Do TCM doctors do blood tests?

I find it strange to have patients coming to my clinic to ask me to perform blood tests for them so that they can check whether their cholesterol levels are adequately controlled by the Chinese Physician's prescribed herbs.

The patients also tell me that the Chinese physician never asked them to go for a blood test. It's their own initiative.

Do Chinese physicians do blood tests? If not, how do they monitor their patients for glucose control, cholesterol levels etc?

I think I should just not think so much and just be happy that I have business and profits from doing blood tests for TCM physicians.

Debate in the papers

I must say today's Straits Times Forum page is filled with letters about doctors!

Today's Straits Times Forum page

If one is sensible and mature, they'll realize that at the end of the day, both patients and doctors should work together rather than against each other if they want to make things pleasant for each other.

I've had my own fair share of "last-minute" arrivals at the clinic. In fact in some cases the patients come AFTER the clinic closing time.

I remember fondly one patient who came to the clinic 5 minutes after we closed for his regular check up for diabetes and to collect his medication.

I asked him nicely whether he knew what time the clinic closed. And he replied "yeah I know. Sorry lah doc. I watched finish wrestling then I come"

"Wrestling?"

"Yeah WWF you know! Smackdown!"

When I told my wife why I came home later than usual, she told me "Next time you should tell those patients that you wished you were watching Smackdown at home too!"

Frankly, all this has nothing to do with what time the clinic writes that it closes. I mean in many cases my clinic opens well past its closing time. Sometimes up to 1 hour after the official closing time. Most of the time we see cases where the patients could have definitely come earlier. But for some reason they don't. I think many Singaporeans work till very late too. So they can only bring their children or elderly parents to see the doctor at late hours after work.

We doctors can understand and accomodate. But we also hope that patients can understand our efforts, appreciate them, and not abuse that service.

Let's work together to make things better. Cheers!

Street 11 clinic replies

Street 11 Clinic reply

The reply from Street 11 Clinic is out.

It looks like a clear case of miscommunication. Did Mdm Gan bring up her concerns to the clinic at the time they presented?

Or did she choose to go straight to the Straits Times instead?

Personally I am never comfortable seeing "doctor-hoppers". These people tend to be rather impatient, ignorant and unwilling to learn more information. What they want are instant cures.

They go to one doctor, don't get the results they want and go to another doctor. Most of the time if you ask these patients whether they know anything about the types of medicines they have been prescribed and the natural course of their illness they would give replies to the effect "Dunno, not interested, dun care"

Doesn't make for a very good patient-doctor relationship. Some would say what relationship?

But you see, the relationship between you and your doctor is very very important in helping you get well. Think about it.

Singapore team entry to Winter Olympics?

I was watching the coverage of the Winter Olympics on TV.

There was a strange game where people slid a polished stone on ice into a target. This was a Winter Olympic sport called Curling.

I was thinking, this sort of game can be played by nations like Singapore. And we could get a team into the Winter Olympics too.

Here's some information about Curling.

http://en.wikipedia.org/wiki/Curling

Anyone keen to explore possibilities of bringing this sport to Singapore?

Regarding drug profit margins

Hugewhalshark wrote :" I find it surprising that doctors make more (I mean more $, not more %) on generics. Let's say a generic sells for $10 a course and a non-generic, high power alternative sells for $30. Maybe you make 60% on the generic = $6. To make the same $6 on the non-generic you only need to make 20%. You mean that the margins can be that different?"

Comment from Hugewhaleshark

The margins for generics are higher than 60%. But that is besides the point.

You see for the doctor earning the same amount of money in your example one patient's bill for her antibiotics is $10 while the other is a whopping 300% higher at $30! And the drug may actually be the same eg Clarithromycin (just different brands and manufacturers and dosing)

It makes a big difference in the psyche of a customer. This is where pricing in business comes in. After adding consultation of $18 and assuming just antibiotics prescribed it's either $28 or $48!. Which would you rather have?

Of course perhaps it would be better if the doctor explained to you and gave you the option of choosing generic vs non-generic then it would be up to you. That would be better right?

But I'm just wondering. Which would you choose?

High prices for common drugs in HDB heartland

I read this blog and its comments on "High prices for common drugs in HDB heartland"

Mr Wang Bakes Good Karma blog

I posted a reply but it does not show up on the blog so I decided to put it here.

