access to the above information could require you to log in to the membership portal. Other resources available via our website (https://www.sma.org.sg) include past position statement and advisories on areas such as Managed Care Contracts and medical fee splitting. You may also raise your queries via our online contact form, phone: 6223 1264 or email: [email protected]. However, due to the nature of the Council and Committee being formed by volunteers and supported by a non-medical secretariat, it may require some time for a formal response to be given to your query.

APR 2016 / SMA News 26 SMA CMEP - PROFESSIONALISM

Professional Responsibilities of the anaesthesiologist

As an anaesthesiologist with that anaesthesiologists are not the awake ends up being very brief. This an interest in professional and primary physicians for the patients then forms an imbalance in the trust clinical ethics, I have always under their care. Surgical patients and depth of relationship between the been fascinated by the ethical do not come to the hospital seeking patient and their anaesthesiologist, labyrinth that we navigate in our anaesthesiologists, but they will and with their surgeon. By the daily practice. We are clinicians to inevitably need one to participate in time patients are presented to the the patients, service providers to their management. Many patients think anaesthesiologist for assessment the surgeons and stakeholders to of their anaesthesiologists as just the and risk discussion, they would have the operating room management person behind the mask — the person been through multiple sessions with team. Anaesthesiologists thus who puts them to sleep and wakes surgical colleagues and are then have ethical responsibilities to their them up when it's over. They often do understandably more focused on patients, medical colleagues as well not realise the comprehensive medical the surgical risks. It can be difficult as the healthcare facilities in which care the anaesthesiologist provides for patients to grasp the concept they practise. preoperatively and beyond. of a separate set of risks for a single surgery, and that the risks Professional Our professional duty begins of anaesthesia may sometimes be responsibilities to the preoperatively. Anaesthesiologists higher than those of the surgery patients carry the responsibility of providing itself. This may lead to downplaying The framework for the care of our preoperative evaluation, optimisation of the anaesthesiologist’s risk patients is rooted in the principles and also the facilitation of informed discussion and estimation with of patient welfare and respect for decision-making, especially with regard the patient. It is also challenging to their autonomy. The main challenge to the choice of anaesthetic technique. assess if the patient is really able to is the difficulty in establishing an understand, retain and process all the anaesthesiologist-patient relationship. Oftentimes, we find that the contact complex information given within that This is primarily due to the fact time with patients while they are short preoperative assessment visit.

SMA News / APR 2016 SMA CMEP - PROFESSIONALISM 27

A dedicated outpatient pre- care for the patient’s physical and to become apparent in front of the anaesthetic evaluation clinic psychological safety, comfort and patient would erode the patient’s allows anaesthesiologists to be dignity. Examples are wide-ranging trust in medical providers and their able to spend time interacting with — from protecting the anaesthetised ability to work together. their patients in a comfortable patient’s modesty to ensuring that environment, weeks before the the patient’s consent and wishes are The anaesthesiologist-surgeon surgery. This could help to enhance respected. This would again require relationship can often be strained the patient’s understanding of the anaesthesiologists to know their in the face of disagreements, discussion, build rapport and trust patients well enough while they are especially over the extent of medical with the anaesthesiologist, and awake so that a custodial relationship interventions in medically challenging act as mitigation against the last can be forged. Anaesthesia training cases. When an anaesthesiologist minute rush to assess patients the programmes should not only focus finds the surgeon’s decisions to be night before, or even morning of, the on producing anaesthesiologists with in conflict with his or her own moral surgery. One can even arrange for good clinical competence, but also or professional beliefs, there should further follow-up or revisits for truly those who are aware of surrounding be an attempt to reconcile these complex cases. This would be an ethical and professional issues. differences diplomatically, which improvement from the traditional may include escalation of the issue workflow of visiting patients the The anaesthesiologist to a higher level or getting a second night before their surgery. To further and conscientious opinion from a neutral colleague. strengthen this understanding, objection If the situation is irreconcilable, general conversation and Invocation of conscientious objection the anaesthesiologist should dissemination of information on the does not exonerate physicians withdraw in a non-judgemental anaesthetic process could even be from duties to their patients. fashion and provide an alternative started earlier at the surgeon’s office. Hence, disclosure of personal for care in a timely fashion.2 After all, it is in the best interest of ethical beliefs to the institution However, if an anaesthesiologist our patients that the surgeons and might be needed for the purpose finds certain intervention decisions anaesthesiologists work as a team to of ensuring the availability of cover. to be in conflict with the accepted care for each patient. Anaesthesiologists should not professional standards of care, abandon or compromise the care ethical practice or institutional On the part of the anaesthesiologist, of patients whose beliefs clash with policies, the anaesthesiologist offering a full risk-benefit discussion their own, but instead arrange for a should then voice such concerns in the best interest of the patient transfer of care. In an emergency, and present the situation to the would require an understanding of the patient’s safety and best interest appropriate institutional body. In their values, medical and surgical would be paramount. Arrangement no instance however, should a condition, as well as prognosis and for another anaesthesiologist could patient be inconvenienced or have healthcare access. This should also be carried on concurrently with life- his or her care compromised due be placed into a wider context beyond saving measures which should be to unresolved differences between the aim to get the patient through provided without prejudice. the anaesthesiologist and the one surgery. Anaesthesiologists surgeon — patient care should should resist the temptation to Professional duties to always be at the forefront of any use medical jargon to restrain or other medical colleagues professional interaction. Maintaining coerce patients who have adequate With the patient’s best interest in a healthy collegial relationship is the decision-making capacity.1 The mind, anaesthesiologists should responsibility of all physicians caring patient’s right for self-determination also bear the responsibility of for their patients. in the presence of informed promoting a cooperative and consent should be respected. In respectful relationship with other Conflicts of interest in challenging circumstances, multiple professionals involved in their care. anaesthesiology engagements over time or seeking One should strive to maintain an Most anaesthesiologists in private the help of surgical colleagues may environment where good quality practice are dependent on surgeons be better options. management can be given. This can to provide patients for anaesthesia be challenging especially when there and it is rare for patients to request Intra-operatively, the major are differing professional opinions, for an anaesthesiologist unless professional and ethical consideration which can be common when dealing they have positive experiences would be that anaesthetised patients with medically complex cases that from a previous surgery. As such, are extremely vulnerable. Ethical require multidisciplinary input. the anaesthesiologists may end up practice should motivate us to step Portraying another colleague in a beholden to the surgeon, which can up as the patient’s advocate and bad light or allowing disagreements lead to conflicts of interest — pitting

