news Farrer Park Hospital 24-hour Walk-in Clinic

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

Other Services Include: Outpatient Consultations Vaccination

Medical/Surgical Emergencies Chronic Disease Management

Medical Screening

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

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

COMFORT. FAIRNESS. VALUE. Farrer Park Hospital 4 5 24 Editorial EDITORIAL Professionalism The Editor’s Musings Fighting for the Professionalism in Dr Tan Yia Swam Good of Humanity Risk Management A/Prof Daniel Fung Dr Seow Wan Tew and Vol. 48 No. 1 2016 24-hour Walk-in Clinic Dr T Thirumoorthy

Located directly above Farrer Park MRT station, our team focuses on o ering EDITORIAL 6 28 BOARD patients prompt medical attention. The Ambulance drop-o and EXEC SERIES Editor feature Diagnostic Imaging Suite are designed in close proximity to the Clinic, Dr Tan Yia Swam New Psychoactive Substances: High Index of The Singapore enabling patients to transit quickly with immediate access to needed services. Deputy Editors Suspicion Needed in Clinical Services Medical Council Dr Tina Tan Dr Lambert Low, Dr Melvyn Zhang and Disciplinary Process Dr Tan Tze Lee Dr Christopher Cheok Lek Siang Pheng and Editorial Advisors Mar Seow Hwei A/Prof Daniel Fung A/Prof Cuthbert Teo Dr Toh Han Chong 8 10 32 Members Dr Jayant V Iyer feature president’s forum SMA CHARITY FUND Dr Natalie Koh Marijuana Lost in Translation New Online Giving Dr Leong Choon Kit Demystified Dr Wong Tien Hua Platform! Dr Jipson Quah Dr Melvyn Zhang and Dr Jonathan Tan Dr Christopher Cheok Dr Jimmy Teo CALENDAR SMA EVENTS EX-OFFICIOS MAR – APR 2016 Dr Wong Tien Hua Dr Daniel Lee Hsien Chieh 12 33 EDITORIAL OFFICE COUNCIL NEWS FROM THE HEART Senior Manager SMA Offers Programmes to Help Foreign An Evening with Sarah Lim Doctors Assimilate Here Snoopy and Charlie Senior Executive Brown Sylvia Thay Dr Jade Kua Editorial Executive Jo-Ann Teo

ADVERTISING AND 13 14 34 PARTNERSHIP EVENT INTERVIEW INDULGE Li Li Loy Denise Jia When the Force Marijuana: Much Ado About Other Services Include: Tel: (65) 6223 1264 Awakens Yes or No? Dracula! Email: [email protected] Mellissa Ang Dr Ravindran Kanesvaran, Dr Juliana Poh Outpatient Consultations Vaccination Dr Adrian Wang and Dr Alex Yeo Medical/Surgical Emergencies Chronic Disease Management Publisher Singapore Medical Association Medical Screening 2 College Road 16 19 Level 2, Alumni Medical INSIGHT EULOGY Centre Singapore 169850 A Glimpse into the IN MEMORY OF Tel: (65) 6223 1264 Past — Medicine in PROF FENG PAO HSII Fax: (65) 6224 7827 Singapore (Part 5) Prof Fong Kok Yong Farrer Park Hospital 24-hour Walk-in Clinic is Email: [email protected] A/Prof Cuthbert Teo URL: http://www.sma.org.sg open everyday throughout festive seasons and UEN No.: S61SS0168E

Public Holidays. DESIGN agency 20 22 38 Oxygen Studio Designs Pte Ltd GP MATTERS OPINION AIC SAYS Level 2, Farrer Park Hospital, 1 Farrer Park Station Road PRINTER Setting the Pace On Call and Feeling GUIDING YOU THROUGH Singapore 217562 | Tel: +65 6705 2999 Sun Rise Printing & Ahead Stressed CHAS AUDIT: A QUICK Supplies Pte Ltd Dr Leong Choon Kit Dr Tan Yia Swam REFERENCE (Part 2)

Opinions expressed in SMA News reflect the views of the individual authors, and do not necessarily represent those of the editorial board of SMA News or the Singapore Medical Association (SMA), unless this is clearly specified. SMA does not, and cannot, accept any responsibility for the veracity, accuracy or completeness of any statement, opinion or advice contained in the text or advertisements published in SMA News. Advertisements of products and services that appear in SMA News do not imply endorsement for the products and services by SMA. All material appearing in SMA News may not be reproduced on any platform including electronic or in print, or COMFORT. FAIRNESS. VALUE. transmitted by any means, in whole or in part, without the prior written permission of the Editor of SMA News. Requests for reproduction should be directed to the SMA News editorial office. Written permission must also be obtained before any part of SMA News is stored in any retrieval system of any nature. 4 editorial

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

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

Following this train of thought, I am reminded of the Chinese saying “ ” (doctors with parental hearts) — it means that doctors should love医者父母心 and care for their patients as they do their children. This would also mean appropriate chastisement when necessary and not pandering to their every whim and demand, which can only lead to a spoilt child. There is now an attitudinal trend towards referring to patients as “customers” and doctors as “healthcare providers”, which is detrimental to the doctor-patient relationship in Dr Tan Yia Swam is an associate the long run. This is a global shift that has been derided by many. Whether or not consultant at the Breast this trend can be reversed remains to be seen. Department of KK Women’s and Children’s Hospital. She continues to juggle the commitments of SMA’s slogan, “For Doctors, For Patients”, succinctly sums up the role of this being a doctor, a mother, a wife professional body. We play a delicate part in protecting and nurturing doctors, so that and the increased duties of SMA they can better look after their patients. The profile of our membership is changing, News Editor. She also tries to keep and SMA News will keep on evolving with the times to meet the expectations of time aside for herself and friends, our members. Some things will stay the same — we will always carry articles on both old and new. professionalism, patient anecdotes, volunteerism and personal reflections. To spice things up, the “Indulge” column will be expanded to include other interesting hobbies that doctors pursue, though its mainstay will still be food and travel. So far, we have covered diving, flying and cooking. I’ve heard of doctors attending sommelier, barista or pole-dancing classes! Yia SwamEditor

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

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

SMA News / jan 2016 editorial 5 Fighting for the Good

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

Dobson et al speaks of another form of advocacy which they termed activism. This form is described by the American Medical Association as advocating for “social, economic, educational and political change”. This is far less common and some may tell us that we should enter politics to achieve it. I beg to differ. There are many issues that politicians and governments cannot address. I would like to think that because doctors are often held in high regard, what we say and do can have social, economic, educational and even political impact. The Daniel volunteers with the Singapore Medical Council Ethical Code and Ethical Guidelines2 state that we should Singapore Association for Mental “participate in activities contributing to the good of the community, including public Health, Singapore Children's Society health education”. In Singapore, we have doctors who advocate for specific causes and Paya Lebar Methodist Girls' and also doctors who enter politics and by default act as social activists. But these School, and hopes to see more are not many. In order to be good advocates, doctors must be kept abreast of what doctors involved in social advocacy. is happening in the world and not just in knowledge and science of the work we do in treatment of illness. The World Health Organisation stated elegantly in its constitution in 1948 that health is not just absence of illness but the maintenance of social, mental and physical well-being. The medical motto of “Not pride of knowledge but humility of wisdom” certainly implies the need to exercise wisdom and to advocate this to Guest Editor A/Prof Daniel Fung the world at large. The future of medicine lies in preventing illness and maintaining well-being and it will require a population health approach and doctors will have to be more than just experts in treating illness. Social activism to improve lifestyles and reduce risks and harmful behaviours will be critical for new medical practitioners.

In this issue, we discuss the importance of doctors being aware of substance abuse and dependence, as well as the physician’s role in managing this growing problem. Like smoking, marijuana is sometimes thought of as a harmless social activity but the evidence suggests that it may be a gateway to a whole host of social problems. Whether it is in woman’s rights, medical students’ welfare, bringing out the best of GPs, managing stress or critical incidents, the concept is the same; we as doctors can do so much more if we see the big picture and lend a hand in making the world a better place. References 1. Dobson S, Voyer S, Regehr G. Agency and activism: rethinking health advocacy in the medical profession. Acad Med 2012; 87:1161–4. 2. Singapore Medical Council. SMC Ethical Code and Ethical Guidelines. Available at: http://www. healthprofessionals.gov.sg/content/hprof/smc/en/topnav/guidelines/ethical_code_and_ethical_ guidelines.html.

Jan 2016 / SMA News 6 feature

for clinicians to be cognisant of these substances. Only when clinicians are aware of these substances would they ­New Psychoactive have a high index of suspicion when they encounter patients presenting with specific clinical manifestations. Substances: Gamma-hydroxybutyric acid (GHB), a metabolite of gamma-aminobutyric acid that has its origins as early High Index of as the 1960s and later became notoriously known as a date-rape drug, was one of the first NPS to be synthesised. GHB has since Suspicion been scheduled as a controlled drug in many countries, including Singapore. Thereafter, the market Needed in saw the emergence of other types of NPS such as synthetic cathinones, eg, mephredone and synthetic Clinical cannabinoids (also known as spice). Perhaps an inherent difficulty in classifying these substances as Services illegal based on class of drugs stems from the fact that some members in the same class may have already been used for their therapeutic This article is an edited version of an properties, eg, the synthetic PROFILE article published on the NAMS website cathinone, bupropion, is commonly (http://goo.gl/WIQWJT). used as an anti-depressant and smoking cessation agent. Therefore, New psychoactive substances it is difficult, if not impossible, to have (NPS), commonly marketed as “bath a blanket ban on whole classes of salts” or “plant food”, are chemical chemicals. This belies the fact that compounds designed by chemists new NPS are hitting the market as Text by to circumvent the current legislation the older ones get outlawed and enter against drugs of abuse. They have the controlled drugs registry. Hence, DR lambert low been touted as “legal” highs, as many it is difficult to ascertain whether a of these synthetic compounds do not clinical syndrome is due to NPS or the fall under the scheduled controlled myriad of such chemicals present. Dr Lambert Low substances list in many nations. This However, an index of suspicion based is an associate has prompted many countries to on certain recurring clinical patterns consultant with the take legislative action against these can possibly lead to an expedient National Addictions diagnosis and treatment, after other Management Service new substances. These drugs are but is currently away on synthetic derivatives from many drug acute medical conditions have been HMDP pursuing further classes, including phenethylamines, ruled out. subspecialty training in cannabinoids, cathinones and the field of addictions. piperazines. However, they Clinical presentation He is a house tutor While there have been disturbing news with the LKC School of frequently escape detection from the Medicine and is also a immunoassay kits commonly used reported in the Sun, of a man tearing off certified acupuncturist. in routine laboratories. The Central his scrotum after using “meow meow” He is producer of the Narcotics Bureau website reports (mephedrone) due to hallucinations, IMH play “8-5”. that heroin and methamphetamine as well as other similar horrid news are the two most commonly abused related to NPS, the presentation is drugs in Singapore, but little is often less conspicuous. Patients may known about the prevalence and not disclose their use of an NPS during problems associated with NPS use history-taking, or they may not perceive in the local context. While NPS is NPS to be drugs, as these substances currently not a problem in Singapore, are marketed as supplements, “plant given the growing incidences of abuse food” or “bath salts”. In the absence of of these psychoactive substances in clinical tests, clinicians should have a European countries, it is important high index of suspicion that patients

SMA News / jan 2016 feature 7

presenting with brief delirium with no opioid-like symptoms such as PROFILE other organic cause may in reality be respiratory depression and decreased labouring from the effects of an NPS. levels of consciousness. Some of these In particular, the Crime Survey of patients have responded well with the England and Wales (CSEW) 2013/14 competitive opioid receptor antagonist found that young persons between Naloxone. Patients who have taken 16 and 24 years old have about a three synthetic cannabinoids such as times greater propensity of using an spice/K2 have also been known to NPS such as mephredone and salvia demonstrate symptoms of sympathetic Text by than the general adult population. overdrive such as elevated heart rate, The CSEW report also suggested that agitation, excessive sweating, high there may be a significant association blood pressure and muscle twitches. DR Melvyn Zhang between the nightlife economy and the Confusion, hallucinations, paranoia and use of NPS, with a greater frequency of cognitive impairment can also follow. Dr Melvyn Zhang is use among those who visit nightclubs currently a senior more frequently. Management of NPS resident (Year5) in overdose and toxicity psychiatry with the National Healthcare Synthetic cathinones such as Having a high index of suspicion Group. He has a special mephredrone are stimulants that based on the pattern of common interest in addictions resemble amphetamines in their action. presenting complaints mentioned and E-health. To date, he The clinical syndrome is, therefore, above would help clinicians to decide has 33 publications, with one of cardiovascular, central nervous on the appropriate management. While major publications in the British Medical Journal, system and sympathetic overdrive, many treatments involve supportive Lancet Psychiatry as manifested as agitation, tachycardia, measures such as hydration and well as the Journal raised arterial blood pressure, dilated monitoring, there is at present no of Internet Medical pupils, hyperthermia, muscle clonus specific antidote for most of the NPS. Research (JIMR). and sialorrhoea. As the syndrome Thus far, the evidence suggests that worsens, confusion, seizures, benzodiazepines may be helpful in arrhythmias and respiratory arrest ameliorating the sympathomimetic may ensue. Biochemical abnormalities overdrive effects associated with the reported include renal impairment with ingestion of NPS. Benzodiazepines can elevated potassium and creatinine, be given intravenously to counteract as well as elevated liver enzymes the sympathomimetic effects on and creatine kinase. The group of the heart, reducing the chance of phenethylamine compounds produce arrhythmias and heart attack, as sympathomimetic effects such as well as preventing seizures. The use Text by agitation, raised blood pressure, of antipsychotics is controversial, tachycardia, dilated pupils, clonus and some have suggested that drug Christopher Cheok and seizures, as seen with synthetic interactions with NPS may render cathinones. Hallucinations due to them unsafe. 5-HT2A agonism, however, are more Dr Christopher Cheok is currently prominent in this group of compounds. Given that NPS usually come in the Vice-Chairman, Biochemical abnormalities reported various combinations of chemicals Medical Board include elevated creatine kinase, and the labelled preparation may (National Addictions deranged liver enzymes, and renal not be the actual constituents, it Management Service) impairment with consequent increased is very important for clinicians to of the Institute of Mental Health. He is a creatinine and serum potassium. first focus more on immediate and visiting consultant to supportive management. the Singapore Armed Besides cathinones and Forces and a member phenethylamine compounds, The use of NPS is a new and emerging of the medical board which have stimulant properties, problem in the drug abuse landscape of the Civil Aviation Authority of Singapore. the piperazine family of drugs such in Singapore. Clinicians need to be He has a special as benzylpiperazine (BZP) and aware of the use of such substances in interest in child and trifluoromethylphenylpiperazine Singapore and to have a high index of adolescent psychiatry, (TFMPP), which have been branded as suspicion of possible NPS abuse when psychological trauma safer choices in lieu of ice and ecstasy, young people present with agitation, and research. also produce stimulant effects. Caution psychosis or confused states. must be exercised, as not all piperazine derivatives exhibit such stimulant properties. MT-45, an NPS from the same family that has recently appeared on the market, has demonstrated