Here's some information for all people out there wondering how doctors can "decide" whether or not you need antibiotics in a typical flu or cold.

Actually there is a way to assess patients to help decide if they need antibiotics. We all learnt it in med school. Yet it is not widely practised. Read on to find out more and why.

Here's how :

Patient comes in with upper respiratory tract symptoms. Doctor suspects it might be bacterial in nature based on clinical symptoms and signs. Do note however that majority of common flu, colds, sore throats and bronchitis are caused by viruses.

Check out what the US CDC Campaigns are like.

What's the cause of your flu, cold, sore throat, bronchitis?

Get smart about antibiotics

Anyway the doctor explains to the patient the possibilities and advises that they perform a "Throat Swab culture and sensitivity" or a "Sputum culture and sensitivity".

This involves swabbing the back of the throat with a sterile cotton swab near the tonsils. The swab is placed in a tube of culture medium. The culture is a laboratory test done to isolate and identify organisms that may cause infection in the throat. What happens is that the test is sent off and the patient gets symptomatic treatment.

The lab will grow the organisms in the culture and identify them. They will also place antibiotics chips into the agar and see which antibiotics kills the bacteria (you can see a zone of clearing around the antibiotic chip). The doctor then gets a report that details the type of bacteria found, and which antibiotic kills it. (Remember there is antibiotics resistance abound these days).

The doctor then gives the patient a call and asks if he/she is better. If not better come back to get the appropriate antibiotic that kills the identified bacteria in her system that is causing the infection.

Information on throat swabs

This way we choose the appropriate antibiotic and know it is necessary. It might be Klacid, it might be something as cheap and simple as Penicillin!

Now for my patients who want to know more about whether they need antibiotics, this is what I tell them. The problem is this. The Labs charge $43.50 for the Throat Swab Culture. This is the COST PRICE to me the doctor. I tell patients this is the cost price which is what they will pay. I won't earn a cent from doing the test. You still want to do the test?

Most responses would be "What? $43.50 to do a test to decide if I need to take antibiotics that cost at the most $30? I think no need lah. You decide doctor. Want to give antibiotics you give. If don't need then don't need."

So I will tell them most flu and colds are viral in nature and antibiotics don't work. And I give them a print out of

Get smart campaign by US CDC

and

Chart of bacterial vs viral infections

for further reference.

But I do tell them that if they don't get better after a 3-4 days or get worse, please come back and consult me because yes sometimes it is a bacterial infection that needs antibiotics.

Communication is the key lah!

Tactics for GPs in Singapore

I was reading a comment made by a 5th year medical student who says he is a future medical administrator over at angry doc's blog.

http://www.blogger.com/comment.g?

blogID=15575652&postID=114052645118601554

Ang Yee, Gary suggested "1. raise GP consultation fees to a suitable one and allow pharmacy to sell medicine instead."

You don't have to raise it. You only need most GPs to charge what the recommended consultation fee is.

The problem is that in Singapore the culture of the patients is that no medicine = no need to pay.

Go see doctor = go get medicine.

If we reverted to a consultation system, the GPs would be happy, but the people would be up in arms. People like Gary in the admin who came up with such unpopular policies would get fired because the Minister would also get fired.

That is the culture in Singapore. It is almost impossible to change now.

I was just thinking about the complaint case again in the ST forum page last night. The one about how this patient got very good medicines but felt she was paying too much. Seems to be that in Singapore, these are the options GPs take in their practices :

1) Give patients cheap generic medicines. Stay away from new drugs unless patients specifically request for them. They are expensive, and inflate the bill to look very scary.

Advantages : It is very cheap in terms of cost. Keeps the overall bill for the patient low and presentable also. Profit margins are higher because of the very very low cost of the drugs. So although you charge $2 for a course of generics, you make $1.90! Compared to say charging $20 for the non generic and making $3!

Disadvantage : patients would say your medicines are old and similar like what they get in SAF camps. Bad for clinic image.

2) Keep the newer non-generic drugs for "special" patients. Either those who are RICH or those who are the "Can give me more better medicine" types.

Advantages : The profit margin is actually lower, but it is good for the image of the clinic. "That clinic give 'special' new medicine you know!"