APR 2016 / SMA News 28 SMA CMEP - PROFESSIONALISM

patient advocacy against loyalty to during emergencies in our institution the referring surgeon. Furthermore, when contracted to do so, and to PROFILE as service providers, the practice of ensure that we are able to handle financial kickbacks, undercutting and such emergencies. This would price-fixing are always a temptation. include measures to maintain our Those who participate in fraudulent state of readiness, such as attending business practices often do so due continuous medical education to ignorance rather than intent. sessions and refresher courses. Hence, it is our ethical obligation to TEXT BY learn and understand the various Due to our unique role which forms of inappropriate business requires the personal handling of Dr Hairil practices in order to avoid becoming controlled and dangerous drugs, unintentionally implicated. we also carry the responsibility of Rizal Abdullah keeping these substances safe from The anaesthesiologist abuse and illicit use. We should be Teaching Faculty, and practice-based vigilant about the signs of possible SMA Centre for improvement substance abuse among our Anaesthesiologists throughout the Medical Ethics and colleagues and learn how to handle Professionalism world have established themselves such cases discreetly and ethically. as leaders in patient safety and quality improvement. I know of many Dr Hairil is a anaesthesiologists who serve within Conclusion consultant in the hospital or specialty committees. department of Much of our training revolves around Every specialty will have anaesthesiology, patient safety and acute care; hence, its own unique ethical Singapore General using our skill set to help develop responsibilities and challenges. Hospital and departmental or hospital guidelines Anaesthesiologists, being currently heads as well as reviewing the practice clinician service providers, the Preoperative Evaluation Clinic. of colleagues, in good faith, are encounter many. These are He holds a special part of our ethical responsibility. obviously on top of the myriad interest in medical Cooperating with both clinical and of ethical responsibilities ethics as well as administrative colleagues to improve which are common among all clinical systems the quality, effectiveness and physicians. It can be a daunting improvement. He has efficiency of the care given would prospect to try and keep within a passion for scuba only serve to improve the patient’s ethical parameters. However, diving and marine conservation, and outcome. This may consist of as long as we practise in the being present and taking part in the tries his best to dive best interest of our patients and as often as possible surgical safety checklist, as well as keep to the common pillars of taking lead in patient safety issues in during his free time. medical ethics — we should be the operating theatre. secure in the knowledge that we are on the right track. As an acute care physician, we are also ethically obliged to be present

References

1. American Society of Anesthesiologists, Guidelines for the ethical practice of anesthesiology. 22 October 2008. 2. American Society of Anesthesiologists, Ethical guidelines for the anesthesia care of patients with do-not-resuscitate orders or other directives that limit treatment. 16 October 2013.

SMA News / APR 2016 SMA CMEP 29 SMA CMEP Appreciation Dinner 2016

1 2 PROFILE

TEXT AND PHOTOS BY Denise Tan

Senior Executive, SMA Centre for Medical Ethics & Professionalism

Legend On 3 March 2016, the SMA Centre for were organised in 2015 and the years 1 and 2. CMEP Board of Medical Ethics and Professionalism (SMA before. Dr Wong also announced that Dr T Directors and Teaching CMEP) held its annual appreciation dinner Thirumoorthy will be stepping down and Faculty mingling before at Moghul Mahal Restaurant in Novotel A/Prof Gerald Chua will be taking over the dinner begins Singapore Clark Quay. A sumptuous buffet position as the Executive Director of the 3. A/Prof Gerald Chua of Indian cuisine was laid out as attendees SMA CMEP. He thanked Dr Thirumoorthy, presenting a token of appreciation to Dr T mingled and enjoyed the night with glasses the founding director of SMA CMEP, for Thirumoorthy of wine in hand. It was attended by SMA’s playing a significant role in paving its growth. President, Dr Wong Tien Hua, SMA CMEP’s board of directors, as well as current and The night ended with A/Prof Chua giving We would like to thank newly on-board teaching faculty. out tokens of appreciation, specially Dr T Thirumoorthy prepared by the SMA, to the board and for his leadership, The dinner commenced with an opening faculty as recognition for their hard dedication and effort speech by Dr Wong, thanking everyone for work over the years. Lastly, A/Prof Chua as SMA CMEP’s their attendance and for their continuous presented a special gift to Dr Thirumoorthy Executive Director over support rendered to the seminars that for his dedicated years in SMA CMEP. the past four years.

