Sunday, June 22, 2014

A Rock And A Hard Place?

This entry deviates from my usual recreational posts. But a recent healthcare-related issue is bothering me significantly and I need to write something about it.

The last thing I need is a phone call or email from one of my big bosses. :)

If you follow the news, you're no doubt aware of the recent revisions in healthcare coverage, in terms of Medisave and MediShield benefits.

While it is a timely move welcomed by many, I have reservations about this sort of "crowd-pleasing" tactic.

In addition, the government isn't addressing serious problems which contribute to poor personal health management, instead focusing mainly on healthcare expenditure and how to ease Singaporeans' burdens.

The nature of my work in the Emergency Department puts me in close contact with tens of thousands of patients each year. We don't need detailed statistics to know that
1) Many patients are aged 75 and above.
2) People are getting much sicker, and
3) A significant number don't bother to comply with prescribed treatment or lifestyle modification advice.

While a proportion of those in (3) have financial constraints, there're many others who behave in this manner due to lack of insight, stubbornness, or even plain stupidity.

Every day, I see at least a few active smokers with known histories of coronary artery disease, asthma or chronic obstructive pulmonary disease (COPD), coming in for angina and wheezing. When I tell them they're not supposed to smoke in view of their pre-existing conditions, the standard response is a sheepish grin, and comments like "Yes, doctor, I KNOW I should stop smoking, but it's SO HARD." And they always find it very amusing, like a joke which we should laugh at, hahahaha.

Then there're those who default follow-up and treatment, saying they have "no time" or "I felt fine so I didn't come back lor". Patients sometimes cite lack of money as a reason, then whip out their iPhones, iPads and other gadgets, or sometimes, a designer bag. I'm tempted to search for them on Facebook to see if they've been going on overseas holidays as well.

20 years ago, I was asked during my medical school interview whether smokers who get lung cancer should receive healthcare subsidies. Being young and naive, I replied yes, and that these would be adequately supported by the Medisave, MediShield and MediFund schemes.

2 decades on, my cynicism and constant frustration make me say otherwise.

Should recalcitrant patients be afforded the same level of subsidy as those who obediently follow their doctors' instructions? The former also tend to clog up the EDs and occupy inpatient beds, in addition to having lower quality of life, thereby sapping more healthcare and community resources.

[ p.s. I am excluding patients with cancer from this discussion, as their aetiologies are widely variable and can't always be attributed to lifestyle choices. ]

Should our government help people who don't even bother to help themselves? Shouldn't patients with such cavalier attitudes about their health be penalized in some way? Maybe arm-twisting tactics are the best solution?

Implementing a monitoring system isn't impossible. Proof of clinic attendance is straightforward, and failure to show up should prompt a phone call and an entry in the computerized records.

As for lifestyle modification, how about making it compulsory for all patients with newly diagnosed or poorly controlled diabetes mellitus, hypertension, hyperlipidemia, asthma and ischemic heart disease to attend health education classes and join support groups, instead of engaging them only during hospitalization and clinic visits? Again, attendance should be marked, and absences met with penalties.

Patients' families should also be roped in. I really can't understand why many young, well-educated Singaporeans show no interest whatsoever in their parents' conditions. There've been many occasions where they don't know the diagnosis, treatment ( including surgery ), medications, or whether their mother / father has been taking his / her medicine. Even the patient doesn't know s/he underwent coronary artery bypass surgery. The definition of informed consent in this country is really quite unfathomable.

Families can do a lot to support a patient's lifestyle choices and compliance to therapy, and should be educated in a comprehensive manner instead of given brief, verbal instructions, 90% of which they forget within a day.

As for cigarettes, I strongly suggest the government take some definitive action and impose high taxes on these products. Nobody gives a crap about those ugly pictures on the packages, or those preachy print and TV ads. The ONLY way you can stop people from smoking is by making the prices of cigarettes so insanely high that no-one can afford them. And of course, step up border patrols to deter smugglers.

Singaporeans' ballooning body mass index also has not escaped my attention. Earlier this week, I attended to an 11-year-old girl who weighs 8kg more than I do. And everywhere I go, I see people stuffing their faces and bursting out of their clothes.

Enjoying your food is one thing, but these days, it seems the Singaporean mentality encompasses everything excessive - eating, spending money, enjoying life. Are our leaders aware of what's going on, and will they do something about it?

If the answer is no, then make sure you build more hospitals and hire more doctors and nurses. And prepare yourself for a catastrophic decline in national health, and its long-term effects on the economy.

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