Jan 2016 / SMA News 8 feature

MARIJUANA

Introduction these days are young and well- rigorous clinical trials. Cannabis Marijuana has recently been legalised educated. Many abusers, however, has also been reported to aid in the for medical use in Canada and the have the perception that cannabis treatment of neurological conditions United States. The legalisation of is not addictive. Clearly, such myths such as epilepsy and headache.4 marijuana is a hotly contested issue surrounding cannabis can be It has also been advocated as a globally. In Singapore, marijuana, also attributed in part to the legalisation treatment modality for multiple known as cannabis, was included efforts for its therapeutic use sclerosis-associated spasticity. as a Schedule I drug in the 1961 overseas. In this article, we will look at Despite these initial findings, more Single Convention on Narcotic Drugs. the current therapeutic applications rigorous clinical trials are needed to Currently, grave punishments are of medical cannabis and the issues prove its clinical efficacy before the meted out to individuals who abuse associated with cannabis abuse. drug can be integrated as part of a or possess the drug, with a fine of up recommended treatment. to $20,000 or imprisonment of up to Medical use of cannabis ten years. In addition, individuals are Medically, cannabis has been Cannabis has also been reported liable to the death sentence if they proposed for use in the treatment to be helpful for individuals import or export more than 500 g of of paediatric developmental and experiencing digestive-related issues cannabis or 200 g of its resin, or more behavioural disorders such as (eg, nausea and vomiting) arising than 1,000 g of the two combined.1 autistic disorder.2 However, evidence from chemotherapy.5 One of the of its effectiveness to date is limited main reasons for the legalisation of In 2015, the Central Narcotics only to single case studies and cannabis overseas is its purported Bureau noted an increase in the reports. Cannabis has also been usefulness in patients with terminal absolute number of cannabis users purported to be of use for cancer conditions. Thus, despite the problem locally. More importantly, the media treatment.3 Studies have advocated of addiction associated with its use, has reported a changing profile of that cannabis might help in the therapeutic usage for this group of these abusers. Instead of the dated inhibition of cancer-related growth patients clearly outweighs the risks, perception of drug users being less as well as curb the spread of cancer due to the potential improvement educated and of a lower socio- cells. These are largely initial findings in quality of life that this group of economic status, cannabis abusers that need to be validated by more individuals will experience. SMA News / jan 2016 feature 9

It is important for medical to develop psychosis earlier as PROFILE professionals to be cognisant compared to the norms in the general that, while cannabis does have population. Prior meta-analyses its therapeutic purpose, there are have reported that these individuals inherent risks associated with its use. develop psychosis three years earlier This is especially important given the than the general population.8 More growing incidence of cannabis abuse recent research has highlighted locally and the changing perception the association between cannabis of the young and educated towards use and suicide, although it does Text by this drug of abuse. It is pertinent for predispose one to an increased risk clinicians to be updated and informed, of suicide.9 so that they can provide their patients DR Melvyn Zhang with the latest information and the The use of cannabis can result in appropriate education. adverse medical complications Dr Melvyn Zhang is such as cannabis-induced arteritis, currently a senior Cannabis-induced cannabis-induced posterior resident (Year5) in problems circulation stroke and even psychiatry with the 10 National Healthcare There is a multitude of psychiatric myocardial infarction. It can Group. He has a special manifestations that could arise from also lead to respiratory issues interest in addictions the use of cannabis, apart from the such as bullous emphysema and and E-health. To date, he addiction itself. Cannabis use may chronic obstructive lung disorder. has 33 publications, with predispose individuals to depressive Developmentally, youths who major publications in the 6 British Medical Journal, and anxiety disorders, in addition start using cannabis at a younger Lancet Psychiatry as to heightening the chance of them age may suffer from neurological well as the Journal developing psychosis.7 complications and executive of Internet Medical functioning deficits. Research (JIMR). Cannabis usage might result in a twofold increment in the risk Conclusion of acquiring schizophrenia and a While there is some evidence corresponding fourfold increase in supporting the clinical efficacy of the risk of psychosis. However, there medical cannabis, the evidence needs are ethnic and genetic variants. It to be carefully considered. Medical should be noted that individuals cannabis may be safe for a special who are homozygous for the VAL/ subgroup of patients. However, for VAL alleles in the catechol-O- medical professionals at large, it is methyltransferase (COMT) genotype important to recognise not only the Text by tend to be at enhanced risk. Those changing trend of drug usage, but individuals who are homozygous also the worrying trend of cannabis Christopher Cheok for the MET/MET alleles in the abuse among young, educated COMT genotype tend to be not at individuals. As medical professionals, enhanced risk. In addition, the usage it is essential for us to be aware of the Dr Christopher Cheok is currently of cannabis has been linked with an adverse effects of cannabis abuse the Vice-Chairman, earlier age of onset of psychosis. and to counsel patients whom we Medical Board Individuals who use cannabis tend suspect are at risk. (National Addictions Management Service) References of the Institute of Mental Health. He is a 1. Central Narcotics Bureau. Drugs and inhalants. Available at: visiting consultant to http://www.cnb.gov.sg/drugs/bannedsubstance/cannabis.aspx. Assessed 2 December 2015. the Singapore Armed 2. Kurz R, Blass K. Use of dronabinol (delta-9-THC) in autism: a prospective single-case-study with an Forces and a member early infantile autistic child. Cannabinoids 2010; 5(4):4–6. of the medical board 3. Caffarel MM, Andradas C, Pérez-Gómez E, Guzmán M, Sánchez C. Cannabinoids: a new hope for breast of the Civil Aviation cancer therapy? Cancer Treat Rev 2012; 38(7):911–8. Authority of Singapore. 4. Benbadis SR, Sanchez-Ramos J, Bozorg A, et al. Medical marijuana in neurology. Expert Rev Neurother He has a special 2014; 14(12):1453–65. interest in child and 5. Tramèr MR, Carroll D, Campbell FA, et al. Cannabinoids for control of chemotherapy induced nausea adolescent psychiatry, and vomiting: quantitative systematic review. BMJ 2001; 323(7303):16–21. psychological trauma 6. Kedzior KK, Laeber LT. A positive association between anxiety disorders and cannabis use or cannabis and research. use disorders in the general population—a meta-analysis of 31 studies. BMC Psychiatry 2014; 14:136. 7. Arseneault L, Cannon M, Witton J, Murray RM. Causal association between cannabis and psychosis: examination of the evidence. Br J Psychiatry 2004; 184:110-7. 8. Large M, Sharma S, Compton MT, Slade T, Nielssen O. Cannabis use and earlier onset of psychosis: a systematic meta-analysis. Arch Gen Psychiatry 2011; 68(6):555-61. 9. Serafini G, Pompili M, Innamorati M, et al. Can cannabis increase the suicide risk in psychosis? A critical review. Curr Pharm Des 2012; 18(32): 5165–87. 10. Duchene C, Olindo S, Chausson N, et al. [Cannabis-induced cerebral and myocardial infarction in a young woman]. Rev Neurol (Paris) 2010; 166(4):438–42. French. Jan 2016 / SMA News 10 president’s forum lostlost inin translationtranslation — Integrating Foreign-Trained Doctors Illustration: Dr Kevin Loy

The local newspapers recently Reports from the UK have PROFILE reported on the increasing number highlighted concerns that doctors of foreign practising doctors in who were qualified outside the UK Singapore, citing a figure of more than were proportionally more likely to 2,100 currently employed in public be subjected to an investigation by hospitals and polyclinics. The influx the General Medical Council about was to meet the increasing demand issues such as poor clinical skills for medical services here, especially and knowledge, lack of knowledge Text by with the inevitable ageing of our of the law or codes, and inadequate population and the rise in incidence of participation in medical education.1 chronic diseases. The gap in supply of Dr Wong Tien Hua doctors has not yet been met by our I wrote to the Straits Times Forum in three medical schools, which enrol November 2015 (reprinted on page 12) to point out that foreign-trained Dr Wong Tien Hua is about 460 students a year, a figure President of the 56th that has doubled since a decade ago. doctors include both foreign doctors SMA Council. He is It will be some time before these and Singaporean doctors trained a family medicine medical undergraduates become full- overseas. Although the percentage of physician practising fledged practising physicians. foreign-trained doctors in Singapore in Sengkang. Dr Wong has grown slightly from 36.45 per has an interest in Regarding the integration of foreign cent in 2011 to 41.42 per cent last primary care, patient doctors into our healthcare system, a year, the total proportion is not an communication and medical ethics. reporter commented that it matters insignificant number. not where a doctor was born or what languages he speaks. What is SMA is of the opinion that this group important is that he is knowledgeable, of overseas-trained doctors requires experienced and caring. While this is some form of assimilation into the certainly true, there are nevertheless local medical practice environment. problems associated with foreign For foreign doctors, the need doctors practising in an unfamiliar is greater because of language healthcare system. and communication barriers and

SMA News / jan 2016 president’s forum 11 difficulties in understanding the from the original intended meaning, to better understand the patient’s local culture. For Singaporeans as the final message communicated health beliefs. trained overseas, they will also is dependent on the translator’s need to understand our healthcare own understanding, subjective Muslims observing the fasting month system, health financing policies interpretation and emotional of Ramadan is a good example of and health laws in detail, and response. It is like the game of how local medical practice needs to ultimately adapt to the way medicine Chinese Whispers, where one person consider religious practices. As fasting is practised here. Both groups are whispers a message to the next in patients are not able to take oral at risk of culture shock if they were line, through a row of players. The medication during the day, doctors thrown head first into the wards and resultant message often becomes need to adjust their prescriptions to clinics. Our highly stressful work modified far beyond its original allow a twice daily dosage. environment is like the deep end of composition and meaning as the Foreign-trained doctors would a learning pool, and trying to stay message gets passed on. also need to brush up on their afloat will be a huge struggle for any knowledge of our healthcare foreign-trained doctor who joins the Even though more Singaporeans are now able to converse in English system, finance and regulatory system. The stress and anxieties, framework. The legislative along with the risk of medical error and doctors can often do without a translator, communicating requirements that apply to doctors from trying to quickly assimilate include the Medical Registration should be minimised, even if it with Singaporeans can still be a colourful affair. Act, the Private Hospitals and cannot be entirely avoided. Medical Clinics Act, Infectious Uniquely Singapore Diseases Act, Poisons Act, to name Indeterminacy of just a few. The “3M” of healthcare translation Our language is both a source of national pride and academic scorn financing, Medisave, MediShield Good communication is a critical Life and Medifund, are constantly component in any relationship, and among Singaporeans. On the surface, a native English speaker evolving and can be confusing even this is especially true in the doctor- for medical professionals. patient relationship, which is based will find it easy enough to navigate our streets and buildings due to on trust and mutual understanding. Role of SMA If predominantly English-speaking the universal use of English in our signs and notice boards. The Since 2011, SMA has been organising foreign-trained doctors had difficulty seminars for foreign-trained doctors with communication in an English- spoken language, however, often presents a challenge. Not only do to provide insights into the Singapore speaking country such as the UK, healthcare system and help our there would doubtlessly be language we speak Singlish, which can be challenging to figure out by itself, colleagues assimilate into our society. barriers in a multi-ethnic country The problem is that these doctors such as Singapore. but we often speak it at a rapid rate, which makes it even less enter our system at different times and Doctors who speak a foreign comprehensible. On top of the four have varying needs. While a half-day language have the option to use official languages, dialects such as seminar is useful as an introduction to translators to help them overcome Cantonese, Teochew and Hokkien local culture, it is difficult to reach out barriers in communication. are also frequently used among to the vast majority of foreign-trained Unfortunately, translators are far Chinese speakers. doctors. A more formalised approach, from ideal and cannot replace the with courses on health law, ethics and intimacy of a direct exchange. We The practice of medicine in our professionalism held at regular intervals, know that the presence of a third local context is subject to cultural would be better placed to serve the party in a confidential setting such and religious norms among our needs of this group of doctors. population. Traditional Chinese as a medical consultation will alter The process of assimilation takes the dynamics of the encounter. Medicine (TCM) is widely available in Singapore and many patients, personal time and effort. Foreign- Patients are less willing to speak up, trained doctors should join a especially regarding their personal both Chinese and non-Chinese, regularly see TCM practitioners or voluntary professional organisation problems, or raise questions that such as the SMA and make use of they perceive to be embarrassing. take traditional medicines for relief of symptoms. The philosophy of the many educational seminars and American philosopher Willard van TCM is very different from that of social events to establish connections Orman Quine coined the term Western medicine, and is based on with our local doctors, who are very “indeterminacy of translation” the principle of yin and yang. For willing to help them navigate the and argued that it is impossible example, patients often relate their intricacies of our local culture and to communicate the full extent symptoms to the notion of internal healthcare landscape. of one’s intended meaning in balance, and may ask doctors if another language. This is because their symptoms are due to “heat” Reference an individual’s understanding of or “cold”. Use of over-the-counter 1. National Clinical Assessment Service. Concerns language is dependent on his or traditional medication, such as pi about professional practice and associations with her native language, which is in pa gao for cough and po chai pills age, gender, place of qualification and ethnicity - turn shaped by that individual’s for gastrointestinal ailments, is also 2009/10 data. Available at: http://www.ncas.nhs. uk/publications/. cultural and societal upbringing. widespread. Doctors practising The presence of a translator makes in Singapore need to have a good communication one step removed knowledge of local alternatives

Jan 2016 / SMA News 12 COUNCIL NEWS

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

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

We agree with the Ministry of Health that there is a need to assimilate the medical professionals from abroad into the local environment. SMA Offers Foreign-trained doctors include both foreign doctors and Singapore doctors Programmes trained overseas. The percentage of foreign-trained doctors in Singapore has grown slightly, from 36.45 per cent in 2011 to 41.42 per cent last year. to Help The SMA started organising seminars for foreign-trained doctors in 2011, as Singapore is unique in its customs and practices.