"My vision for SMA CMEP is that we enable a learning platform to assist doctors 3 in their quest to continually develop in the multiple roles (CanMeds 2015 Physician Competency Framework) that the practice of medicine in Singapore requires.

Dr Thirumoorthy urges us to “stay competent, stay compassionate, stay service- ful.” To that, I add a call to refocus on three core attributes of our profession: Love, Servitude and Humility.

Love others more than ourselves; Serve the interests of our patients before our own; and remembering always, the Humility of wisdom" – A/Prof Gerald Chua, Executive Director, SMA CMEP (since April 2016)

We look forward with confidence for the continued growth of SMA CMEP under the leadership of A/Prof Gerald Chua.

APR 2016 / SMA News Jointly Organised by: SCS-SMA Cancer Education Seminar Series 2016

Date: 7 May 2016, Saturday Time: 1 pm – 5 pm (Lunch will be provided) Venue: Health Promotion Board Auditorium (3 Second Hospital Avenue) Number of CME Points: Pending approval from the Singapore Medical Council To register, visit https://www.sma.org.sg/academy or fill in the form below

Topic: Lung Cancer Lung cancer is the second most common cancer among Singaporean men and the third most common cancer among Singaporean women. As a GP, you can advise, encourage and empower your patients to take ownership in adopting healthy lifestyle practices for cancer prevention. Sign up for the SCS-SMA Cancer Education Seminar Series to learn how you could be a life changer for the patients you care for. Early detection saves lives.

Time Programme

1 pm Registration (Lunch will be provided) 2 pm Introduction to SCS–SMA Cancer Education Series 2016 GENERAL David Fong, Chief Operating Officer, Singapore Cancer Society PRACTITIONERS 2.15 pm Epidemiology of Lung Cancer ARE THE FIRST LINE OF DEFENCE 2.25 pm Lung Cancer Screening AGAINST 2.45 pm Video-Assisted Thoracic Surgery in Lung Cancer Treatment CANCER. 3.05 pm Stereotactic Body Radiotherapy in Lung Cancer Treatment 3.30 pm Advanced Lung Cancer — Optimism In Nihilism 3.45 pm Question & Answer 4.15 pm Closing Address 5 pm End

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Please return this slip for SCS-SMA Cancer Education Series to Carina Lee, Singapore Medical Association, 2 College Road, Level 2, Alumni Medical Centre, Singapore 169850. Tel: 62231264, fax: 62247827 or email: [email protected]. sg. A confirmation email will be issued to all applicants.

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32 from the heart Project Yangon Love, Live, Learn

Although we had been thoroughly What really touched my heart was informed of the Burmese how he whipped out a makeshift SMA and the SMA Charity people’s immense warmth and fan and began fanning everyone, Fund support volunteerism hospitality, nothing could have even though he too was sweating among our profession. SMA prepared us for the kindness and profusely from the heat. News provides charitable friendliness that we experienced organisations with during this trip in May 2015. Meeting healthcare needs complimentary space to Translated into English, “Yangon” publicise their causes. To find out more, email news@sma. What was intended to be a health means “the end of strife”. However, org.sg. Visit the SMA Cares screening conducted for their benefit for many of the villagers, including webpage at https://www. turned out to be the embodiment of little Aung Kyaw Moe, life is a sma.org.sg/smacares. the spirit of kindness which touched constant struggle to move on from our hearts greatly. We felt genuine the devastating past. He was one warmth that was not forged for the of the villagers who were relocated Are you interested in making sake of tourism and it was evident in from Hlaing Township to Shwe Pyi a difference by reaching both the young and old. Thar with virtually nothing after a fire out to a community that is largely neglected medically? An eager helping hand 1 Are you willing to take part in I will always remember the day I was a pioneering effort to bring busy preparing the equipment for the first-rate healthcare to people glucometer station during a health who lack regular access to a screening session as the village kids healthcare provider? Do you scampered around in excitement and seek to gain experience in curiosity. Amid the chaos, I noticed another community through an overseas healthcare an older boy watching my actions volunteer trip? Your clinical intently and shushing the kids around expertise will be greatly him, attempting to get them to valued and will go a long quieten down. way in improving the lives of many. Please email the The boy, whom I later learnt was Project Yangon team at named Aung Kyaw Moe, gestured to projectyangon2015@gmail. the equipment beseechingly before com or contact Ralene Sim thumping his chest enthusiastically. at 9711 2590 if you would To my surprise, I realised that he 3 like to join us on our health wanted to help me. I shook my screening trip from 27 to 30 head, but he wouldn’t take no for an May 2016 or make donations answer. After I performed the blood of drugs, equipment or funds. glucose test on the first villager, he Any form of sponsorship put on a pair of gloves and assisted would be most welcome. me seamlessly without any prior instructions. He helped by removing the plasters from their wrappers and placing them on the villagers’ fingers. He even took the initiative to guide them to the next screening station.

