Tuesday, March 04, 2008

Health Minister's Comments

About the A&E, that is.

Skimmed through the Straits Times article today, and was amused to read that there may be plans to raise A&E charges in the future to minimize abuse.

My question is: by how much?

Our fees recently went up by a paltry $10, and patient attendances are still hitting record highs.
Singaporeans are an affluent bunch, especially the well-educated ones ( a significant proportion of whom are also quite young ). We see many of them as self-referrals, so paying a bit more isn't likely to be an effective deterrent.

I don't think it's fair to penalize the genuinely sick cases or the old / poor population, in order to keep the numbers down. ( Ultimately, I doubt any of the suggested measures will make a difference to begin with. )

The best solution, I feel, is to strengthen the primary healthcare sector by boosting manpower at polyclinics and ensuring adequate training of primary care physicians.

Friends of mine who work at the OPS always tell me the same horror stories: not enough doctors, too many patients, insufficient time for each case, unbearable stress...
Many have left government service for more reasonable working conditions in private practice. Which then aggravates the manpower and patient care problem.
The same thing happens in restructured hospitals. It's a vicious cycle, people.

I just finished a shift in the consultation area today. Let me give you a few examples of the cases I saw.
( I shall leave out the origin of the referrals from other doctors. )

1) Patient with "buttock abscess x 2 weeks, not better with 2 courses of oral antibiotics, please admit for I&D". Turned out NOT to be an abscess, nor anywhere near the buttock. Measured 1-2cm, non-tender, not inflamed, patient very comfortable. Discharged as a possible sebaceous cyst, with an O&G clinic appointment.

2) "LIF pain x 1 month, ?LIF mass" - no mass, no tenderness on palpation, extremely comfortable. Given colorectal appointment for further workup.

3) My favourite: "Left little toe pain x 1 month after trauma. X-ray today shows ( I quote ) 'fracture little toe', please see urgently, KIV admit for ORIF"!
The referring doctor's name sounds local. Where did this person study medicine?!

Self-referrals ( i.e. came to A&E on their own without a referral from another doctor ):

1) NS boy with left leg contusion. Walks with no problem, leg completely normal on examination. X-ray ( no surprise ) normal. Discharged with light duty.

2) Bread-and-butter stuff like flu, viral fever, mild gastroenteritis -- many are young, ambulant and comfortable. Never occurred to them to visit the GP / OPS.

On other days, I've seen "urgent" referrals for deranged liver function tests, which actually comprise mildly raised transaminases with normal bilirubin and no symptoms.
When the patients come to us, they expect a full workup, including a scan.
Who gets blasted in the end? We A&E doctors, of course. We're the ones who get saddled with managing patient expectations, which wastes precious time that should be spent on more important tasks.

Am I wrong to say that Singaporeans don't seem to rely on primary physicians as much as they should? Some patients even tell me they refuse to go to the polyclinic because the waiting times there are too long ( even though WTs at our department can hit 4-6 hours on bad days ). Others tell me they "don't trust non-specialists", not realizing that the A&E's are run mostly by medical officers.

At any rate, the abuse of the A&E is a massive problem which cannot be solved overnight. We could do a detailed analysis of every case that comes through our doors to pinpoint the main contributing factors, but this is horribly time-consuming and we don't have the resources to perform it.

So bottomline: continue to suffer in silence. Until some mass casualty incident occurs and overwhelms the whole healthcare system, shaming the entire country and thus prompting full-throttle action from The Powers That Be.

I may not live long enough to see that day ( and I intend to live till I'm at least 90 :)).

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