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

We hope that foreign-trained doctors who currently do not voluntarily join Doctors medically related professional bodies, which can help them understand local contextual issues and interact with the local medical fraternity better, will find Assimilate Here the SMA and our educational outreach and development programmes helpful in understanding the local culture and clinical practice environment. This letter was first published in the Straits Times Forum Dr Wong Tien Hua page on 28 November 2015. President Singapore Medical Association 56th SMA Annual General Meeting

Date : Sunday, 17 April 2016 Time : 2 pm–4 pm (Buffet lunch In summary, please submit the following documents lease P r will be served from 1 pm) to the Honorary Secretary by 12 noon on 1 March ark you Venue : Alumni Auditorium, Level 2016 (Tuesday): m ar calend 2 Alumni Medical Centre, 1. Your letter, if you wish to propose Resolutions and Singapore 169850 Constitution Amendments [Article XI Section 1(iii) and Article XII Section 2, SMA Constitution] E-Annual Report: The SMA Annual Report 2015-2016 and 2. The Nomination Form if you wish to nominate candidates audited Financial Statements ending 31 December 2015 will to fill the ten vacancies in the 57th SMA Council [Article move from print to electronic platform as part of SMA’s ongoing VIII Section 3a, SMA Constitution]. The Form is circulated efforts to support environmentally sustainable practices by with the Notice of AGM in the January mailbag. reducing our carbon footprint. Members can access and read 3. The Response Slip (which is also circulated with the the Annual Report and Audited Financial Statements from the SMA website. A downloadable PDF version will be made Notice of AGM in the January mailbag) to available online, for members who wish to print a hardcopy for (a) Request for a printed copy of the Annual Report your own reference. (b) Confirm your attendance for AGM and to sign up for AGM lunch. Members who prefer to receive a printed copy may submit your request by returning the AGM Response Slip to the SMA Secretariat via fax: 6224 7827 or email: [email protected], or respond DR DANIEL LEE HSIEN CHIEH online: https://www.sma.org.sg/agm by 1 March 2016. A limited Honorary Secretary quantity will be printed for mailing to members upon request. 56th SMA Council

SMA News / jan 2016 EVENT 13

For the past three years, SMA has popcorn and drink combo set. Tickets 2 been organising annual Members’ to the premiere screening were sold Appreciation Nite events that aim to out within three days after registration give recognition to individuals who was opened to our members. have contributed to the Association’s work throughout the respective year. Over 510 guests attended this year’s From 2012 to 2014, SMA Members movie screening. Some guests were able to catch up with old arrived as early as 5 pm to secure friends from various specialties and better seats within their allocated institutions at the premiere movie section of the theatre. Everyone screenings of the Hobbit trilogy. was hyped up to be the first few in The Association also hosted our Asia to catch the premiere of what committee members, volunteers and was easily the most talked about SMA Charity Fund's donors at these movie for the year. Amid excited events, in appreciation of their time chatter among our guests at the 3 and dedication to the work of SMA. cosy ticketing area at Shaw Theatres Since the Hobbit film series ended its Balestier, we spotted a few Darth run in 2014, we chose a movie of the Vaders and plenty of light sabers more long-running, intergalactic sort among the enthusiastic crowd! for 2015. We are pleased to say that SMA now The SMA Members’ Appreciation represents more than 7,500 doctors Nite 2015 was held with the premiere and medical students in Singapore screening of the long-awaited Star as well as overseas. Together, we Wars: The Force Awakens movie on look forward to advocating for a 17 December at 6:30 pm, at Shaw better healthcare environment, for Theatres Balestier. All SMA members doctors, for patients. If you have were entitled to purchase a pair of any exciting new ideas for next PROFILE tickets at a discounted rate from our year’s Members’ Appreciation TEXT BY website, approximately two months Event, do share them with us at before the event. Each pair of tickets [email protected]. And may also included a complimentary the Force be with you in 2016! Mellissa Ang

Senior Executive, 1 Membership Services

Legend 1. Complimentary popcorn and drink combo sets ready for collection 2. The Force is strong with this one! 3. Star Wars figurines greeted guests at the registration counter

Jan 2016 / SMA News 14 interview

R IJ U A N A A M

Y E ? S o r N O

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

I believe that there are better ways PROFILE Dr Ravindran Kanesvaran (Oncologist) to cope with the stressful living in Singapore than to resort to the Marijuana (also known as cannabis) recreational use of marijuana. is a plant grown in some parts of There are very few pros to medical the world for its medicinal value and marijuana. We have so many good oftentimes, consumed recreationally antiemetics for CINV that there for its psychotropic effects. Its is little reason to consider using use for medicinal purposes dates marijuana or cannabinoids. I can back more than 3,000 years. The only see housing agents benefitting text BY cannabis plant produces a resin from this, because if it is approved, containing psychoactive compounds it may boost the rental market as Dr Ravindran called cannabinoids. The highest people rent spaces to grow the plant. Kanesvaran concentration of cannabinoids is My main concern is that marijuana found in the female flowers of the may become the drug of choice for plant. Clinical trials conducted on abuse even if it’s strictly regulated. Dr Ravindran Kanesvaran medicinal cannabis are limited. The is a medical oncologist US Food and Drug Administration As mentioned above, with the at the National Cancer (FDA) has not approved the use of new generation of antiemetics for Centre Singapore cannabis as a treatment for any CINV, there is little role for medical who specialises in GU medical condition. However, FDA marijuana use for the patients I treat oncology and has an has approved two cannabinoids interest in Geriatric in oncology. There is also limited Oncology. He is currently (dronabinol and nabilone) for use in data for its use to treat other cancer- the President of the SSO chemotherapy-induced nausea and related complications. (not the great Singapore vomiting (CINV). Symphony Orchestra Dr Adrian Wang but the lesser known Marijuana has been found to (Psychiatrist) Singapore Society have a number of medicinal uses. of Oncology). In oncology, its main indication I think the evidence base for the overseas has been in CINV. There medical use of marijuana remains have been three small studies using limited. While it may help in pain cannabis for this purpose and only control and nausea, its effects one of the three showed any benefit remain unpredictable and it's difficult when compared to placebo. As to decide if the benefits outweigh the far as I know, there is no data to risks. The risks are that it can trigger support its use for other cancer- psychotic reactions and may cause related symptoms such as pain or cognitive and memory impairments. poor appetite. There is also a possible link between

SMA News / jan 2016 Interview 15 cannabis use and schizophrenia in I feel that evidence of the benefits of PROFILE young people. medical marijuana, even in the areas of pain management, remain limited. I am also worried that some people may use medical marijuana as an The most prominent effects of excuse for recreational use. Some marijuana are mediated by receptors people may think that recreational in the brain. Acute intoxication is use of marijuana is harmless, but its characterised by euphoria, loss of long-term effects have not been fully short-term memory, stimulation evaluated. In addition to the adverse of the senses and impaired linear effects I have mentioned, there is thinking. Adverse effects include TEXT BY some evidence that long-term use depersonalisation and panic attacks, can lead to dependency, chronic while common physical effects include Dr Adrian Wang states of intoxication, and cardiac and increased heart rate and reddened respiratory problems. There is also conjunctivae. Use of marijuana in the possibility that marijuana may be chronic, high doses may cause subtle Dr Adrian Wang received a "gateway drug" that can lead people cognitive impairments that appear to his MBBS from the National University of to experiment with harder drugs such be long-term, though the duration of Singapore in 1990 and as cocaine and amphetamines. impairment is unknown. Marijuana Master of Medicine use may be a risk factor for the (Psychiatry) in 1996. He The pros of medical marijuana are development of cognitive impairments has also received training that for a selected group of patients, in individuals with underlying mental in the treatment of bipolar such as those with cancer or chronic illness. Although marijuana causes disorders at Stanford pain conditions, it may alleviate dependence, the addictive power and University. Before commencing private suffering. We will also need a new withdrawal symptoms produced are practice at Gleneagles set of prescribing guidelines to mild compared to cocaine, alcohol, Medical Centre in 2005, provide doctors with a framework on heroin and nicotine. he was Chief of the prescribing it safely. Department of General With relevance to my practice and Psychiatry at the Institute Although there are some evidence as evidenced in animal testing, of Mental Health, and that marijuana may help with cannabinoids reduce hyperalgesia and the Chief CARE Officer of the National CARE depression, anxiety and bipolar allodynia associated with formalin, Management System. disorder, these are not strong capsaicin, carrageenan, nerve injury His main area of specialty evidence. The risks may outweigh and visceral persistent pain. Two is the treatment of mood any potential benefits. Thus for now, I obvious targets are spasms in multiple and anxiety disorders. cannot think of any strong compelling sclerosis and resistant neuropathic reason to use it in the patients I treat. pain. The dose administered should be the minimum quantity, repeated four Dr Alex Yeo or six hourly and gradually increased (Pain Specialist) until relief is attained.

The recent interest for wider access to According to FA Campbell’s study on cannabis or cannabinoids as analgesic the effectiveness of cannabinoids in chronic painful conditions seems in pain management, the best TEXT BY to be logical. It is true that the human analgesia achievable with single- body contains cannabinoid receptors dose cannabis in nociceptive pain Dr ALEX YEO in the central and peripheral nervous is equivalent to single-dose codeine system, although the functions of 60 mg, which rates poorly on relative these receptors and their endogenous efficacy compared with non-steroidal ligands may still be unclear. The Dr Yeo Sow Nam is anti-inflammatory drugs or simple Director of The Pain debate on legitimising the use of both analgesics. However, raising the Specialist, Mount Elizabeth the natural chemicals that act on cannabinoid dose to increase the Hospital. He was trained cannabinoids receptors and synthetic analgesia would result in more at the Prince of Wales cannabinoids has been ongoing for adverse effects. Compared with the Hospital, Sydney and was the first in Singapore to many years. In Britain, doctors used relatively negative analgesic results to prescribe cannabis. In a survey obtain accreditation in in nociceptive pain, the suggestions the pain management conducted in 1994, 74% of UK doctors of cannabinoids’ efficacy in spasticity specialty, awarded by indicated that cannabis ought to be and neuropathic pain are perhaps the Australian and New available on prescription. To date, the more intriguing, as the therapeutic Zealand Faculty of Pain synthetic, nabilone, is the only legally need in these areas is greater than Medicine. He was the first Fellow of Interventional available cannabis preparation in in postoperative pain. To date, there the UK. It is licensed solely for use Pain Practice (USA) is insufficient evidence to support in Singapore. in nausea and vomiting induced by the introduction of cannabinoids into chemotherapy. Recreational smoking widespread clinical practice for pain My special thanks to Ms Mabel of cannabis in the 20th century and management, although the absence of Poon Lee Shin, my clinic the consequential restrictive federal evidence of effect is not the same as manager, for her kind assistance legislation have functionally ended the evidence of absence of effect. in preparing this article. all medical use of marijuana. Overall, Jan 2016 / SMA News 16 insight A Glimpse

intoMedicine the in Singapore (PartPast 5) 1920 to 1933: A New College Building, Students’ Club, School of Pharmacy This is the fifth instalment of a series on the history of medicine in Singapore.

1

In 1920, approval was given to build of Anatomy and an extension of the Medical Council is now situated), the a new College building, designed by building housed the dissection room. Department of Biochemistry, a student Major PH Keys. The foundation stone laboratory and the Department of was laid on 6 September 1923 and The first floor of the COMB housed Materia Medica (pharmaceutics and the new building was opened officially the Council Chamber, the Principal’s pharmacy). The mezzanine floor was on 15 February 1926 by the Governor Chambers, administrative and part of the library. Services provided of the Straits Settlements (SS), department offices, the Keith Museum by the library were rather limited, and Sir Laurence Nunns Guillemard. After (which later housed the Medical Library students were allowed to take out the completion of the College of located in the centre of the first floor, in certain books on long-term loan as Medicine Building (COMB) in 1926, an 80 ft by 26 ft room) with courtyards personal textbooks, for books were a the Tan Teck Guan Building was on either side (one courtyard was rare commodity in those days. On the then occupied by the Department near where the pond at Singapore second floor, there was a main lecture