SMA News / APR 2016 from the heart 33

wrecked their homes. They had to her forehead. A clinical examination PROFILE rebuild everything from scratch and revealed coarse crepitations needless to say, higher education consistent with bronchiectasis; in the and healthcare is a luxury that they local context, it was most probably cannot afford. from tuberculosis.

Many village children have no Fortunately, there was a happy choice but to discontinue school ending for both mother and child. We after Primary Six or even earlier to managed to connect them with some Text by bring in extra income, despite being local doctors who assured us that bright, inquisitive and deserving. they would follow up on the boy. Dr Health wise, all parents want the Lim explained: “It gave us a sense of Ralene Sim best for their children, regardless achievement knowing that we helped of their circumstances. However, find the right diagnosis and, more Ralene Sim is a circumstances do dictate prognosis importantly, connected him to a local second-year medical and it is unfortunate that there is a healthcare system that could provide student who feels severe lack of healthcare facilities treatment for children like him.” privileged to be part where they are located. of the Project Yangon There was also a two-year-old family. Having helped One of our Project Yangon doctors, suffering from developmental delay out last year, she will Dr Samuel Lim, encountered a and failure to thrive. “His mother told be embarking on a breathless and febrile 14-year-old boy us that as a baby, he was diagnosed trip again this year from the village who presented with with heart problems but no further together with other asthma that was difficult to treat. work-up was done. She then gave us medical students His mother didn’t need to convey her a clinical history consistent with tet who share the same worry to us in words — it was evident, spells while cardiac examinations passion for reaching with her hand constantly over her supported the diagnosis of possible out to the less son’s shoulder and the creases on tetralogy of Fallot,” recalled Dr fortunate in developing Lim. “After much negotiation, we countries. She feels managed to get local doctors on site that the villagers’ 2 to refer him to a local charity clinic unrelenting spirit of which had special funds to refer the genial hospitality and child to a tertiary centre. It would be immense gratitude most ideal if we had set aside funds made every minute to help such children get the care put into planning for that their own healthcare system the project worthwhile. can actually provide but their social standing cannot afford,” he added. Legend 1. The kids of Shwe Pyi All in all Thar dressed in their school uniforms after school The trip went by in a whizz due to 2. Aung Kyaw Moe, the the flurry of work that engulfed us boy who brought smiles to every day, but one thing was clear — everyone with his industrious nothing was more uplifting than the spirit and kind heart during villagers’ warmth and gratitude which health screening 3. Our valued doctors who dispelled our weariness and returned 4 are part of our Project the spring to our steps. During this Yangon family, all ready to trip to Myanmar, the reward for take on health screening with trudging off the beaten track was that their smiles and equipment of an endless repository of stories 4. Dr Samuel Lim caught in action during our and smiles to light our souls for the health screening entire trip and beyond. Will you be the reason for someone’s grateful heart? Or will you be the recipient of Photos by Project Yangon gratitude-eliciting acts of genuine kindness? Why not achieve both by volunteering with Project Yangon?

APR 2016 / SMA News 34 INDULGE

With long working hours and heavy responsibilities, many physicians hardly have energy to spare for themselves at the end of a work day. However, three physicians show us a glimpse of the benefits from committing to the fitness activity of their choice.

hen I first started pole Apart from its health benefits, what dancing in 2012, I never amazes me most is that pole dancing would have expected it to has an empowering effect on women: become such a big part of in a world where one is so used to my life, or that I would end up in dance. criticising others for their looks or Yet now, I am at the pole studio at least physique, you can walk into a class three times a week and on some days, where judgement is left at the door and I am not sure I want to leave. Over the anyone can learn to dance regardless past three years or so, the pole studio of shape, size, age and fitness. Beyond has been my little solace from a crazy the fun, the challenges and the benefit world at the end of a long day, where of getting fit, pole fitness also changes Dr Jeanne Ong is a second I am among a loving people’s perspective year resident at the National community and can "It is not easy to of body image; women University Healthcare System. lose myself a little bit learn to accept their She graduated from NUS Yong sustain a fitness regime Loo Lin School of Medicine in dance. with our busy work bodies for what it is in 2012. Her weekly fitness schedule but a little capable of rather than Pole dancing, or pole how it looks. regime aside from pole discipline seems to go a dancing often includes yoga fitness as some and CrossFit. The studio people like to call long way." It is not easy to she pole dances at is Ecole it, has become a sustain a fitness De Pole Singapore and she prominent and almost regime with our busy has participated in Amateur Competitions in Singapore and ubiquitous form of work schedule but a Hong Kong. alternative fitness little discipline seems all over the globe. to go a long way for There are countless me, along with finding competitions held a fitness regime that worldwide, as well as works for my lifestyle. instructors who make Once I started work, a living by travelling running for long the world attending distances was no competitions, teaching longer an option as workshops and my legs always felt performing. For me, it all started with fatigued. I am glad that I found pole watching a video and the strength, fitness as an alternative — a fitness flexibility and athleticism exhibited activity with so much fun; I sometimes appealed to me instantly. I started forget that I am trying to exercise! midway through my housemanship year and as they say, the rest is history.