Disadvantages : Downside is that the cost of the medicine from the pharmas is very high. So profit margins are lower. Yet the bill is scary to the patients. You will get complaints letters like these in the Straits Times http://straitstimes.asia1.com.sg/forum/story/0,5562,372710,00.html?

3) Create a niche market for yourself. Go into some special area of interest which is as far removed from mainstream general medicine as possible. Eg Aesthetics, alternative medicine, nutrition, mesotherapy etc.

Advantages : Mainstream medicine is not lucrative because people will not pay GPs extra to manage what they can get for much cheaper at the polyclinics or the subsidized specialist clinics. But they would pay for what they cannot get there. Serve the rich and prosper.

Disadvantages : Be prepared to be ostracized by the morally righteous right wing groups. Medical malpractice insurance does not cover mesotherapy anymore.

4) Stay away from being a absolutely good practising doctor. Patients want to hear what they want to hear. Patients who have very minor trivial problems should be treated seriously and told they are very ill and need a lot of treatment. Especially the chronic clinic hoppers. This endorses their fears and addresses their concerns. They will like the doctor. Give conditions like tension headache a different sounding diagnosis like Migraine. Common colds should be called excessive heatiness in whichever dialect and treated with the most unusual concoctions.

Advantages : As most of these problems are self limiting they will get better anyway, but they will attribute it to the treatment the doctor gave! Patients will love you the knowledgable doctor who tells them they have a "serious" problem when other doctors dismiss them.

Disadvantages : The rest of the profession would call you a quack. Problem in staying sane treating all these neurotic hypochondriacs.

5) For patients with chronic problems eg Diabetes and Hypertension, just give them the token medication and if their condition is not severe just say it is well controlled even when it isn't. The patients will like you. For example for hypertension, if the BP is 160/90 tell them "For your age it is ok so don't worry"

Advantage : They will keep coming back because you are the only doctor who tells them what they want to hear, never increases their medicines unlike other doctors, especially the young guy across the road who says that above 140/90 means Grade I hypertension for patients 18 and above according to MOH clinical practice guidelines.

Disadvantage : none, is already widely practised.

6) For patients with very poor compliance or very badly managed conditions, tell them to go to the hospital, OPS because treatment is very expensive and going there would be cheaper. Waive the fees for these patients. They will appreciate it.

Advantages : The aim is that you don't want to have a bad rep of treating gone case type patients who die on you. When the death comes, they will call you to sign the death cert and you can still make money for the visit.

Disadvantage : none

Yes market forces are at work. But it works both ways. For a GP to survive and prosper in Singapore, he has to know what the market wants and adapt accordingly. There is no place for the practise of good proper family medicine in Singapore. We are not Australia or Canada we have to accept that.

What's the definition of "selling MCs"?

What's the definition of selling MCs?

To me, that means people come to the clinic, the doctor doesn't even bother to see them, they pay a fee and they walk of with an MC for days off work. That's selling MC.

Now some people have told me (especially so in the SAF), that selling MC means giving MC to patients who are "not really sick".

Now here's where it gets very silly. How do doctors make a diagnosis? History and physical examination, and if needed investigations to confirm the diagnosis. But most of the diagnosis is made from the history taking.

Whena patient decides to lie about certain symptoms eg say they have bodyaches, had fever before taking Panadol, runny nose, cough...... is there any way for the doctor to objectively prove that they are faking it in a standard consultation? Well the answer is definitely no.

That's not how doctors should be practising. We cannot be second guessing and questioning the reliability of the patient's complaints. That's not the way it goes. In fact the more unusual the presentation, the more serious the symptoms sound compared to what we find on clinical examination, the more likely the doctor would want to perform investigations to exclude certain conditions or confirm them.

So the truth is, if a patient complains of headaches, muscle aches, eye aches, joint aches, runny nose, cough and sore throat and ask for a day's rest, most private GPs would give the patient that rest. It is part of the treatment. In fact it's the BEST treatment. Incidentally, in the MOH distributed circular for "Criteria for Suspect Dengue", this was what was written :

A suspect case of dengue fever (DF) is defined as an acute febrile illness with two or more of the following features:

Headache
Eye pain
Myalgia (muscle aches)
Arthralgia (joint aches)
Rash
Hemorrhagic manifestations (bleeding)
Leukopenia (a drop in white blood cells on blood test)

So as you can see, if you told the doctor you have headache, muscle aches and joint aches with an acute onset of fever, you would be a suspected dengue fever case already!