SMA News / jan 2016 insight 17 hall (later the New Lecture Theatre), two to the Alumni Association of King standing was acquired for the Central lecture rooms (later Allen and Farris Edward VII College of Medicine. (The Expressway and the association moved Lecture Theatres), the Department name was further changed to Alumni temporarily to Houseman’s Quarters. of Biology and the Department of Association of King Edward VII College On 3 August 1988, Dr Kwa Soon Bee Bacteriology with its Bacteriology of Medicine and Faculty of Medicine, (then Permanent Secretary for Health Student Laboratory. Level three housed University of Malaya, in 1952.) In 1948, and Director of Medical Services, the Department of Physiology. There the association formed a building appointed 1984, retired 1996) assisted was no central staircase; instead a pair subcommittee to look into the building the association with obtaining the use of staircases led to the mezzanine floor. of a clubhouse. An application was of the old Department of Scientific made to the Government, in 1952, Services Building at the junction of The building’s design, the work of for the lease of a site in the General College and Outram Roads. The Alumni architects Keys and Dowdeswell, Hospital (GH) compound. The Association building was renovated is reminiscent of classical Greek application was approved and a 99-year and occupied in December 1989, and monuments such as the Acropolis lease on the site was granted at an officially opened by Dr Kwa on 21 July of Athens. Allegorical bas-relief annual rent of $1. On 3 April 1954, the 1990. Later, the Association Alumni and sculptures and moulding on both foundation stone for the association’s the Gordon Arthur Ransome Memorial sides of the facade depict the teaching building given by the Government was Fund Committee (of which Dr Chee and practice of medicine. These laid by the Director of Medical Services, Phui Hung was chairman), presented were conceived by the Italian artist, Dr WJ Vickers. On 10 October 1955, the the Ministry of Health with two large Cavaliere Rudolfo Nolli (who also Medical Centre at GH on 4A College oil paintings, which now hang at the designed similar ornamentation on Road was officially opened by the Vice- COMB. When the Alumni moved out of the facade of the Old Supreme Court Chancellor, Sir Sydney Caine. In the its building in 1988, Dr Chen’s billiard building), and executed by Mr J Sharpe early years, the activities were limited table was transferred to the Singapore Elliot. The sculptures are surrounded because graduates were scattered all General Hospital Recreational Club by moulded plastered architraves with around Malaya. (doctors’) lounge, while the first table a circular motif. The building is fronted was transferred to the Pathology by eleven sculptured timber doors. In January 1957, the Constitution was Department’s Recreational Club. The These doors stand behind the fluted changed and the association was first table was eventually refurbished columns of the Doric colonnades. Over reconstituted with three branches: to its original state in 1994 and the central doorway is a bas-relief Northern, Central and Southern. In restored to its rightful place in the of a Roman eagle, which classically the 1960s, the centre was renovated, billiard room of the Alumni building, signifies a civil or official building. and housed the Singapore Medical courtesy of Tun Dr Mahathir. Association (with Dr Arthur Lim as In 1920, the Medical Student’s President), the Academy of Medicine, In 1924, the College was apparently Recreation Club began publishing a the College of General Practitioners, briefly closed.2 The closure partly student magazine, The Medico, for a the Singapore Dental Association, the reflected the anti-colonial attitude in period of four years. In one issue, Pharmaceutical Society of Singapore, Malaya, grouses between European Prof CJ Smith had this to say about the and the Singapore Government Medical staff of the College and GH and the local medical students: “The students and Dental Officers’ Association. principal Dr GH MacAlister, as well as a here, compared with those at home, The Centre had a lecture theatrette, lack of dialogue between the European were too gentle and timid, and their swimming pool and dining facilities administrative staff of the College manners were too good for medical (the caterer, Ah Foo, was said to have and the students. The precipitating students.” Around 1921, there was a first been curt to everyone in his broken event was a trivial one. One night, a attempt to form a corporate medical English). The lecture theatrette’s slide student violinist and saxophonist of body, and the Graduates Association projector and sound system were the Federated Malay States (FMS) was founded with Dr EW de Cruz as under the charge of a Malay man Hostela at Sepoy Lines started playing president. However, it became defunct.1 named Bakri, who was remembered tunes, attracting the attention of as being very quiet. Doctors who the European sisters staying at the The Students Medical College attended talks at the theatrette called nearby Sister’s Quarters, who lined Graduates Association was inaugurated him MOHD (most observant house up and cheered. Someone (who was on 5 September 1923 by a group of doctor), because he sat through all the probably opposed to fraternisation with graduates of the medical school at a meetings and lectures. the natives) informed Dr MacAlister. meeting of the fifth Congress of the He put up a notice that such un- Far Eastern Association of Tropical In the basement, there were two billiard gentlemanly behaviour should cease Medicine in the Victoria Memorial Hall. tables. One table was bought from and the notice was slashed. This led It was managed by a committee of 12 the UK with funds donated by two to the student representatives of the with Dr Chen Su Lan as the president. doctors from Penang, Dr Mahathir FMS Hostel and the Medical College The main aim of the association was from Kedah and Dr Tow Siang Yew. Union being summoned and told off to make the College a University and The second table was later donated by the principal. The following week, to elevate the status of its graduates by Dr Chen Su Lan. The billiards the students decided to boycott a from assistant surgeons to medical room had an attendant, Ah Poh, who social event in which the Governor officers. On 27 December 1930, at a demonstrated snooker tricks. Annual would be giving away sports prizes. meeting held at the Europe Hotel, the reunions began in 1963. In 1985, The College Council, however, took the name of the association was changed the land on which the Centre was view that the students, in absenting

Jan 2016 / SMA News 18 insight themselves from the function, had In 1926, Dr JC Tull succeeded PROFILE insulted the Governor and, in turn, His Dr Finlayson as the next Government Majesty the King. The College was thus Pathologist. He was also the honorary closed and the students expelled from physician to the Governor of Singapore. the hostel. Later, some non-hostelite A chair in Pathology was created at students apologised to the principal King Edward VII College of Medicine, and the College was re-opened. A and Dr Tull concurrently held the Chair in Commission of Enquiry set up by the Pathology until his retirement in 1936. College maintained that the students had indeed insulted the King, and In 1928, the SS Government appointed text BY meted out severe punishment to the its first pharmacist, Mr T Roebuck, at the students involved. One student was GH, and the Medical College appointed expelled from the College, some were him as its lecturer in pharmacy. In 1929, A/Prof suspended for one year, many for six the School of Dentistry was established months, and all those due to sit for in the College and produced its first Cuthbert Teo their examinations were prevented dental graduates in 1933. from doing so. Editorial Advisor The 1929 class of medical students The Department of Bacteriology was was the first batch to undergo the A/Prof Cuthbert Teo is established in 1925, led by Prof A Neave six-year medical course initiated at the trained as a forensic Kingsbury.3 Besides activities such recommendations of the GMC. Among pathologist. The views as teaching, routine bacteriological the graduating students were Drs ES expressed in the above article are his personal diagnosis and vaccines production, Monteiro, Benjamin Sheares (born 12 opinions, and do not research work was also performed on Aug 1907, Dr Sheares became Malaya's represent those of viral diseases and leprosy. first local professor of obstetrics and his employer. gynaecology in 1951, and Singapore's In 1926, the College and its hospitals second President on 2 January 1971, Photos by SGH Museum were inspected by Sir Richard an office he held until his death on 12 Needham, Inspector of the General May 1981), N Amad, RG Gunatilika, Lim Medical Council (GMC). In his report, Eng Cheang, Benjamin Chew (founder Legend Sir Needham told the GMC that, in of the Singapore Anti-tuberculosis 1. Lecture room, College his opinion, the graduates should be Association) and AW Moreira. of Medicine awarded the MBBS because of the high 2. Council Chamber, standard of the College. He wrote: “In In 1933, Sir Richard Needham inspected College of Medicine as much as the Singapore diploma is in the College, and again he reported its no way inferior to the recognised MBBS high standards to the GMC. In 1934, the degree, the letters ‘LMS Singapore’ Registration of Pharmacists Ordinance frequently give the wrong impression, was passed, establishing a Pharmacy at all events to the public, of the Board. When the Ordinance was enforced professional status of the holder. In in 1935, 42 persons were registered as course of time no doubt a university pharmacists. In October 1935, the College will be established in Singapore which introduced a Diploma in Pharmacy will provide for the students of the course, and in the same year, the School College an MBBS degree.” of Pharmacy was established.

References 1. Soh CS. The Alumni Story. In: Lim KH, ed. At the Dawn of the Millennium: 75 Years of Our Alumni. Singapore: Singapore University Press, 2000:49-52 2. Sandosham AA. Old Times at King Edward VII College of Medicine. In: Lim KH, ed. At the Dawn of the Millennium: 75 Years of Our Alumni. Singapore: Singapore University Press, 2000:218-24. 3. Taylor MB, Chow VTK. The Evolution of Teaching and Learning Medical Microbiology and Infectious Diseases at NUS. Annals Acad Med 2005; 34(6): 98C-101C.

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

SMA News / jan 2016 EULOGY 19 ­In Memory of Prof Feng Pao Hsii: Rheumatologist Extraordinaire Text by Prof Fong Kok Yong, Senior Consultant Rheumatologist, Department of Rheumatology and Immunology and Chairman, Medical Board, Singapore General Hospital

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

In 1969, he went to Israel for further training under the auspices of the World Health Organization Research Fellowship and is still well remembered by friends there. Prof Yehuda Shoenfeld wrote, “I am so sorry to hear about the demise of Prof Feng, a great and long-time friend who not only did so much together with us Prof Feng is indeed the Father of my last conversation with him on but was a real friend of Israel, having Rheumatology and SLE in Singapore. 28 November 2015; we talked about been trained in our country. The world family, kids, our Singapore society without Prof Feng will be different. I While he was a high achiever, he and politics, overseas friends, his will cherish him in my heart.” also paid attention to individuals health and yes, the training of younger under his charge. Dr Chew Li Ching rheumatologists. On 24 December, Indeed the rheumatology world will be vividly remembers, “Prof was also a the sky opened and poured for more different without Prof Feng. He was a gentleman with a caring heart. I recall than half an hour before the sea man of few words, but when he spoke, when I first set foot in Singapore, he burial could proceed. Prof Feng will we listened. When he had a vision, frequently enquired if I had settled be remembered as a visionary, an he brought it to fruition. That was in and was happy in my work during academic, a mentor, a caring boss, a how rheumatology started as a new the early days. And in the latter years, family man and a great friend to all. discipline in 1986 — advancing from when the kids came along, he would aches and pains to one dealing with often ask how they were doing and the diverse nature of autoimmunity even remembered their names. He like lupus. In the same year, the was a great man who had a big heart.” Prof Feng Pao Hsii was an SMA National University of Singapore Honorary Member and served as awarded Prof Feng with an MD for his In the last two years, frail health the Editor-in-Chief of Singapore work, Systemic Lupus Erythematosus hindered his mobility, but his mind Medical Journal from 1978 to 1987. (SLE) in Singapore — A Clinical Study. was just as sharp and seeking. I recall

Jan 2016 / SMA News 20 gp matters

Family Medicine Setting the Pace Ahead

2015 has been an exciting year for uncommon. Yet, their passion for “Hi, Dr Leong, I have me. I have had the joy of hosting research is undaunted. This passion applied for family medicine Dr Eugene Chua, a FM resident is contagious. attached to my clinic during his third residency. Could you be my year in medical school. I am also In November, I spent a week Down character referee?” beginning to see a bountiful harvest Under, giving my full attention to my – Victoria, my first LPE student from my years of advocating for FM family, especially the children. After among the pre-med and medical watching sunsets for the third day students, trainees and residents. in a row, we got bored. I decided It is especially comforting when I to drive 300 km to the Wheat Belt “Dr Leong, I have decided receive texts from students who in Bruce Rock to have lunch with enquire about FM residency or ask my classmate, Dr Caleb Chow, who to apply for family me to be their referees for their moved to Australia not long after medicine residency.” residency application. Even my son, we completed our bond. Caleb will – Fei Yee, my student from family who dreams of a medical career, share his story in another instalment medicine (FM) elective student wants to be a GP! of this column, so that we may draw lessons from his experiences.

Optimising the Visiting Caleb in the Wheat Belt opened my eyes to what a GP’s work “Oh, Dr Leong, just wondering, GP potential is like there. I also saw real integrated have you submitted the Before I get too carried away, I was care in action. Caleb is the only referee documents for my reminded that Singapore GPs have GP in town, and his clinic caters to much to do before we can be on par residency application?” everyone, from the youngest to the with our contemporaries overseas. oldest. He performs minor surgeries, – Ken, my Graduate Diploma in manages the hospital ward, looks FM trainee At the time of this writing, our very after patients with dementia in the motivated counterparts up north nursing home and counsels those were having their annual primary who are stressed out. He does care research conference in Kuala preventive medicine, conducts health “Dr Leong, I am thinking of Lumpur. It is their belief that, through talks to the residents of the town switching my residency from sharpening their research skills, they and administers vaccination. He can bring out the best in primary exemplifies a healthy lifestyle. internal medicine to family care. We face similar challenges as medicine, what do you think?” our Malaysian colleagues — many Interestingly, he also started a cafe – Shy Xian are solo GPs in private practice, while to encourage social interaction. some work in government-funded He plants vegetables and rears clinics where long waiting time is not chickens and fish in his backyard.

SMA News / jan 2016 gp matters 21

His staff even help to look after an organisations (VWOs), schools PROFILE orphaned baby kangaroo! “Is Uncle and even resident committees. My Caleb a doctor or a vet?” my daughter good friend, Dr Ang Seng Bin, is quipped at the sight. a fine example for us to emulate. He is the vice-president of the National Council for Social Services Reflecting and and chairs the Ang Mo Kio Family giving thanks Service centre. Besides VWOs, we can also TEXT BY for 2015 consider volunteering our services So, what have we GPs done for at Singapore Medical Council or ourselves, the fraternity and the public? Dr Leong Choon Kit professional bodies such as the SMA, Academy of Medicine and As we start a new year, it is timely College of Family Medicine. Editorial Board Member for us to reflect on and give thanks for our accomplishments in 2015, Establishing primary Dr Leong Choon Kit is a and plan on what to achieve for care research GP in the private sector. ourselves, our family, our colleagues He is an advocate of the and the public in the year ahead. Research in primary care is an ideal doctor which is unexplored field, with many gems exemplified by one who waiting to be uncovered. The results is good at his clinical Collaborating with practice, teaching, Regional Health Systems will help shape better management plans for the public. Private GPs are research and leadership (RHS) in the society. His idea of sitting on these gold mines. Our polyclinics and hospitals are social leadership includes bursting at the seams. GPs in private contributing back to I concede that research is the society and lending a practice can definitely help offload last thing on my mind as a solo voice to the silent. their patients. Many hospitals and private GP. However, we can always their respective departments are collaborate with polyclinics and the Disclaimer: exploring and experimenting with RHS to achieve this. I often dream The names listed in the shared care models. While it can be messages are not the real of emulating Dr Tan Ngiap Chuan, frustrating and slow in getting these names of the students. a GP who also focuses on primary schemes to work, it is important care research. for us to play our part. It also gives us the chance to understand the Teaching FM from young challenges our colleagues encounter Achieving the abovementioned will in the public institutions. certainly help to bolster the standing Reaching out to foreign of the fraternity and increase the colleagues public’s confidence in their GPs. However, the most important thing is It has been reported that Singapore replicating this reality. faces a shortage of doctors and that an increasing pool of foreign doctors Primary care is crucial in improving are among us. It might be a good idea our healthcare system. Besides for us to reach out to them and help supporting the public sector in them assimilate into our society and serving the population and aiding healthcare system in the year ahead. our foreign doctors to adapt, we Making FM attractive should also challenge the younger generation to take up FM as their It is a sad fact that many parents lifelong career. prefer their doctor children to become specialists. I have even To do that, we must teach, shape heard of colleagues whose spouses and inspire the next generation of refused to talk to them after they doctors, like my friend, Dr Teo Boon had chosen FM as their specialty. It See, a GP in private practice and a is really up to the GPs to make our professor in FM. specialty more appealing. Hopefully, by this time next year, we In my opinion, contributing more to can reflect and be thankful that we our society may improve the public’s have inched forward and upward a perception of GPs. We can chip in tiny bit. to help at various voluntary welfare

Jan 2016 / SMA News 22 Opinion on call and feeling stressed!