SMA News / APR 2016 INDULGE 35

very weekend, as one heads religion, the weekend ride is the weekly off to the early weekend clinic service. An alarm call at 4 am is the or ward round, there is a high invitation to the morning coffee before chance of meeting the local a slow warm-up to the old Longhouse cycling community; mostly pacing — the de-facto meeting place for alongside the roads and occasionally most cycling groups. Cycling is such around the neighbourhood cafe. Take a serious affair that the riders of the a closer look and one might spot a Joyriders, one of the larger cycling familiar face in the peloton or breakfast groups that gather at the Longhouse, crowd, donned in Lycra trimmings even appoint noms de guerre for its rather than in surgical scrubs. members (Dr Chickenblood, I was). After a quick morning prayer, the Dr Foo Chek Siang is a Enter the Mamil (acronym standing group regularly scuttles off at 5 am general surgeon in private practice. He is striving to for “middle-aged men in Lycra”), as promptly, taking on the sleepy island achieve the optimum work-life defined in the landmark 2010 BBC of Singapore in its many permutations balance, without forgetting news article, with its newer described (mainly westwards or eastwards). social and corporate variant: the Muddy responsibilities, having been Mamil, who favours “Life is like riding a Road cycling in so inspired by mentors in the muddy trails over Singapore offers the bicycle. In order to France and Australia. the tarmac, from the different aspects of 2016 publication of keep your balance, you Singapore not fully the Telegraph, albeit of must keep moving.” appreciated in other lower impact factor. forms — a whiff of Road cycling is a retirement sport fresh grass (with the occasional for me, having shifted gears out from piquancy from dung) along Kranji triathlons; dozens of triathlon races, Countryside, the morning mist along with two ironman-distances, does take Hort Park and sunrise along the a toll on the body. Esplanade. Road cycling also offers great opportunities beyond our Endurance sports have always shores, being a year-round recreation complemented a busy clinical work that is arguably safer than skiing. schedule, as a sort of mental escape and relaxation for the tired soul. To Cycling has been a great leveller: it perk it up, the caloric negative nature narrows social schisms, inspires of cranking the bike does bode better conversation and has taught me for a bon vivant lifestyle than a flashy patience. It has had its harrowing

Seeking fun riding up an active volcano — Mount Ijen sports car. moments and sacrifices, but as a wise in East Java man once said: “Life is like riding a If road cycling were bicycle. In order to keep your balance, the official Mamil you must keep moving”.

4C on the summit of Col du Tourmalet, during a yearly pilgrimage to the hallowed Fresh air up at Col d’Aspin in the French Pyrenees mountains of cycling

APR 2016 / SMA News 36 INDULGE

took up Muay Thai three years ago, and having an outlet for that stress learning from someone who has is fantastic. Let’s face it, it feels good lived and fought in Thailand with to vent and hit something after an ten professional fights under his upsetting day at work. Additionally, belt. What initially piqued my interest you can’t occupy yourself with worry was the gracefulness in which the while training. Otherwise, you’ll get hit fighters moved and the intensity of in the face or mess up the drill you’re the sport. working on in this fast-paced sport. I also believe that regularly doing an Muay Thai may seem brutal to some: activity that detaches you from the two guys in a ring pummelling the daily grind helps you to be a happier Dr Magdalene Liau obtained her medical degree at heck out of each other, hoping to and more carefree person. University College Dublin in come out of it intact. Yet in reality, you Ireland, in the year 2011. Since start with the basic From a girl who then, she has moved back to techniques, working on "Never get so busy with has mitral valve Singapore to be closer to home the bags and pad work making a living that regurgitation and who and family. She is currently pursuing the field of medical with a trainer. You’ll you forget to live for used to repeatedly aesthetics, hoping to make it also do countless yourself." fail her 2.4 km run to her eventual career path. push-ups, sit-ups someone who is able and various other bodyweight to do ten strict pull ups — I think I’m exercises designed to leave you doing alright. I’m proud of how far I’ve a trembling wreck. This, I speak from come and the invaluable friends I’ve personal experience. made along the way.

With all that said, I was hooked from My two cents’ worth for fellow the moment I started. My current colleagues is that life is about balance. fitness regime involves a combination Never get so busy with making a living of Muay Thai, circuit training and that you forget to live for yourself. Pick weightlifting four to five days a week. up a hobby and get excited about life I also frequently travel to Thailand, the outside of work. You’ll find that you’ll mecca of Muay Thai, to learn more on be a better doctor for your patients. the art from the locals in dedicated training camps.

Contrary to what some people may think, I dislike running and thus, Muay Thai is the perfect form of cardiovascular exercise for me. It is a physically demanding full body workout that burns plenty of calories. Besides the cardiovascular benefits, it also improves mental sharpness as you are required to react quickly to instructions or to block kicks from your trainer, which has improved my coordination and reflexes tremendously.