So if a patient who is sick requests for a day off, I usually give it to them. Unless of course they are really chronic regular MC seekers. Even then this is hard to prove and there are a lot of sensitivities involved.

Anyway, there was no course in medical school called "How to diagnose a malingerer in General Practice 101"

East Coast Parkway!

I went to East Coast Parkway for a dinner at a restaurant last night.

I have not been to East Coast for years!

I must say that the place has changed quite a bit! New buildings, new restaurants.

But gosh there were so many people!! For one, there was a long jam leading from the ECP into the service road and into the car park. The free carparks were totally full. Even if you wanted to park illegally you could not. All the illegal spots were taken up too!

Even the paying car park had a queue.

When we got to the park area it was filled with people! Looked more like those CNY Pasar Malam markets. Only this time there were bicycles and roller bladers zipping past dangerously close to knocking people down!

I must say it was hardly scenic or tranquil. East Coast Park is more like another shopping centre these days. No wonder there is talk of having flea markets and all. It is ALREADY like a flea market for heaven's sake!

I wonder why President Nathan doesn't come to the park on weekends? I mean if he is really interested in meeting people and be in touch with the ground, he should come on the weekends. It's crawling with thousands of his people. Instead he goes on weekday mornings when the average man has to go to work. Who are those other people who go to the park on weekday mornings anyway? Rich men? Tai tais? Retirees? Talk about a skewed perception of reality.

Supermarket shopping bags vs garbage bags?

I heard on the radio how the supermarket chain NTUC was hoping to get more customers bring their own bags instead of using plastic bags to bag their products home.

They talked about it as an environmentally friendly effort.

It was also mentioned that at present moment the many tonnes of plastic bags that are disposed of is used to produce heat in the incinerators, which means it is not totally wasted.

But again it was emphasized that they hope that shoppers would use less plastic bags.

Now I don't know about other people. But in the HDB flat that I live in, almost all the households bag their refuse using the shopping plastic bags. We throw our refuse into a rubbish chute. The chute opening measures 45cm by 35cm. On top of the chute door is a sign saying "Please bag your refuse before throwing it down the chute"

Now if you ask me. It is hygienic and a good thing that people bag their refuse. It makes collection of the rubbish easier and reduces smell and other hygiene risks. So bagging is the way to go. What is the best bag to use? Plastic bags. Whether they are commercial (usually black) garbage bags or supermarket bags, they are still made of plastic.

I think the current balance is good. People go to the supermarket, they get plastic bags. They go home and use the bags to bag their refuse.

Now should the supermarkets stop giving plastic bags and people bring their own bags. Then we will either see people buying commercial garbage bags to bag their refuse or see them throwing it down the chute unbagged! In the first instance, what's the difference to the environment if we throw commercial plastic garbage bags vs supermarket plastic bags? Isn't it the same?

In the second instance, there will be more problems for the garbage collection companies not to mention health risks from poor hygiene conditions around the rubbish collection points. Think flies and insects and stray animals....

Another thing about commercial black garbage bags, they are too big. The chute opening is 35cm by 45 cm. How big is a standard commercial garbage bag? Bigger than that. So we will not be able to fill the bag optimally with rubbish because it won't fit the chute door! Hence more wastage of plastic.

I think the real reason for this drive is that the company has looked at how much they spend on plastic bags. And they realize that although they have already passed the cost to the customers in the pricing of products, if they could save on plastic bag usage and keep product prices as they are.......they will get MORE PROFITS!

I think the companies are pretty smart here. But they can't hoodwink everybody.

Saving Private Hamster Day 2

Interesting what happened yesterday. Here it goes...

My wife brought the hamster to the vet. But before seeing the vet, Michelle had started eating and eating and eating.....

When they saw the vet, Michelle was running on the wheel. The vet asked my wife what's wrong with the hamster? And my wife told her. The vet looked at my wife and said "Well it doesn't seem like she's inactive now!"

The vet took her and checked her and said that besides being slightly dehydrated, he couldn't find anything else wrong with her.