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

Dr tan yia swam 2. People: relationships with partners, Stress spouses, parents, children, Dr Tan Yia Swam is an Stress comes in many forms, and neighbours, maids — all these are associate consultant at manifests in many ways. I broadly already stressful enough. In our the Breast Department classify them into happy and upsetting line, we usually see people who of KK Women’s and stressors, and will be discussing only are at a bad spot in their own lives Children’s Hospital. She the latter in this article. Each group (like illness or tragedy) and these continues to juggle the commitments of being can be further divided into three frazzled individuals often need a doctor, a mother, a main categories: personal, people to vent their anger on someone, wife and the increased and events. Examples of upsetting so it is no surprise that healthcare duties of SMA News stressors include: staff end up bearing the brunt of Editor. She also tries it sometimes. to keep time aside for herself and friends, both 1. Personal: mental and physical old and new. ailments — eg, a minor illness like 3. Events: car accident, MRT an upper respiratory tract infection breakdown, air-con leaking, or being (URTI), or something more serious late for work. Anything can be a like a stroke/cancer. Doctors are stressor, including major life events just as prone (maybe even more such as marriage, divorce, birth, so?) to some forms of mental death and travel. illness, for a multitude of reasons.

SMA News / jan 2016 Opinion 23

Manifestations Coping Before the call We all show stress differently. The I envy some people who seem to cope • Sleep early the night before trick is to recognise it in ourselves, with stress very well. No anger, no • Post a little prayer/plea on and in each other. Try not to be too sleep problems, no worries. One dear Facebook/Twitter for a good call smug when telling your stressed- friend, who’s like that, tells me: “It’s easy, • Check who your team out, burned-out colleague: “Oh, people who irritate me are all stupid and partners are, who the covering just relax lah, what’s there to be beneath me, so why stress? Things just consultant is, and who the stressed about?” You may not happen, just go with the flow!” I was admitting senior doctor in the know the full circumstances of that amazed to hear that, not just from him, emergency department is person’s stressors. It’s also difficult but also from a few others who seem • Charge handphone battery! to recognise when you are the main very chill and relaxed ALL the time! I stressor for someone else! But the won’t say I agree with their views but it situation should become obvious sure is a refreshing perspective! During the call when the other person tries to avoid • Don’t wear red underwear you because you scold him/her Gillian wrote a great article on stress • Don’t ever brag about how too much. A much more sinister and coping in the 2015 April issue relaxed one is (“Wah! EOT no type of stressful colleague is the (https://goo.gl/D0EVXR), so I would like cases ah?) one who pretends to be concerned to focus specifically on what’s unique • Abide by food restrictions for you, but is secretly prying your to our field: what is more stressful than (the list is as extensive secrets out and feeding them to being on call? Being the solo warrior as confinement practices the boss (ie, backstabber or sh*t- against heaps of changes to be done? and merits its own table stirrer). What’s scary is that he/she (Or so it feels on most days!) given below) is not even aware of the harm he/ • Bathe early (to wash away she is causing! Here are the various I have heard of so many practices bad luck) versus… manifestations of stress: and superstitions that doctors have • Don’t bathe (so as not to give devised to cope with a stressful call, the impression that one is free) 1. Psychosomatic: this one no need some unique to certain disciplines/ • Don’t take the “last” lift, ie, the to explain right? Diagnosis of departments/hospitals — do write in one furthest down the corridor exclusion. But fellow doctors, be (email: [email protected]) if you have • Bring an extra battery mindful not to UNDER-diagnose more that weren’t mentioned! and charger yourself, ie, brush off symptoms • Don’t lose your piece of paper until they blow up in your face! Despite priding myself as a thinking, with changes and admissions! modern, scientific woman, I did start 2. Physical: stress ulcers! Classical. observing some of these customs after Frequent URTIs. Musculoskeletal learning about them in the past… and After the call aches and pains. Menstrual the habits have lasted till today. Those • Hand over on time and go off upsets. Erectile dysfunction? of you who no longer do calls — do you post-call in a timely fashion find this nostalgic? Those still on call, (if your department has such 3. Mental: anxiety, anger, do let us know how these work for you! a culture) depression, insomnia, • Enjoy a facial/massage hallucinations (eg, hearing phone I hope this simple write-up was a wee • Enjoy a movie ringing or patients crying in call bit helpful, and will inspire you to read • Enjoy a good meal room), thinking that colleagues up more relevant, scientific articles on • Go back and sleep are talking bad about you (but stress and coping! Keep healthy, • Go exercise then, this COULD be true…). stay sane! • Make requests never to be on call with xxx ever again!

Food to eat during call Food NEVER to eat during call

• Coke Light or Coke Zero • Chilli and spices (in case of diarrhoea) (to reduce admissions) • Chinese bao (as it may mean for one to • Green tea (for good luck) “bao”[or “do”] everything, may also refer • Kopi-o kosong (ie, black coffee only with to a shroud) NOTHING else) • Beef (or “niu rou” in Mandarin, which sounds • In general, eat when you can because you like “neuro” — heard this from neurology and won’t know when the next meal will be neurosurgery colleagues) • Pineapple tarts (as this brings in “prosperity” and “business”)

Jan 2016 / SMA News 24 professionalism

Clinical Incident Management – Professionalism in Risk Management

What are clinical Seeking information and or the hospital after an unexpected closure adverse event. incidents? The patient and relatives will want A clinical incident is any unplanned to know how and why the event What is Clinical Incident event during the medical care of a occurred.2,3 They will want the patient, which causes, or has the doctor-in-charge or a senior doctor Management (CIM)? (in contrast to a house or medical potential to cause, unintended or CIM is an open disclosure process 1 officer) to explain what had happened unnecessary harm to a patient. that seeks to proactively help doctors and to answer their questions. The incident could be an adverse communicate with patients and outcome where injury or harm is their relatives when clinical incidents caused by medical management Seeking accountability happen. Studies have shown that about or complication instead of the They will want to know if the hospital 10% of patients suffer an adverse event underlying disease, or a near miss has carried out any investigation(s) during hospital admissions; most are or sentinel event (an unexpected to prevent such incidents from system issues rather than the result occurrence involving death, serious happening again. The incident could of the doctor’s negligence.4 Many physical or psychological injury). be a serious reportable event, requiring hospitals may have a service quality the hospital to report to the health department that oversees complaints The following are the consequences authorities and conduct a root cause about services and care, but most of and expectations of patients after a analysis to prevent a recurrence. these complaints, if they arise from clinical incident: adverse outcomes, are not proactively Medico-legal and managed. One of the aims of CIM Seeking compensation malpractice fallout is to take immediate action after an Following an adverse outcome, Legal suits claiming that the doctors adverse event, prevent or reduce future the duration of hospital stay may involved were negligent and complaints harm to patients/consumers, reduce increase, incurring higher costs of to the medical council can arise the likelihood of negligence claims hospitalisation and out-of-pocket following a serious clinical incident. and restore the patients’ faith in the expenses for the patient. The patient hospital. This is especially important, may be unable to return to work for Risk of breach in doctor- as the same studies have suggested a longer period of time, or worse, the patient relationship that about 50% of adverse events may adverse outcome may result in severe be preventable. disability or death. The patient and the family would have lost their trust in the doctor and/

SMA News / jan 2016 professionalism 25

CIM is activated when a clinical event meet to discuss the case and make PROFILE is serious or has potential medico- preparations to meet with the patient legal implications. It works best when and family as soon as possible. the CIM team (eg, from the clinicians, Careful preparations are required, TEXT BY medical board or risk management and include open discussions office) is informed of the incident about the incident, whether there is before the patient lodges a complaint. liability on the part of the doctors Dr Seow Wan Tew Hence, the medical or nursing staff involved (hence the need to involve should alert the CIM office when independent medical experts and Teaching Faculty, SMA they encounter unexpected adverse legal counsel, if necessary), whether Centre for Medical Ethics outcomes or complications during the to admit liability if deemed present, & Professionalism care of a patient. and the wording of an apology or expression of regret to be extended to Dr Seow is a An example would be a laparoscopic the patient. neurosurgeon practising at the KK Women’s procedure ending up as a laparotomy & Children’s Hospital due to bleeding from a vessel injury The discussions will include and at the National during the intended procedure. The information about the patient’s Neuroscience Institute. CIM process is organised to allow the condition, such as the seriousness of He has had some doctors involved to take charge of the the current illness, further treatments legal training and problems themselves, with assistance if needed, treatment duration, duration had been actively from the hospital’s legal department, of disability to work, as well as further involved in medical risk management at KKH and clinical governance, business office follow-up and care. Finally, there is the the NNI. He facilitates and other departments. One common issue of cost and whether the hospital some of the MPS risk request is for the business office to and doctor (through the doctor’s management workshops stop billing the patient until the situation medical indemnity insurance) will waive and has been a member improves, as a patient who has just some or all of the fees. The hospital of the SMA CMEP for suffered an adverse outcome is likely to may also separately conduct an internal several years. be angry and unhappy when presented medical review of the incident to ensure with a bill. an unbiased and accurate review. The findings of this review may be passed Many patients who have experienced on to the patient. serious adverse outcomes, commonly request for medical reports and these should be vetted by the hospital’s Steps in CIM lawyers. Requests for medical reports Acknowledgement and must be addressed in a timely manner, taking responsibility TEXT BY as any delay may be viewed as a lack The steps in a CIM meeting with of respect for the patient and may the patients, with or without Dr T Thirumoorthy raise concerns of cover-up. From a their family members, involve risk management point of view, the acknowledging the seriousness of hospital’s insurers and the doctors’ Executive Director, SMA the incident, followed by an apology Centre for Medical Ethics medical indemnity provider will have to or expression of regret. The apology & Professionalism be informed. would have been carefully crafted before the meeting because of its Dr Thirumoorthy has CIM aims to reduce litigation and medico-legal implications, since been involved in the undue publicity while attempting an apology may mean admitting SMA CMEP for the last to meet the needs of patients and liability or responsibility. When no 15 years and has been their relatives who want answers. Faculty at Duke-NUS admission of liability is offered, the It bridges the communication gap Medical School since apology would be an expression between the patients and hospital by 2007. His teaching of regret on the sufferings that the creating a comprehensive solution responsibilities include patient has undergone. subjects on clinical skills, to ensure prompt, effective and professionalism, medical consistent conversations. Most CIM ethics, communications programmes train senior doctors and healthcare law. He in communication skills to help the Active empathic listening has been practising primary doctors involved handle the Another important aspect involves medical dermatology difficult conversations that are often listening to the unhappiness and at Singapore General encountered after adverse outcomes. difficulties the patient and family have Hospital since 2002. encountered since the incident. Not uncommonly, they tend to experience Comprehensive frustrations with doctors or nursing staff and the care rendered during preparation and following the incident. There may When CIM is activated, the CIM office also be accusations against particular staff and doctors involved typically doctors and/or nurses.

Jan 2016 / SMA News 26 professionalism

Questions about the incident itself In many instances, more than one disclosure conversation between the often need to be answered. These may conversation session with the patient doctor, hospital and the patient and include questions that have been asked and relatives may be required. Each relatives. It is important to ascertain and answered before. New information meeting should be planned as as complete a picture of the adverse will have to be given, especially if a thoroughly as the first one. When event as possible, in a timely manner medical review was conducted. promises are made during the CIM and to reaffirm the patient’s trust session (eg, to provide a report within in the hospital by acknowledging Rebuilding the a certain time period), they should the patient’s difficulties following relationship be followed up and honoured. It is the event. Expressing regret or After the disclosure, the future care important that the CIM team is seen apologising for the situation, and follow-up of the patient will be to be honest, transparent, truthful, responding to the patient’s questions discussed to avoid dis-abandonment. empathic, sincere, and having the and demands, and reiterating the In many situations, the patient may interest of the patient in mind. This hospital’s commitment to care for not want any further association also means the team must be easily the patient, help to rebuild strained with the doctor or hospital, preferring contactable and accessible. Hence, relationships. An offer of financial aid to be cared for by another doctor it is crucial that a reliable staff is through a goodwill waiver may reduce and hospital. The CIM team can appointed to be the contact person the risk of an acrimonious dispute help facilitate this by contacting for the team and hospital. resolution at a later time. the requested doctor and hospital, providing medical reports and making Conclusion When conducted skilfully, CIM can the transfer arrangements. help to re-establish the patient’s trust CIM is a process that aims to in the doctor and hospital, facilitate Finally, there is the discussion about reduce complaints and legal claims the physical and psychological waivers. If the hospital offers a waiver, against doctors and hospitals recovery of the patient, and preserve it is “without prejudice”, given out of following an adverse outcome, the sacred doctor-patient relationship goodwill and does not constitute an by proactively initiating an open that is lost when things go wrong. admission of liability. The question of whether to offer a waiver is always a difficult one; while a waiver may help patients financially through a References difficult time, they may assume that the hospital is admitting liability by 1. Department of Health, Western Australia. Clinical Incident Management Policy. Perth: Patient Safety offering the waiver. Hence, this should Surveillance Unit, 2015. 2. Stephen F, Melville A, Krause T. A study of medical negligence claiming in Scotland. Available at: www. be discussed and agreed upon with scotland.gov.uk/Resource/0039/00394482.pdf. Assessed 10 December 2015. both the hospital’s and doctor’s 3. Vincent C, Phillips A, Young M. Why do people sue doctors? A study of patients and relatives taking legal lawyers. Further, patients who action. Lancet 2004; 343:1609. accept the waiver have to sign a final 4. De Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The Incidence and Nature of settlement agreement. in-Hospital Adverse Events: A Systematic Review. Quality and Safety in Health Care 2008; 17(3):216 –23.

Looking for potential clients and business partners? Advertise with

news

Contact Li Li Loy / Denise Jia at 6223 1264 or [email protected] to book an advertising space now!