To me, I think stress relief is one of the most important benefits that Muay Thai has offered. Due to the nature of

Top to Bottom our jobs as doctors, we accumulate a Photo taken with the trainers at a popular fitness fair amount of stress during the day facility known as Unit-27 in Phuket, Thailand Group photo with friends after completing Singapore’s first Spartan race event in November 2015 In Phuket, Thailand at a famous Muay Thai training camp, Tiger Muay Thai calendar 37 SMA EVENTS MAY – JUN 2016 DATE EVENT VENUE CME POINTS WHO SHOULD ATTEND? CONTACT CME Activities 3 May Achieving Safer and Family Medicine Margaret Chan 6223 1264 Orchard Hotel 2 Tuesday Reliable Practice All Specialities [email protected] 4 May Family Medicine Margaret Chan 6223 1264 Mastering Adverse Outcomes Orchard Hotel 2 Wenesday All Specialities [email protected] 5 May Achieving Safer and Family Medicine Margaret Chan 6223 1264 Orchard Hotel 2 Thursday Reliable Practice All Specialities [email protected] 7 May Achieving Safer and Novotel Singapore Family Medicine Margaret Chan 6223 1264 2 Saturday Reliable Practice Clarke Quay All Specialities [email protected] 7 May Cancer Education Series 2016 Health Promotion Carina Lee 6223 1264 TBC Doctors Saturday — Lung Cancer Board Auditorium [email protected] 14 May Family Medicine Margaret Chan 6223 1264 Mastering Adverse Outcomes Orchard Hotel 2 Saturday All Specialities [email protected] 24 May Mastering Difficult Interactions with Family Medicine Margaret Chan 6223 1264 Orchard Hotel 2 Tuesday Patients All Specialities [email protected] 25 May Mastering Shared Family Medicine Margaret Chan 6223 1264 Orchard Hotel 2 Wednesday Decision Making All Specialities [email protected] 28 May Achieving Safer and Family Medicine Margaret Chan 6223 1264 Orchard Hotel 2 Saturday Reliable Practice All Specialities [email protected] 29 May Family Medicine Shirong or Huda 6223 1264 BCLS SMA Conference Room 2 Sunday All Specialities [email protected] 4 June Ng Teng Fong General Doctors and healthcare Carina Lee 6223 1264 CMEP Health Law Seminar TBC Saturday Hospital Auditorium professionals [email protected] Non-CME Activities 8 May 42nd SMA-Eagle Eye Centre Inter- Home United Youth SMA Members Azliena Samhudi 6223 1264 NA Sunday Hospital Soccer Tournament Football Academy and Guests [email protected] 14 May SMA Members Mellissa Ang 6223 1264 SMA Annual Dinner 2016 Raffles Town Club NA Saturday and Guests [email protected]

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:

Resident Physician (A&E/ 24 hours Walk-In Clinic) Based in Singapore, you will be part of a team of dedicated doctors and paramedical 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.

Requirements: • Basic medical qualification registrable with Singapore Medical Council • Possess a valid practising certificate from the Singapore Medical Council • At least 3 years of clinical experience post-housemanship. • Postgraduate medical qualifications and relevant experience are advantages • Good oral and written communication skills • Good interpersonal skills • Good team player

Kindly email: [email protected] or call 9670 0472 for a friendly discussion.

www.parkwaypantai.com

APR 2016 / SMA News 38 aic says THANK YOU, OUR GP PARTNERS, FOR SUPPORTING CHAS! By Agency for Integrated Care

To recognise and thank our General Practitioner (GP) partners As CHAS complements the Chronic Disease Management for their continuing support for the Community Health Programme (CDMP), which offers CHAS subsidies to Assist Scheme (CHAS), Agency for Integrated Care (AIC) patients with chronic conditions, the scheme has made and the Ministry of Health (MOH) jointly organised a CHAS . consistent and continuous care a lot more accessible, Appreciation Lunch & Continuing Medical Education (CME) especially for the lower- to middle-income patients. event on 5 March, 2016 at the Furama Riverfront hotel. Introduced by the Ministry of Health in 2012 to make Into its third year, this year’s theme was “Fostering closer healthcare affordable and accessible for everyone, CHAS working relations between GPs and Specialists”. In line with subsidises medical and dental treatments for lower- to the theme, the event aimed to encourage more collaboration middle-income Singaporeans, as well as Pioneer Generation with our GP partners in order to provide healthcare at the (PG) citizens, at participating GP and dental clinics across appropriate setting. A psychiatrist and two respiratory the island. As of April 2016, there were more than 1,500 physicians from Tan Tock Seng Hospital (TTSH) not only CHAS GP and dental clinics and about 1.4 million CHAS and shared clinical updates but also their experiences and efforts PG beneficiaries. in right-siting care. A rheumatologist and a family physician also paired up to share case studies on co-managing a But it is not only patients who benefit from CHAS. common group of patients. According to Dr Toh Khai San of SATA CommHealth, CHAS To further show appreciation to the CHAS GPs this year, a has helped his organisation to be more deeply involved in special tribute video capturing CHAS GPs at work and their eldercare. “We have a Doctors-on-Wheels programme, where dedication in caring for CHAS patients was screened. we go to Senior Activity Centres to see patients on a regular basis,” he explained. “Almost all of them are under CHAS. The event was graced by Guest of Honour Associate This makes our programme more sustainable because Professor Benjamin Ong, Director of Medical Services (DMS) the government defrays some of the cost. It’s very much at the MOH, as well as special guest Associate Professor welcome.” Kenneth Mak, Deputy Director of Medical Services (DDMS). When asked if he would encourage other GPs to join CHAS, In his opening address to the 100 GPs present, DMS affirmed Dr Toh replied, “Yes, definitely. CHAS is very relevant, the crucial role GPs play on the front line of Singapore’s especially for those staying in housing estates and the healthcare system, making them well placed to identify those suburbs. And also because of our demographic changes at risk and follow up with regular consultations. “Primary care with the aging population.” transformation is a major focus of the Ministry of Health, and rightly so,” he announced. “GPs are key partners in this Although many GPs in attendance readily agreed that journey of care transformation, and CHAS is an integral part they would recommend CHAS to fellow doctors, some of our effort to help patients get under GPs’ care for chronic who joined last year commented that it was an initially disease management.” daunting process that was quickly made much easier by