Anyway in the end he just gave a syringe of glucose water to feed her if she gets slow and inactive again.

When I went home the hamster was like normal. I noticed she is on an eating binge though.

Looks like all's well. We haven't had to feed her the syringe of glucose water.

We're gonna get her a bigger cage tonight.

Anyway here's my assessment of the whole episode.

Firstly the hamsters lived together at the shop in the same enclosure. The pet shop people told us they could stay in the same enclosure. They asked to see what type of enclosure we would be using and we brought it to them. They saw it and said it's ok. And they put the 2 hamsters into the enclosure for us. I have read on the net that Syrian hamsters are definitely solitary animals and should not be bred with another hamster of any breed. Winter whites and Campbells are supposedly more likely to live together. In fact the Campbell male does not need to be seperated after the female gives birth because he helps to raise the young!For the other breeds it's a definite no-no to have the male around because the female is more likely to eat the young.

So the fact that we mixed the two in the same cage was not solely our decision. In fact the pet shop people are still telling us that we can mix their bedding (smell) together after two weeks and try to put them together again. So apparently winter whites do live together.

But I'm probably not going to take that chance again.

Secondly, whatever I did for Michelle helped her. But I agree that from another point of view, what I did was not the best thing to do. But I would like to say a few things regarding my decision to do what I did.

When I read up on the treatment protocols for rehydration, I found them very practical and logical. I was also confident of giving the hamster a subcutaneous injection of fluid into the back of her neck. Perhaps people who regularly handle needles and syringes and give injection would appreciate what I'm saying. Little aspects like how deep the needle penetrates, feeling the give, withdrawing to check you are not in a vessel, the resistance felt when pushing the fluids in....these are skills and experiences not every layman would have. I did ask a few people about how they give the hamsters injections (these were pet owners who saw how the vet did it, as well as lab researchers who do give the injections to the hamsters they work with). They all said the same thing, pinch up the skin at the back of the neck and inject it subcutaneously.

While I was not confident of giving the fluids intraperitoneally, I was very confident of the skin on the back of her neck. As part of my biology classes and medical classes I have handled these rodents before. And one of the things I have done is dissecting a hamster. So I do know how their skin is.

I made a decision to do the subcutaneous injections after much thought. It was not a light decision. Much research was done before proceeding with it. I knew what I was doing and was confident. And looking at the contents I was injecting ie saline and dextrose I was certain these would not possibly be the cause of death to the hamster. The information on the amounts of fluids required was also available on the net.

I feel happy for Michelle that she is well again. In fact my wife now says that instead of the hamsters being the kids and hers, they have become my babies because I'm more anxious about them more than anyone else in the family. My wife and kids are actually amazed that just simple "salt and sugar water" injected could make such a marked improvement in less than a day.

But I do agree that on principle, the best person to treat a sick hamster is a vet. However between doing nothing and letting nature take its course and a medical doctor giving subcutaneous injections into the back of the hamster's neck, I think the latter would be preferred.

There are people out there who might have just left the hamster to die and say that spending money to see the vet is a waste of money. Well that's them. I think we should value life and if you are able to spare the money to save a life, please do so.

Off to the vet

I've told my wife to take the hamster to the vet.

We'll see what happens.

Cruelty to animals

Uglybaldie brought up a good point about cruelty to animals.

When a vet gives an injection to a hamster, is that animal cruelty?

What about lab researchers who do the same in the labs? (See : http://www.brocku.ca/researchservices/ethics/animalcare/assets/documents/standardoperatingprocedures/health/health_15.pdf)

What about someone like me giving the injections to my pet hamster?

Worth pondering over don't you think?

Saving Private Hamster Day 1

Last night I injected a total of 2mls of 5% Dextrose and 2mls of Normal Saline into the hamster's neck subcutaneously.

We also gave her some oral feeds of Pedialyte solution. Total about another 2mls. She was very very weak. Hardly struggled at all.

This morning she was still lethargic but moving a bit more. When we tried to pick her up she started to struggle quite a bit. That was a good sign.

Gave another 3mls subcutaneously and oral feeds 2mls.

Observed her for a while. She's opening her eyes. Could climb onto her wheel and made a few walks on it.

Looks like things are picking up.