SMA News / jan 2016 professionalism 27

Medico-Legal Seminar on Mental Capacity – Assessment & Report Writing for Doctors

30 April 2016, Saturday 1.30 pm – 4.30 pm, Academia Number of CME Points: 2

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

Time Programme 1.30 pm Registration (Lunch will be provided) 2.00 pm Introduction 2.10 pm Patients lacking Capacity (Temporary/Fluctuating) - Dr Nagaendran Kandiah, Programme Director, National Neuroscience Institute Dementia Programme 2.30 pm Overview of Mental Capacity Assessment for Doctors - Prof Goh Lee Gan, Senior Consultant, Division of Family Medicine, National University Hospital & Member, Public Guardian Board, Mental Capacity Act, Ministry of Social & Family Development, Singapore 2.50 pm The Medical Reports — Discerning the Good, Bad and the Ugly - Ms Lim Hui Min, Director of Legal Aid, Legal Aid Bureau 3.50 pm Panel Discussion: MCA, LPA Certification and Mental Capacity Testing - Dr Colin Tan, District Judge, Family Justice Courts - Dr T Thirumoorthy, Executive Director, SMA CMEP - Prof Goh Lee Gan - Ms Lim Hui Min - Dr Nagaendran Kandiah 4.20 pm Closing 4.30 pm End of Session

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

Name: Handphone no.:

Email: Profession/Specialty:

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

Registration (inclusive of GST): 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 Complimentary for all doctors as having your photographs and/or videos taken by SMA and its appointed agents for the purpose of publicity and reporting of the event. 28 exec series The Singapore Medical Council

Disciplinary Process – A Study of a Recent Case

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

PROFILE

TEXT BY Lek siang pheng mar seow hwei

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

SMA News / jan 2016 exec series 29

In November 2014, the High Court is precisely the point that the High two prosecution experts could not of Singapore (also known as the Court in Dr Ang’s case, comprising have stood as legitimate bases for Court of Three Judges) overturned Sundaresh Menon CJ, Andrew Phang convicting Dr Ang on that charge. the verdict of the Singapore Boon Leong JA and Judith Prakash J, This is because the factors that the Medical Council (SMC) Disciplinary found lacking in the analysis of the prosecution experts relied on were Committee (DC) that Dr Lawrence DC — there was no determination in respect of an earlier period (6.30 Ang, an obstetrician, was guilty by the DC of what the standard of pm to 8.15 pm). However, since of one charge of professional care was. In such a case, how does the DC did not take issue with the misconduct (in relation to the need one conclude that Dr Ang had, so to management during that earlier to call for a neonatologist to attend speak, fallen short? period (which was the subject of or be on standby for a delivery) and one of the acquitted charges), the that, among other penalties, he There is a lesson here for those DC should focus instead on the should be suspended from practice interested in medico-legal matters. events that occurred after 8.15 pm. for three months. At the disciplinary The issue of standard of care is Besides, the DC did not explain why committee inquiry, the DC had crucial in the legal analysis of a it preferred the evidence of the two acquitted Dr Ang of three other complaint or suit brought against prosecution expert witnesses to that charges relating to the obstetric a doctor. As to what the standard of the defence expert witnesses. management of his patient. of care for treatment should be, it does not mean the ideal practice. The High Court also thought that In doing so, the High Court found Instead, the relevant benchmark is it was important in this case for that the conviction of Dr Ang on that what is known as the Bolam test. In the DC to identify the point in charge was unsafe, unreasonable other words, if the doctor’s actions time at which the duty to call for a and contrary to the evidence are supported by a responsible body neonatologist arose, because if that because the DC had: of medical opinion, he would not duty arose at, say, 8.30 pm, Dr Ang’s 1 failed to determine the standard be negligent. Hence, the fact that breach had to be assessed in light of conduct the doctor was a patient has obtained a medical of the fact that, by about 8.45 pm, to be judged by, or from view in support of his complaint or he had asked for a neonatologist which his departure could be claim does not necessarily mean to attend to a patient next door, sufficiently serious to amount to the doctor had fallen below the and by around 8.50 pm, he had professional misconduct; standard of care. Further, the fact commenced the delivery of the 2 failed to explain its reasons that the patient eventually suffered complainant’s baby. for preferring certain medical harm does not necessarily mean opinions over others in the face that there was negligence and/or The High Court also commented of conflicting medical opinions professional misconduct. that, while there may be significant on key issues; practical difficulties in finding the 3 taken into account facts that One must determine the standard precise answers to those issues, it went beyond the ambit of the of care and whether the doctor was nevertheless the responsibility relevant charge; and has fallen below that standard. of the SMC to lead the evidence 4 made at least two factual findings In addition, in SMC disciplinary addressing these matters and the that were contrary to the evidence. cases, professional misconduct responsibility of the DC to evaluate has to be made out. Professional the evidence before coming to the This decision came in the wake of misconduct is made out in at conclusion. Given the DC’s failure to highly publicised criticisms from least two scenarios: first, where analyse the charge in the aforesaid the Singapore Court regarding two there is an intentional, deliberate reasoned manner, that was a fatal decisions that the SMC DC had departure from standards observed flaw that in itself warranted the made in 2012, and announcements or approved by members of the setting aside of the conviction. regarding reforms to the disciplinary profession of good repute and process that governs doctors, competency; and second, where Hence, for claimants contemplating made in July 2014 by the SMC and there has been such serious legal action against doctors and Ministry of Health. negligence that it objectively for medical experts who are portrays an abuse of the privileges being asked to provide opinions What might one glean from these that accompany registration as a that would be used in medical cases? medical practitioner. malpractice litigation or complaints, it is important to first establish what Some, like the author of a forum In Dr Ang’s case, the DC relied on the standard of care applicable to letter to the Straits Times (10 the two SMC prosecution expert that case would be. December 2014), may think that witnesses’ views to conclude that perhaps the DCs are more stringent Dr Ang should have acted differently. Another significant aspect of the in applying medical standards than However, the High Court found November 2014 judgement by the the courts. On the other hand, this that the factors relied upon by the High Court was its order that the

Jan 2016 / SMA News 30 exec series

SMC is to pay Dr Ang the costs of The High Court held that the DC Court’s reasons for reversing the appeal, as well as the costs of would have an implied ancillary power the DC’s conviction on the the inquiry proceedings that took to make costs orders against both fourth charge (which was the place before the DC. parties and not just the doctor alone. subject of the appeal to the High Such an implied ancillary power to Court) are largely similar to the After the November 2014 judgement, make a costs order against the SMC reasons given by the Complaints the SMC wrote to the High Court to could not be easily displaced and Committee in dismissing the clarify this costs order, and the High indeed could not be displaced just complaint in the first place. Court invited both parties to tender because the Medical Registration Act submissions on whether the Court was silent on the issue. 2 The errors made by the DC in had the power to make such a costs convicting Dr Ang were largely order, and if so, whether it should be As for the power of the court, the contributed to by the SMC. exercised against the SMC in this High Court held that there was an particular case. implied ancillary power (the power The charges were not sufficiently to hear and determine appeals from particularised; the type of In March 2015, the High Court a DC), as well as a power under professional misconduct that released its decision on the costs the Supreme Court of Judicature Dr Ang was alleged to be guilty order. The High Court affirmed its Act (which vests in the High Court of was not specified, and this earlier costs order. the same powers as that of the undermined the ability of the Court of Appeal in the exercise of DC to properly evaluate the In doing so, the High Court held that: its appellate jurisdiction), to make a evidence. Further, the DC had 1 the DC has the power to order costs order against the SMC. considered extraneous facts, and costs of the disciplinary committee presumably, this arose from the inquiry against the SMC; In determining whether the power to SMC’s submissions. 2 the High Court also has the order costs against the SMC should power to order costs of the be exercised, the High Court in 3 Dr Ang was initially cleared by the disciplinary committee inquiry this case cautioned that excessive Complaints Committee but was against the SMC; and emphasis should not be placed then made to endure two tranches 3 there was ample justification in on the consideration that a public of proceedings, which he should Dr Ang’s case to order the SMC to or regulatory function is being never have been put through. bear the costs of the disciplinary exercised by the SMC. This is an He would have had to incur committee inquiry as well as the important but not conclusive factor. significant costs in his defence. costs of the appeal. The High Court found that a multi- The legal principles above were This is a significant development on factorial approach should apply stated by the High Court to also be two counts. Firstly, it was hitherto in deciding whether to order costs applicable to disciplinary tribunal believed that the DC does not against a body exercising a public inquiries under the current regime of have the power to order costs of or regulatory function. Ultimately, the Medical Registration Act. Dr Ang’s the disciplinary committee inquiry what the Court seeks to do in each case was under the previous regime. against the SMC in the event of an instance is to make an appropriate acquittal of a charge. Secondly, costs order that is just and reasonable The High Court’s decision to order before this case, the High Court in the circumstances of the case. costs against the SMC was the first had never ordered the SMC to pay a time the SMC had been asked to doctor the costs of the appeal even In finding that costs should be bear the acquitted doctor’s costs of when the latter had succeeded in ordered against the SMC for the disciplinary committee inquiry. his appeal against a DC decision. Dr Ang’s case, the High Court Given its relevance to disciplinary considered the following points: tribunal inquiries that may be In relation to the power of the DC to 1 It could not be said that the on-going or are to be undertaken, order that the SMC pays the costs of charges were brought against the High Court’s November 2014 the disciplinary committee inquiry, Dr Ang on grounds that appeared judgement, as well as its views set the High Court noted that, while the to be reasonably sound. out in the March 2015 judgement on Medical Registration Act was silent costs, would have to be considered on the issue of making a costs order There was no available reason carefully by the parties and counsel against the SMC, the Court also said to explain the Minister of involved in such inquiries. that it was difficult to imagine that Health’s decision to require the the Parliament intended for the SMC disciplinary committee inquiry to to be immune from adverse costs proceed despite the findings of orders. It noted that even the Public the Complaints Committee. The Prosecutor was not immune to DC’s reasons for dismissing the adverse costs orders. first three charges and the High

SMA News / jan 2016 SMA-ITE Skills Certificate in Healthcare (Outpatient) - ITE Traineeship Scheme Organised by: Singapore Medical Association

Looking for courses for your Clinic Assistants to One-Year Course Outline: upgrade their skills and knowledge? Hurry and Semester 1: register them now. This course will train your • Module 1: Basic Healthcare [60 Hours] Clinic Assistant to provide quality service! Semester 2: Participants will be trained in Health Screening and • Module 2: Clinic Dispensing [40 Hours] Laboratory Tests, First Aid and Emergencies, Reception • Module 3: Outpatient Care [20 Hours] and Clerical Duties, Dispensing Medicine and Drug Management. A nationally-recognised ITE Skills Lectures and practical sessions will be held on: Certificate will be awarded upon successful completion • Saturdays, 2 pm – 6 pm; or of the one-year programme. • Sundays, 9 am – 3 pm Do sign up for the ITE Traineeship Scheme to equip existing and new clinic assistants with the necessary Venue: skills. You are eligible to claim from SkillsConnect The Verge (Nearest MRT Station: Little India ) Training Grant when you sign up for the Traineeship. Registration closing date: 5 March 2016 Applicable for Singaporeans and Permanent Residents only. Commencement of next course: 19 March 2016

For more information, contact Jen / Huda / Shirong at 6223 1264 or [email protected]. To register, download the registration form from http://goo.gl/RY4NJH (URL is case-sensitive) and return to Singapore Medical Association via fax: 6224 7827 or email: [email protected]. 32 SMA CHARITY FUND

N e w Online Giving Platform!

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

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

For further enquiries, please contact [email protected].

SMA EVENTS MAR–APR 2016 DATE EVENT VENUE CME POINTS WHO SHOULD ATTEND? CONTACT

CME Activities

19 March Denise Tan 6223 1264 Medical Expert Witness Training Academia TBC Doctors Saturday [email protected]

9 April SMA Seminar: Tax Obligations on Doctors and Healthcare Carina Lee 6223 1264 M Hotel TBC Saturday Medical Practice Professionals [email protected]

9 April Denise Tan 6223 1264 Medical Expert Witness Training State Courts TBC Doctors Saturday [email protected]

30 April Medico-Legal Seminar on Mental Doctors and Healthcare Carina Lee 6223 1264 Academia TBC Saturday Capacity Professionals [email protected]

SMA News / jan 2016 from the heart 33

Snoopy Charlie Brown – A Charity Movie Event

The Association of Women Doctors seminars, forums and workshops PROFILE (Singapore) (AWDS), Singapore relating to health concerns, Film Society (SFS) and National particularly those pertaining to University of Singapore Medical women and families. Society (NUS Medical Society) collaborated to raise funds at the In his welcome speech, Mr Kenneth charity premiere of “Snoopy And Tan, Chairman of the SFS, explained Charlie Brown: The Peanuts Movie” that the film society is a non- in aid of NUS Medical Society’s profit organisation that promotes community involvement projects. the appreciation of movies, as Text and The premiere was held on Thursday, both an art form and a medium of photos by 10 December 2015 at Golden Village popular entertainment. SFS curates GVmax, VivoCity. and showcases a year-round Dr Jade Kua programme of feature and short The premiere was attended by almost films from all over the world, many Dr Jade Kua is a 600 guests, including underprivileged of which are otherwise not available consultant paediatric children from various organisations, to Singapore audiences. emergency physician whose seats were sponsored by with KKH. She works generous donors. Guests were treated Donors were thanked by Mr Wong closely with various to a series of activities prior to the Wen Kai, President of the NUS ministries to helm community projects, movie, including photo opportunities Medical Society, for their generosity. particularly those that with the Medical Society Bear mascot, He described the society as educate schoolchildren and free popcorn. Singapore's longest-lasting and the general public representative body for university on basic resuscitation Booths had also been set up by students. He said that for 67 skills. She also contributes frequently medical students to showcase their years, the NUS Medical Society on editorials about community projects. The three NUS has sought to create a learning children's health aimed Medical Society flagship events community that supports the at young parents. She is featured at the premiere were the holistic growth of medical students, passionate about travel, Neighbourhood Health Service, Public helping them to develop into ethical, horology and music. Health Service and Project Lokun. empathetic and competent doctors. It does this through advocacy of 1. Excited children Leaders of the AWDS, SFS and student interests, administrative mobbing the Medical NUS Medical Society also gamely management of student activities Society Bear mascot. posed with guests who requested and serving as the point of contact for photographs and answered for external parties seeking to reach questions about their organisations. out to the medical students.

When asked about the role of AWDS, The evening ended on a high note Dr Karen Soh, President of the AWDS, as guests left the theatre chatting replied that AWDS has been pivotal in excitedly about the adventures of promoting women’s rights in relation Charlie Brown while the movie's to health and career advancement theme song, Meghan Trainor's "Better in medical practice. Dr Soh also When I'm Dancing", played on. 1 added that AWDS actively organises

Jan 2016 / SMA News 34 INDULGE

Much Ado About Dracula!