AIC141.16 - SMA News Apr'16_v7.indd 1 8/4/16 5:27 pm aic says 39

the proactive assistance of the CHAS team. “There was a lot of paperwork, but the CHAS team actually came over and taught us the whole system. They’re very responsive,” remarked Asia HealthPartners Clinic’s Dr Chong Yeang Chern, who joined CHAS in 2015 to better serve her PG patients.

For Dr Ow Boon Hin of Universal Medical Clinic, it was such an event that motivated him to sign up for CHAS. “What was really memorable was the networking. I got to talk to fellow GPs who had joined CHAS, which allowed me to clarify my doubts,” he explained.

The event was also an excellent opportunity for the 100 CHAS GPs who attended to be kept updated about the various primary care initiatives. TTSH, Health Promotion Board and the Community Health Centres had information Information booth set up by Tan Tock Seng Hospital at the event. booths at the event to publicise their schemes and to sign interested GPs up for their programmes. Meanwhile, AIC had a booth to promote Primary Care Pages, Community Care- GP Partnership Training Award and the Mental Health GP Partnership Programme.

The GPs expressed their enjoyment of the event and shared that they found it useful. “Of course I would like to see this event happening again next year,” said Dr Ow when asked if he would attend it again. Many other GPs also found the talks enriching, requesting for more material on various schemes. Within the day, TTSH received 18 leads from GPs who expressed a keen interest to tie up with the hospital.

Although CHAS has come a long way since 2012, AIC . believes there is much more to be done, and will strive to get more GPs on board. AIC would like to express our appreciation to our GP partners for supporting CHAS The CHAS team is always ready to assist you with your queries over the years and for working closely with us to provide affordable and accessible healthcare to the community.

Special thanks to our distinguished speakers:

Dr Puah Ser Hon Dr Albert Lim Adjunct Assistant Prof Dr Anita Lim Dr Tan Tze Lee Associate Consultant, Senior Consultant, Jaspal Singh Dhaliwal Senior Consultant, Senior Physician, Tan Tock Seng Hospital Tan Tock Seng Hospital Consultant, Tan Tock National University The Edinburgh Clinic for the presentation on for the presentation on Seng Hospital for the Hospital for the for the presentation Updates on Asthma Updates on Asthma presentation on Managing presentation on Managing Management Management Depression in Primary Care on Managing Inflammatory Inflammatory Arthritis Arthritis

What to Expect When Clinic Sign Up for CHAS

The CHAS team provides a hand-holding experience to each and every clinic, which means guidance every step of the way for a seamless integration of CHAS:

• A dedicated account manager to assist clinics in the CHAS application process • On-site training for doctors and clinic assistants on the use of the CHAS Online portal for claims submission • Regular information sessions on CHAS updates • Support for any CHAS-related query through the CHAS hotline (6632 1199) during office hours

Contact us at [email protected] if you would like to sign up as a CHAS clinic, or if you have any further enquiries