Treating my hamster

I think Michelle the hamster is probably dehydrated.

I google searched a bit about fluid therapy for hamsters. Found some information at research sites that use animals for research.

For example
http://www.medresearch.utoronto.ca/b_9_2.html

I checked with an online friend who has brought his hamster to the vet before and he said the vet injected fluids into the skin and stomach.

I reckon thats subcutaneous and intraperitoneal fluid replacement.

After I finish work tonight, it's off to perform some hamster fluid resuscitation at home.

Meanwhile my wife is doing some syringe feeding at home.

Hamsters gone crazy!

Last weekend my wife and the two kids aged 4 and 3 went to a pet shop.

The pet shop had too many hamsters and were giving them up for adoption. My kids and wife wanted to get 2 hamsters.

My cousin had a hamster and had an enclosure with all the wheel and stuff. Her hamster had died of cancer a couple of months back. So we borrowed the equipment from my cousin and on Sunday we went to collect 2 hamsters from the pet shop. We bought pet food and sand bath from the shop.

They gave us 2 winter white sapphire breed hamsters that had been living together in the same cage at the shop.

We put them into our enclosure and they were alright with it and each other. While we were going home, they mostly stayed in this little soap box like thing. It was a tight fit for both of them but they huddled together.

When we got home my wife filled the soap box thing with the bath sand.

The 2 hamsters came out and started to explore the enclosure. Then after a while we heard some high pitched shrieks and squels. Then we saw them fighting. The bigger hamster (Celeste) wanted to get onto the wheel but the smaller (Michelle) (My kids named them don't ask me why) one screamed at Celeste and they fought. Then Michelle went into the soap box and started bathing herself in the bath sand. And she did not come out. Whenever Celeste wanted to get into the soap box, Michelle would bite her.

We thought that Michelle was one selfish bitch. Only wanting the sand bath all to herself. Anyway she never came out of the soap box. And everytime Celeste got close we would hear a shriek.

Overnight.....and next morning we saw that Celeste had a cut on her nose. Michelle was still in the soap box. I told my wife that we should buy another soap box for Celeste because she had to sleep on the wheel.

So we went to buy another soap box. We put it in and Celeste liked it.

My wife wanted to change the bedding of the enclosure so we took the 2 hamsters out. After that we put Celeste back in first and played with Michelle (they have this ball thing that the hamster can run inside on the floor)

When we put Michelle back into the enclosure, Celeste ATTACKED her. She pounced on her and bit and bit and bit her on the back and butt! The screams from Michelle were terrible!

Michelle ran into the soap box and hid there.

At that moment we realised that we were wrong. Celeste who is bigger was attacking Michelle who is smaller, not the other way around. And Michelle was too scared and injured to fight back. So she hid in the soap box. She did not come out to eat nor drink for 2 day! I guess I would do the same if there was this person outside, 1.5 times my size waiting to bite me and beat me up.

We rushed out to get another cage from a pet shop nearby and quickly put them in seperate cages.

I told the kids, that was a good example of how we should always know the full story before we start passing judgment and labelling people names.

Anyway right now Michelle has been very lethargic and weak. She has not eaten anything and drunk very little water. I think she's dying. We'll do our best to feed her some protein mixture and water with a syringe. Her wounds don't look that serious but I am no vet.

Hopefully we can nurse her back to health, but it doesn't look promising.

It's been a slow week

Got nothing new to post about leh.

Got no good movies to watch leh.

Football all bad news for Liverpool leh.

I am busy helping my kids raise hamsters. The two hamsters fight until got blood man! Had to seperate.

But you guys want to hear about raising hamsters ar?

The missing dollar paradox

Three ladies go to a restaurant for a meal. The bill is $30. They each put $10 on the table, which the waiter collects and takes to the cashier.

The cashier tells the waiter that the bill should only have been $25 and returns $5 to the waiter in $1 coins.

On the way back to the table the waiter realizes that he cannot divide the coins equally between the three ladies.

As they didn’t know the total of the revised bill, he decides to put $2 in his own pocket and give each of the ladies $1.

Now that each lady has been given a dollar back, each of the ladies paid only $9.

3 times 9 = 27.

The waiter has $2 in his pocket.

Two plus 27 is $29. The ladies originally handed over $30. Where is the missing dollar?