Mention Romania, and images of 1989 and continued under debate PROFILE Dracula, world-class gymnastics during democratic rule. Be wowed and the Danube River are conjured, by chandeliers weighing tonnes, but planning for this trip made me curtains with gold embroidery and realise that the country has so much tassels, endless marble columns more to offer. The most direct route and staircases, and state-of-the-art from Singapore to Romania’s capital, conferencing facilities. One cannot Bucharest, is by Turkish Airlines via help but think that one man’s crazy Istanbul. City express buses and the idea of building such a palace TEXT and Henri Coanda Express train connect indeed showcases the country’s photos BY the airport to the main Piaţa Unirii best and proves that Romania can (Union Square) or the North Railway and will accomplish! Dr Juliana poh Station. I strongly recommend staying in the Old Town, which is littered with We were spoilt for choice when century-old buildings such as the CEC it came to alfresco dining in the Dr Poh is a part-time Palace, the National History Museum, Old Town. Activity builds up in the emergency physician the Military Museum, the University, afternoon till late at night, with and full-time mother, old churches and others. You get the street performers entertaining who dabbles in cooking picture of a city steeped in history. the crowd as they enjoy local or experiments and clan work, leaving no time international cuisines. Trip Advisor’s to spare. Like any other metropolitan city, recommendation of The Artist was Bucharest has a modern metro an adventure, I must say. The Spoon network that brings tourists to most of Legend the city sights. However, I must warn 1. The Parliament Palace, that some of the attractions are plain the second largest building 1 humongous, and it is a considerable in the world. 2. Sarmale, traditional walk to the entrances. (Do rent a Romanian cuisine bicycle if you are short of time.) It took 3. Palinka souvenirs from us almost 45 minutes of brisk walking Dracula land to cross the Constitution Square and 4. Sour soup at Restaurant Liberation Boulevard along the front Sergiana, Brasov facade of the Parliament Palace to get 5. Spoon Tasting Menu at The Artist, Old Town, Bucharest to the side entrance, which is another 6. Traditional Trdelnik bread 10 minutes up a slope. On most days, sold outside the zoo ticketed guided tours are available at 7. Panoramic view of the regular intervals. Vidaru Dam and Lake 8. View from the Clock The Parliament Palace is the Tower in Sibiu second largest building in the 9. Seas of sunflowers en route world, after the Pentagon, and the one-hour tour showcases just ten per cent of the most elaborately decorated rooms and corridors in the twelve-storey complex of 1,100 rooms! Construction commenced five years before the Revolution in

SMA News / jan 2016 INDULGE 35

Tasting menu (70 leu = S$24) scored melting glaciers, Vidaru Dam with its a big fire in 1689 and later restored, in presentation, with its classic drink, man-made lake and endless stretches but it still retained its blackish facade. also called The Artist (Prosecco of coniferous trees. We even drove It houses the biggest bell in Romania with black pepper and lemon grass), head-on into a flock of sheep and and an impressive pipe organ. We complementing the food beautifully. watched them surround us! As Jeremy stayed overnight in a pensiune in I would be surprised if they are not Clarkson of Top Gear exclaimed aloud Brasov and had dinner at Sergiana, awarded a Michelin star soon! as he drove along the highway in his an authentic Romanian restaurant in Aston Martin in 2009: “This is the best a vault! You haven’t been to Romania There was so much to see with the road in the world”! if you haven’t tried the traditional limited time we had, but we were Romanian dish, sarmale, minced repeatedly reminded by the locals Approximately three hours away meat rolls in cabbage leaves, and to take time out for Herastrau Park from Bucharest is Brasov city with its Transylvanian sour soup served with and the adjacent Village Museum, an famous 14th century Black Church, so a huge green chili. We were absolutely outdoor setup of village houses from named because it was destroyed by stuffed after all that and a traditional all over Romania with a mind-boggling collection of ancient windmills, costumes and household artefacts. The boat ride on the stunning lake was truly relaxing; I wondered why they had to provide free Wi-Fi!

We were fortunate to experience the Transfagarasan Highway, which is only open from July to October. Crossing the Carpathian Mountains, this road is perfect for exploring the Transylvanian 2 3 region, and was a big, costly project for strategic military access in the 1970s. The winding road with steep hairpin turns and long S-curves was nothing short of spectacular. Our seasoned driver had to make several stops along the way, as we couldn’t get enough pictures of the breathtaking scenery. With every turn, the scenery was just picture-perfect — there were para- gliders, avid cyclists, small streams, 4 5

6

Jan 2016 / SMA News 36 INDULGE

7

8 stew with polenta. And take my word An hour’s drive away from Alba for it – the Romanians make the best Iulia is the Turda Salt Mine of Cluj lemonade on this planet. County. Mining equipment and machinery are displayed in the We made the “compulsory” visit to mine-turned-museum, which dates Bran Castle, a fortress made famous back to the 13th century. A jacket is by Vlad Dracula, more popularly recommended, as it gets pretty cold known as “Dracula’s castle”. Despite 13 storeys underground. The Terezia being a touristy setup that Vlad mine at the bottommost is the oldest himself never inhabited, it was chamber open to visitors and has a still interesting to explore its spiral salt lake on which you can paddle stairways and quaint furniture (and a boat for a token fee (10 leu). How imagine how short people of that exciting to paddle in semi-darkness! period were). I was more captivated One can also play kiddie golf, take by the beautifully-preserved medieval a ferris wheel ride, play a game city of Sighisoara, a designated of table tennis, or buy salt mine UNESCO World Heritage Site. Vlad’s souvenirs such as bath salts and salt birthplace (admission fee 5 leu only) bar deodorants and soaps. Or just at Citadel Square is now a café selling sit, and admire the spectacular salt Dracula souvenirs and (ahem) one of stalactites and efflorescence! the “reddest” wines of the region. A 9 short but challenging climb up 176 I had the privilege of visiting the steps on School’s Hill leads to the Tirgu Mures County Hospital where gothic Church on the Hill, the most emergency medicine first started in important architectural monument of Romania – a truly modern facility with Sighisoara, which offers a viewpoint ICU beds, advanced technology for of the historic city of cobbled alleys medical oversight of other emergency and numerous turrets. departments and an impressive helicopter evacuation service. It had Our memorable road trip continued the familiar sight of crowded corridors onwards to Sibiu, the European and harassed emergency physicians, Capital of Culture 2007, and Alba Iulia, same as back home! a city of historical significance even before the Middle Ages. It was here After a week of scenic drives, endless that the largest fortress in Romania, sunflower and polenta fields, pine Alba Carolina, was built; the perimeter trees and historical buildings, we measures 12 km! After WWI, on 1 drove ten hours back to Bucharest December 1918, the proclamation along the Transalpina Highway, of the union of Transylvania with the which in itself was another once-in- Kingdom of Romania was conducted a-lifetime experience. Some say it in The Unification Hall. The National surpasses the Transfagarasan with Day (also known as Great Union Day) its beauty! I think my descriptions will of Romania is still celebrated here not be able to do justice either way. every 1 December! We spent hours You will just have to make this trip to exploring the well-preserved hall, decide for yourself. university, cathedral, Roman ruins and the six gates; good walking shoes are recommended!

SMA News / jan 2016 SMA CHARITY FUND 37

PAY YOUR 2016 MEMBERSHIP FEES BY 31 JANUARY 2016 AND STAND A CHANCE TO WIN 1 OF 2 APPLE WATCHES!

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

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

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

Photo used is for illustrativeJan purposes2016 / SMA Newsonly 38 aic says GUIDING YOU THROUGH CHAS AUDIT: A QUICK REFERENCE (PART 2) In SMA News Nov ‘15 issue, we have covered issues related to the Patient Consent Form and issuance of patient invoice. In this issue we will cover clinical documentation; general medication and investigation that are not claimable under CHAS.

CLINICAL DOCUMENTATION MEDICATION AND INVESTIGATION

Diagnosis in case notes must be consistent with the Medication: Examples that are not claimable under CHAS information submitted on CHAS Online. CHAS GP clinics are minimally required to keep the following set Traditional and complementary medicine of documents: (e.g. herbal medicine) Vitamins and/or dietary supplements

clinical notes relevant conditions) Lifestyle modifying medications notes (e.g. to treat hair loss or for weight-loss) For Complex Chronic with complications, GP’s Intra-articular viscosupplementation clinical notes must document the causal link between the chronic disease and its complications Sedatives-hypnotics

Prescription or clinical notes detailing medication Investigation: Examples that are not claimable under prescribed, if any CHAS

Records of laboratory tests carried out for Investigations prior to establishing the condition diagnosis and follow-up, if any for a CDMP condition under chronic subsidy, e.g. OGTT for a pre-diabetic patient Please note that for each patient, each clinic can only Investigations unrelated to the management of submit 1 acute claim or 1 chronic claim, but not both the claimed condition on the same visit date. Screening tests included in lab packages, e.g. STD screen, hepatitis screen, and tumour markers

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

Non-compliant Claims

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

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

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

If you have a question on CHAS which is not covered above, kindly contact AIC at [email protected] or 6632 1199 Ground floor clinic for takeover at Biopolis. 1003 sq ft. Modern, SALE/RENTAL/TAKEOVER tastefully fitted with full interior design, immediate move-in condition. For regular partner +/- takeover. Geylang clinic. 9674 0321. 3 consultation/procedure rooms, reception, pantry, private exclusive entrance, ample carpark. Must see to appreciate! Rent $5K neogotiable. Clinic for takeover at central location in Raffles Place. Approximately Call 9789 2388 Angeline. 1400 sq ft. Fully equipped (treadmill, sound proof room etc.) room for 2-3 doctors. Vacant April 2016. For enquiry, please call 9010 1133. POSITION AVAILABLE/PARTNERSHIP D19 ground-floor shop at Simon Plaza, 2-mins to Kovan MRT. Seeking full-time and part-time general practitioner/family physician 968 sq ft with water point, toilet and 3-phase wire. Within private for our clinic. Please call or text 9367 6933 for a confidential discussion. condominium and landed property enclave. Immediate occupancy, carpark available. Suitable for GP/Specialist clinic. Please call 9635 Seeking independent and motivated full-time partner doctors or 5188 or email [email protected] associate doctors for GP practices. Attractive salaries with possible profit sharing partnerships. Plenty of local and overseas training Clinic for rent. Prime next to lift, #06-01 Gleneagles Medical Centre. opportunities provided for suitable candidates. Please email CV to Immediate. 656 sq ft. Renovated. SMS 9680 2200. [email protected] Newly renovated rooms for lease available at Gleneagles Medical Centre and 2 units for lease available at Mount Elizabeth Novena. Established medical aesthetic group in CBD area is looking for Please call Miss Karen 6258 7965 if interested. motivated doctors who are looking for growth opportunity. Both part time and full time positions are available. Joined partnerships are For Sale. An integrated medical suite at Novena Medical Center welcomed as well. All applicants are required to have COCs. Candidates located at Square 2, linked to Novena MRT & TTSH. Selling with with prior experience and knowledge are preferred. Comprehensive vacant possession. Size 904 sq ft. $4.2M. Call Truddy Tan at skill development training programmes will be provided. 9850 4876 for more information & to own a unit here. If you’re keen in joining our winning team, kindly email your detailed resume to: [email protected] Serviced clinic for rent at Mount Elizabeth Novena Hospital. Fully equipped and staffed with IT support. Immediate occupancy. Choice ONLY Group Pte Ltd is looking for doctors with passion and has an of sessional and long term lease. Suitable for all specialties. Please eye for aesthetics. Experience with application of lasers and medically call 8668 6818 or email [email protected] certified to perform BOTOX/Fillers is preferred. Remuneration and working hours are negotiable. Send resumes to: [email protected] SCM: buy/sell clinics/premises. Takeovers: (1) D14, industrial & HDB; (2) Hougang, practice with shophouse; (3) D21, affluence catchment. Very high volume Eye Surgeon Tanjong Pagar Hotel- looking for Eye Rental: (i) Holland HDB shophouse; (ii) Adelphi; (iii) D21, share with Surgeons as Associates/Partners. Fully equipped OT and lasers. Fully specialist, MRT. Sale: Bishan ctrl shophouse. Kok Yein 9671 9602. Medisave accredited. Call 9856 0386 for discussion. Jurong East Street 31 clinic for rent. Near HS Rail Terminal, NTUC Mart behind. Sharing with Eye Surgeon. Call 9856 0386. MISCELLANEOUS Mount Elizabeth Novena Hospital whole unit 581 sq ft for rent/2 Brand new BREWER Patient Examination Couch, model #4000, with separate rooms for rent. Per Room $2,000. Flexible arrangement. drawers opening to patient’s right. Retractable leg extension. Cocoa Call Adrian 9188 0684. colour. 3-year warranty. Selling at $3000/-. Call Clinic at 6733 1856.