AIC141.16 - SMA News Apr'16_v7.indd 2 8/4/16 5:27 pm SALE/RENTAL/TAKEOVER Dr Abel Soh Wah Ek MBBS (S’pore), MRCP (UK) 34 sqm Paediatric clinic for lease from June 2016. Shared overheads negotiable. Please call Ms Prunella 9626 7607. Dear Friends and Colleagues, SCM: Buy/sell clinics/premises: Takeovers: (1) D14, ind/HDB; I have commenced private practice at Mount Elizabeth Medical Centre. I was previously (2) D21, High Turnover. Rental: (i) Holland, former 40 year HDB consultant endocrinologist at Singapore General clinic space; (ii) Chai Chee ind, 1045 sq ft; (iii) D21, share with Hospital (SGH) as well as at Raffles Hospital. specialist, MRT. Sale: Mall Shop, D14. Kok Yein 9671 9602. I graduated from National University of Singapore (NUS) in 2000 and obtained MRCP (UK) in 2006. I pursued advanced specialist Clinic for rent. Prime next to lift, #06-01 Gleneagles Medical training in endocrinology and obtained my specialist accreditation in 2010. I was awarded Centre. Immediate. 656 sq ft. Renovated. SMS 9680 2200. the SingHealth HMDP Fellowship in Diabetes in Pregnancy at Joslin Diabetes Centre, USA, in 2010. In 2012, I received the Singapore Health Shop for Rent: #02-33 & #02-34 Coronation Plaza, about Quality Service Gold Award. 240 sq ft & 640 sq ft, glass panel facing Bukit Timah Road – Prior to leaving for private practice, I was actively involved in undergraduate and postgraduate teaching at SGH. I served as Adjunct Assistant Professor in can display Advertisement. Please call 9815 6090. Medicine at Duke-NUS Graduate Medical School and Clinical Senior Lecturer at Yong Loo Lin School of Medicine, NUS. I was also in the Core Faculty of the SingHealth Internal Medicine Residency program. In 2011, I initiated the pre- Connexion Medical Suite clinic space available immediately Ramadan counselling program for Muslim patients with diabetes in SGH. I for rent. 646 sq ft. directly linked to Farrer Park Hospital, hotel am currently the Vice-President of the Singapore Association for the Study of Obesity (SASO). & spa, MRT. 12th floor. Bare finish. For specialists only. Please Besides seeing patients with diabetes mellitus, thyroid disorders, lipid call Steven Chia +65 8133 4933; Crystal Yu +65 8121 9326. abnormalities, calcium and vitamin D disorders, osteoporosis, adrenal and pituitary disorders, and obesity, I subspecialise in managing women with endocrinological problems during pregnancy (e.g., gestational diabetes mellitus, Serviced clinic for rent at Mount Elizabeth Novena Hospital. thyroid disorders). I can perform ultrasound scan of the thyroid and ultrasound- Fully equipped and staffed with IT support. Immediate guided fine needle aspiration biopsy of thyroid nodules for patients as well. occupancy. Choice of sessional and long term lease. Suitable I look forward to working with you to provide comprehensive endocrine care for your patients. for all specialties. Please call 8668 6818 or email serviced. [email protected]. Abel Soh Diabetes, Thyroid and Endocrine Clinic Mount Elizabeth Medical Centre 3 Mount Elizabeth, #12-11, Singapore 228510 Tel: 6262 2008, Fax: 6262 2278 POSITION AVAILABLE/PARTNERSHIP Email: [email protected]

Drs. Bain and Partners welcomes dedicated medical doctors to join our established and growing city practice. We offer a competitive remuneration package with comprehensive benefits for successful doctors. A post graduate qualification in occupational medicine would be an advantage. Good prospect of profit sharing/partnership for committed doctors with a long term out look. Interested applicant, please send your CV to [email protected] or call 6532 5522.

New town clinic near MRT seeking doctors who wish to work Part Time / Semi - Retired. Preferably with own pool of follow up patients. All specialties welcome. Profit Sharing Partnerships. SMS only: 9108 0632. Email: [email protected].

Position Required: Aesthetic doctor with full medical registration. Location of clinic: East Singapore. Working hours: Full-time or part-time negotiable. Salary: Negotiable. Please contact: Dr. YM Wong (9665 1966) or Ms Cindy Wee (6278 6988).

(1) F/T GP @ town - Salary: S$15,000 per month; Mon to Fri: 9am to 6pm; Sat: 9am to 1pm (Off on Sun & PH). (2) P/T GP @ town - On call: about 1 trip per day; Mon to Sat 6.30pm to 11pm; Sun & PH: 9am to 6pm; Email CV: doctorhr88@gmail. com or SMS/WhatsApp: 9823 8157.

For regular partner +/- takeover. Geylang clinic. 9674 0321.

Town Practice looking for Family Medicine; and Aesthetically- trained Doctors. Good remuneration packages available. Interested parties kindly send resume to [email protected].

CASHLESSOur SERVICE* For patients with private integrated shield plans

Deposit Fast access NO required

Personalised Payment upon quality care NO discharge

6 in 10 Medishield Life policyholders are covered by Private Integrated Shield Plans.^ Parkway East Hospital is pleased to offer a Cashless Service so eligible patients* are able to admit with no deposit and no payment required upon discharge.

*ELIGIBILITY CRITERIA: OUR CLINICAL SPECIALITIES:

- Singaporeans / Permanent Residents • Anaesthesiology • Neurosurgery - Estimated bill sizes of up to $30,000 (Pain Management) • Obstetrics & • Cardiology Gynaecology - Medisave balance of at least $10,000 • Dermatology • Ophthalmology - Patients with Private Integrated Shield Plans • Gastroenterology • Orthopaedic Surgery for private hospitals: • General Surgery • Otorhinolaryngology 1. AIA HealthShield Gold Max A • Hand Surgery • Paediatric Medicine • Internal Medicine • Renal Medicine 2. Aviva MyShield Plan 1 • Neurology • Respiratory Medicine 3. Great Eastern SupremeHealth Plan P Plus • Urology 4. NTUC Income Enhanced IncomeShield Preferred 5. Prudential PRUshield A Premier - Subject to terms and conditions, pre-existing PARKWAY EAST HOSPITAL conditions, exclusions, and causes of hospitalisation 321 Joo Chiat Place Singapore 427990 For appointment or enquiries, please call To check on your eligibility and queries for the (65) 6377 3737 or email [email protected]. Cashless service, please contact Parkway East Hospital

Admission / Business Office at (65) 6340 8600. Parkway East Hospital is accredited by Joint Commission International ^ Figure drawn from article: Salma Khalik, ‘Health coverage: Are you overinsured’ (The Straits Times, Jan 23, 2014), yourhealth.asiaone.com