I was conferred the Ministry of Health’s Arrhythmia and Cardiac Electrophysiology Professional Announcement Healthcare Manpower Development Plan • Ambulatory Holter ECG Monitoring (HMDP) scholarship to pursue fellowship • Signal average ECG testing training in Interventional Cardiology, at the • Heart rate variability, Heart rate Alfred Heart Centre and Epworth Hospital turbulence and QT analysis in Melbourne, Australia. In addition to • Event ECG recorders and monitoring Dear friends and colleagues, percutaneous coronary interventions, I am • Pacemaker interrogation and program- trained to perform peripheral endovascular ming After 16 years of service in the public healthcare sector, I have com- interventions like lower limb angioplasty • ICD interrogation and programming menced private practice at The Heart Specialist Clinic in Mount and renal artery stenting and renal nerve • Cardiac resynchronisation interrogation Elizabeth Medical Centre, Singapore. denervation, as well as in structural heart and programming interventions like transcatheter aortic • Cardiac Electrophysiological studies Besides holding a concurrent Visiting Consultant post at the following re- valve replacements (TAVR), percutaneous • Catheter ablation of cardiac arrhythmia structured tertiary hospitals: Tan Tock Seng Hospital and Khoo Teck Puat patent foramen ovale (PFO) closures, • Device implantation (pacemakers, ICT, Hospital, I am a fully accredited consultant interventional cardiologist, percutaneous left atrial appendage CRT) with admitting privileges, at the following private hospitals: Mount Eliza- (LAA) closures, balloon aortic and mitral • Lead and device extraction beth Hospital, Mount Elizabeth Novena Hospital, Gleneagles Hospital, valvuloplasties. I have a particular interest Parkway East Hospital, Mount Alvernia Hospital and Farrer Park Hospital. in complex coronary interventions, like Interventional Cardiology bifurcation stenting and chronic total • Percutaneous Coronary Intervention After completing my Basic Specialist Training (BST) in Internal Medicine at the Singapore General Hospital and Advanced occlusions (CTO) interventions. (“stenting”) Specialist Training (AST) in Cardiology at the National Heart Centre Singapore, I attained membership with The Royal • Structural heart interventions College of Physicians of the United Kingdom (MRCP UK). Today, I am a Fellow of the Academy of Medicine, Singapore At The Heart Specialist Clinic, we • Peripheral endovascular interventions (FAMS Cardiology), a Fellow of The Royal College of Physicians of Edinburgh (FRCP Edin), a Fellow of the European provide comprehensive specialist care in • Renal Denervation Society of Cardiology (FESC) and a Fellow of the Asian Pacific Society of Interventional Cardiology (FAPSIC). I am also an heart health matters. The full suite of sub- American College of Sports Medicine (ACSM) Certified Clinical Exercise Specialist. specialty interests and facilities include: I look forward to your continued support and to partner you in providing the best Whilst in institution practice, I have been active in clinical research and have been Principal Investigator of a number General cardiology services possible specialist care in cardiovascular of multinational interventional cardiology registries and randomized control trials (DELIVER study and DEB-Only Small • General cardiac screening medicine to your patients. Vessel Disease study, SIGNIFY study, REDUCE study, RESPECT-HF trial), and have also been Co-Investigator in several • INR monitoring landmark international studies like the PLATO and CURRENT/OASIS 7, IMPROVE-IT and LEADERS FREE trials. I have • ECG numerous publications in peer-reviewed journals in the field of Interventional Cardiology, and have been invited as fac- • Exercise stress test Yours sincerely, ulty to lecture in regional and international Cardiology conferences like AsiaPCR, EuroPCR, TCTAP, HKSTENT-CICF, • Ambulatory blood pressure monitoring ECC, TOPIC, CCT. Dr Julian K.B. Tan FRCP (Edin), FESC, FAPSIC, MBBS (Singapore), Echocardiography MMed (Internal Medicine), MRCP (UK), ACSM Besides clinical research, I have been involved in the teaching and mentoring of medical students, residents, senior • Echocardiography – 2D, 3D and cardiac (Clinical Exercise Specialist), FAMS (Cardiology) residents and nurse clinician trainees. I am a Clinical Senior Lecturer at the Yong Loo Lin School of Medicine, NUS and a dyssnchrony studies Consultant Interventional Cardiologist Core Clinical Faculty Member of the NHG Cardiology Senior Residency Program and a Clinical Teacher at the Lee Kong • Transeophageal echocardiography The Heart Specialist Clinic Chian School of Medicine. • Dobutamine stress echocardiography

The Heart Specialist Clinic Pte Ltd 3 Mount Elizabeth, #14-09/10 Mt Elizabeth Medical Centre Singapore 228510 Tel: (65) 6235 8733 | Fax: (65) 6235 8955 Email: [email protected] | [email protected] M E D I C A L C L I N I C

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

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

A very real focus on patient care enabling medicine to be practised and service; without any third party interference; Significantly lower patient numbers, A significant remuneration upside for based on our patients being those suited to our style of medicine; prepared to pay for quality time with their doctor; Standard work week hours, with the possibility of flexibility with the No panel contract arrangements, number of sessions worked.

For more background, please view our website at www.imc-healthcare.com Please send your CV together with a cover letter stating the reasons you are attracted to IMC, to [email protected]

ADS Prunella

The Art Fellas is proud to present 2 award winning local artists at Art Stage Singapore 2016! REN JIAN HUI YEO CHEE KIONG Ren Jian Hui & Yeo Chee Kiong

兄弟 Brothers, 2009, Oil on Canvas Black Banquet, 2011, 8m x 1.2m x 0.9m 180 x 160 cm

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

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

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

Ren Jianhui (b.1956) Yeo Chee Kiong (b.1970)

Born in Chengdu, China. Ren graduated from China is an award-winning professional sculptor known for his Parkway Shenton Pte Ltd, a subsidiary of Parkway Pantai Limited, is uniquely playful and unexpected juxtapositions. a private primary healthcare solutions provider. We invite dedicated Central College of Arts and Crafts, and was mentored by individuals who are passionate and driven to join us as: Prof. Wu Guanzhong. An alumnus of the Nanyang Academy of Fine Arts (NAFA) 1. General Practitioner (Correctional Healthcare) and the Glasgow School of Art, U.K., Chee Kiong has 2. General Practitioner (Health Screening) Since 2000, Ren Jianhui became gradually known in the international art scene, and was invited to hold solo garnered critical attention for his practice-winning awards At Parkway Shenton, we provide sponsored postgraduate such as First Prize, LTADTL Art Competition 2012, Expo training opportunities in addition to our comprehensive suite exhibitions in Singapore, Kuala Lumpur, Tokyo, New York of benefits. Join us for a challenging career and opportunities and Jakarta, etc. He participated in the Biennale Station, the regional Grand Prize for Asia-Pacific Breweries for personal development. Chianciano, Italy, in 2009, and was awarded with an Foundation Signature Art Prize (2008), the National Art Based in Singapore, you will be part of team of dedicated doctors Council's Young Artist Award 2006 and the Grand Prize of and paramedical staff rendering healthcare and providing Honourable Mention for Painting, including an impending comprehensive care to our patients. You will also play a key role Leonardo Da Vinci Award. Ren’s art works have been the 2nd CDL Singapore Sculpture Award in 2005. in the maintenance of clinical standards and the delivery of a service experience for our patients. collected by various art museums, private foundations and organisations around the world. In 2010, his work, 'The Wind & Wings' has been awarded Requirements: the Legacy Sculpture for Singapore 2010 Youth Olympic • Basic medical qualification registrable with Singapore Medical Council Ren’s style of painting is a unique fusion of chinese ink Game (Youth Olympic Village). • Postgraduate medical qualifications are an advantage and western oil techniques. From his style to the way we • Possess a valid practicing certificate from the Singapore see him paint what he feels he’s living, many refer him as In Addition, 2 works by Chee Kiong titled, ‘Pedicure’ was Medical Council displayed in the • Relevant experience is an advantage a ‘Rebel Master’. • Good oral and written communication skills ground level of MBS • Good interpersonal skills His painting are often infused with deep complex Expo and Convention ART STAGE • Good team player meaning, which serves to reflect the society and Centre's foyer. SINGAPORE For position 1, kindly email: [email protected] portrayal of human nature through careful observation of 21– 24 JAN’16 or call 92346086 for a friendly discussion. For position 2, kindly email: [email protected] the world. or call 97827710 for a friendly discussion. Please state “Position — Your Name” in the subject header of your email application. Enquiries, please contact us at: [email protected] www.parkwayshenton.com Tel: 6702 4001/6702 4003 Opening Hours: FB: www.facebook.com/theartfellas Mon-Fri: 9 am - 6pm 46 Kim Yam Road, #02-25 Sat & Sun: 2pm - 6pm WE ARE ASIA The Herencia, Singapore 239351 Public Holidays: By Appointments Only

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

artstagesingapore artstagesg artstagesg artstagesingapore The Art Fellas is proud to present 2 award winning local artists at Art Stage Singapore 2016! REN JIAN HUI YEO CHEE KIONG Ren Jian Hui & Yeo Chee Kiong

兄弟 Brothers, 2009, Oil on Canvas Black Banquet, 2011, 8m x 1.2m x 0.9m 180 x 160 cm

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

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

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

Ren Jianhui (b.1956) Yeo Chee Kiong (b.1970)

Born in Chengdu, China. Ren graduated from China is an award-winning professional sculptor known for his Central College of Arts and Crafts, and was mentored by uniquely playful and unexpected juxtapositions. Prof. Wu Guanzhong. An alumnus of the Nanyang Academy of Fine Arts (NAFA) Since 2000, Ren Jianhui became gradually known in the and the Glasgow School of Art, U.K., Chee Kiong has international art scene, and was invited to hold solo garnered critical attention for his practice-winning awards exhibitions in Singapore, Kuala Lumpur, Tokyo, New York such as First Prize, LTADTL Art Competition 2012, Expo and Jakarta, etc. He participated in the Biennale Station, the regional Grand Prize for Asia-Pacific Breweries Chianciano, Italy, in 2009, and was awarded with an Foundation Signature Art Prize (2008), the National Art Honourable Mention for Painting, including an impending Council's Young Artist Award 2006 and the Grand Prize of Leonardo Da Vinci Award. Ren’s art works have been the 2nd CDL Singapore Sculpture Award in 2005. collected by various art museums, private foundations and organisations around the world. In 2010, his work, 'The Wind & Wings' has been awarded the Legacy Sculpture for Singapore 2010 Youth Olympic Ren’s style of painting is a unique fusion of chinese ink Game (Youth Olympic Village). and western oil techniques. From his style to the way we see him paint what he feels he’s living, many refer him as In Addition, 2 works by Chee Kiong titled, ‘Pedicure’ was a ‘Rebel Master’. displayed in the ground level of MBS His painting are often infused with deep complex Expo and Convention ART STAGE meaning, which serves to reflect the society and Centre's foyer. SINGAPORE portrayal of human nature through careful observation of 21– 24 JAN’16 the world.

Enquiries, please contact us at: [email protected] Tel: 6702 4001/6702 4003 Opening Hours: FB: www.facebook.com/theartfellas Mon-Fri: 9 am - 6pm 46 Kim Yam Road, #02-25 Sat & Sun: 2pm - 6pm WE ARE ASIA The Herencia, Singapore 239351 Public Holidays: By Appointments Only

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

artstagesingapore artstagesg artstagesg artstagesingapore Yona 月华 MBA, FCHFP & AFC, Court of the Table, Top of the Table Representing Manulife Financial Advisers, part of Manulife (Singapore) Pte. Ltd. Please Call 97271702 or email: [email protected] Dear Medical Specialists Sucessful Individuals Like You Deserve Only the Best!

• With years of experience and expertise, I am well-positioned to provide you with sound advise to help you achieve your financial goals. • You will have access to a wide range of solutions from Manulife as well as other trusted partners. • You have worked hard to get to where you are today. Would you like to know more about your preservation of your assets and distribution to your loved ones? Let me help you meet your unique financial needs. Our Universal Life The answer to your legacy and retirement planning needs You are cordially invited for a Legacy Planning & Dinner Presentation at Raffles Hotel. Please call for details.

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

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

Parkway Pantai Limited (PPL) is the largest private healthcare provider www.asiamedic.com.sg and operates Mount Elizabeth Novena Hospital, Mount Elizabeth Hospital, Gleneagles Hospital and Parkway East Hospital — all accredited by Joint AsiaMedic is a leading healthcare provider in Singapore. Commission International (JCI). To support our expansion plans and better serve our growing Our Accident and Emergency department / 24 hour clinics provide first-line presence, we invite you to be part of our team. 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. We are recruiting full-time Clinicians for the following positions: All our medical and surgical specialists are well-trained and ever–ready to support the handling of emergencies effectively and efficiently. By adopting Radiologist a team approach towards the management of emergencies, we ensure the ▪ FRCR or equivalent with subspecialist in Musculoskeletal MRI smooth and expedient management of all patients. ▪ Fellowship trained & must be registrable with the Singapore Medical We invite dedicated individuals who are passionate and drive to join us as: Council Resident Physician (A&E/ 24 hours Walk-In Clinic) Based in Singapore, you will be part of a team of dedicated doctors and Consultant Nuclear Medicine Specialist 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 ▪ FRCR, MRCP or equivalent Parkway service experience to our patients. ▪ Must be registrable with the Specialist Accreditation Board in Nuclear Medicine, Singapore 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. Aesthetic Physician Requirements: • Basic medical qualification registrable with Singapore Medical Council ▪ MBBS or equivalent & is registrable with the Singapore Medical Council • Possess a valid practising certificate from the Singapore Medical Council ▪ Post-graduate Diploma in Aesthetic Medicine is an added advantage • At least 3 years of clinical experience post-housemanship. • Postgraduate medical qualifications and relevant experience are advantages ▪ Must be familiar with lasers, botox and fillers • Good oral and written communication skills • Good interpersonal skills • Good team player Interested applicants, please email your contact details and Kindly email: [email protected] or call 9670 0472 for a friendly curriculum vitae to [email protected] discussion. www.parkwaypantai.com

We invite Consultants / Associate Consultants and Resident Physicians to join our Anaesthesia Team The department will offers comprehensive perioperative assessment and optimization for both the inpatient and the outpatient. Pain services for both acute and chronic pain will be provided to the patients and life/critical care support services for patients with trauma, airway issues, and cardiac arrest will also be extended. There will be 18 operating theatres (including one hybrid operating suite) and two cardiovascular laboratories within the operating theatre complex. We are currently looking for like-minded individuals to join us in pioneering the future of integrated healthcare. If you share the same passion, have a heart to serve and dare to take bold steps to transform care, we want to hear from you!

• Candidates must possess a basic medical Degree registrable We o er a competitive salary and comprehensive benets package with the Singapore Medical Council and/or a recognised that will commensurate with your qualications and experience. post-graduate qualication such as MMED Please write in with your full resume together with names of 2 referees and medical testimonials to: • For specialist positions, candidates must have completed specialist training, with recognised post-graduate qualication Chairman, Medical Board registrable with the Singapore Specialist Accreditation Board. Ng Teng Fong General Hospital 1 Jurong East Street 21 • Possess leadership qualities, as well as excellent interpersonal Singapore 609606 relationship and communication skills We invite Consultants / Associate Consultants and Resident Physicians to join our Anaesthesia Team The department will offers comprehensive perioperative assessment and optimization for both the inpatient and the outpatient. Pain services for both acute and chronic pain will be provided to the patients and life/critical care support services for patients with trauma, airway issues, and cardiac arrest will also be extended. There will be 18 operating theatres (including one hybrid operating suite) and two cardiovascular laboratories within the operating theatre complex. We are currently looking for like-minded individuals to join us in pioneering the future of integrated healthcare. If you share the same passion, have a heart to serve and dare to take bold steps to transform care, we want to hear from you!

• Candidates must possess a basic medical Degree registrable We o er a competitive salary and comprehensive benets package with the Singapore Medical Council and/or a recognised that will commensurate with your qualications and experience. post-graduate qualication such as MMED Please write in with your full resume together with names of 2 referees and medical testimonials to: • For specialist positions, candidates must have completed specialist training, with recognised post-graduate qualication Chairman, Medical Board registrable with the Singapore Specialist Accreditation Board. Ng Teng Fong General Hospital 1 Jurong East Street 21 • Possess leadership qualities, as well as excellent interpersonal Singapore 609606 relationship and communication skills UOB_BB_Payroll_SMA Mag_210(W)x297(H)mm.ai 1 1/10/15 4:03 pm

C

M

Y

CM

MY

CY

CMY

K