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VO L . 5 0 N O . 8 | AU G U S T 2 0 1 8 | M C I ( P ) 0 5 0 / 0 1 / 2 0 1 8
WAR N
DIABETES
One People, One Nation, One Singapore
news
CON T E N T S
Vol. 50 No. 8 2018
EDITORIAL
BOARD
Editorial Insight
04 The Editor’s Musings 20 Weight Loss – A Viable Way to
Editor
Dr Tan Yia Swam Manage and Reverse Type 2
Dr Tan Yia Swam
Deputy Editors
Diabetes Mellitus?
Dr Tina Tan Dr Tan Tze Lee
Dr Tan Tze Lee Feature
Editorial Advisors
05 War on Diabetes – Where Are
A/Prof Daniel Fung We Now? SMA CMEP – Medical Ethics
A/Prof Cuthbert Teo Dr Wong Tien Hua 22 Professional Accountability (Part 2)
Dr Toh Han Chong Dr Peter Loke
Members
Dr Chie Zhi Ying
Dr Jayant V Iyer Interview
Dr Jipson Quah
Dr Jonathan Tan
24 Holistic Care for Singapore’s
Dr Jimmy Teo Vulnerable Population – Interview
Dr Alex Wong with Dr Goh Wei Leong
EX-OFFICIOS
Dr Lee Yik Voon
Dr Lim Kheng Choon Event
28 Ready, Let’s Golf!
EDITORIAL Sylvia Thay
OFFICE
Senior Manager
Sarah Lim
Assistant Manager
Sylvia Thay
Editorial Executive
Jo-Ann Teo
ADVERTISING AND
PARTNERSHIP
Li Li Loy
Tel: (65) 6223 1264 President’s Forum
Email: adv@sma.org.sg 08 A National Campaign,
PUBLISHER A National Effort
Singapore Medical Association Dr Lee Yik Voon
2985 Jalan Bukit Merah
#02-2C, SMF Building
Singapore 159457
Tel: (65) 6223 1264
Council News From the Heart
Email: news@sma.org.sg 10 SMA’s Letter and MOH’s Reply on 32 A Purposeful and Fun-Filled Day:
URL: https://www.sma.org.sg Doctors’ Duty to Report Unfit-to- Combined Effort for Hospice Patients
UEN No.: S61SS0168E Drive Cases Tan Si Qi and Joshua Tan
DESIGN AGENCY
Oxygen Studio Designs Pte Ltd 12 Forging Ties across the Causeway AIC Says
Dr Wong Tien Hua
PRINTER 34 Connecting Seniors to Social and
Sun Rise Printing & Health Support in the Community
Supplies Pte Ltd 13 Honouring Excellence
Agency for Integrated Care
14 Highlights from the
Honorary Secretary Indulge
Opinions expressed in SMA News reflect the Dr Lim Kheng Choon
views of the individual authors, and do not 36 Recipes for the Home Cook
necessarily represent those of the editorial Dr Soh Poh Choong, Dr Alex Wong and
board of SMA News or the Singapore Medical
Dr Tan Tze Lee
Association (SMA), unless this is clearly
specified. SMA does not, and cannot, accept
Survey
any responsibility for the veracity, accuracy 15 Joint Survey on the Public
or completeness of any statement, opinion or
advice contained in the text or advertisements Sentiments towards the
published in SMA News. Advertisements of National Electronic
products and services that appear in SMA News
do not imply endorsement for the products Health Record
and services by SMA. All material appearing
in SMA News may not be reproduced on any
platform including electronic or in print, or
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.
editorial
Tan Yia Swam
So many things have happened in recall anybody claiming the system’s
the medical landscape in the past security would be invincible. I also
weeks – so much that I cannot do not recall anybody elaborating
decide which to comment on. After on the consequence of a successful
serving on the SMA Council for hack – ie, that when (not “should”) Editor
more than ten years, I know that one happens, all exposed content
few readers grasp the spectrum would be open to reading, copying Dr Tan is a consultant at the Breast
of matters that we (as volunteers, or alteration. In retrospect, this Department of KK Women’s and
mind you) grapple with. But recent raises an interesting point about Children’s Hospital. She continues to
events have left even “old-timers” the NEHR: If security can never be juggle the commitments of being a
shaking their heads in disbelief. immortal, surely a patient should
doctor, a wife, the SMA News Editor and
This issue was originally intended surrender his/her current rights
the increased duties of a mother of three.
as a call to arms, to join in the to privacy and confidentiality of
She also tries to keep time aside for
waging of the “War on Diabetes”. his/her personal data, only after a
herself and friends, both old and new.
Though still important, this has been process of informed consent meeting
overshadowed by the shocking the Montgomery test standards.
cyberattack on Singapore Health Back to the present. The official
Services’ (SingHealth) database reaction to the loss of personal
that has left 1.5 million patients data was short and brief. The SMS concentrate on my job. I can’t do it
(me included) personally affected. notification said: “Your name, IC, race well if I have to simultaneously worry
and birthdate were accessed but not about IT, financial, legal and other
I have long been a supporter of the
altered… No action needed.” This non-medical problems as well. A
National Electronic Health Record
reassurance seems different from an heartfelt appeal to the authorities: It
(NEHR). Those of us in the restructured
independent website that advised helps tremendously when we know
hospitals find it very useful for tracing
that my name, IC and birthdate that you listen, and that you take our
patients’ results from years ago or
are all that is necessary to steal (or points to heart when we voice our
from other institutions. In preparation
clone) my identity. This point was concerns. It matters hugely that you
for a compulsory nationwide
not dismissed upon direct enquiry, do not dismiss us so casually. Please,
implementation of the NEHR, the
but neither was any advice offered listen. And thank you for doing so.
Ministry of Health has held meetings
in recent months to seek the opinions on how to reduce the risk. Talking to PS: Due to the time constraints in
of the professional bodies, including learned friends, and a quick online producing this newsletter, we were
SMA. Three recurring concerns I heard search, produced some useful advice not able to cover more aspects of
raised were of: surrendering personal which I have implemented. If you telemedicine in this issue. We do have
control of individual privacy; replacing had been affected by the SingHealth one in the works, so keep a lookout
patient confidentiality with generic database hack, I hope you have for it in the coming months – a young
“authorised access”; and an instinctive taken steps to protect yourself too. entrepreneur is developing an app for
feel that no security system, however I want to end by saying: I am just personal medical records, which allows
comprehensively designed, can a simple doctor. I am here to look each individual to limit the access as
be invulnerable. Speaking only of after patients. I need support from he/she wishes. I’m sure this would be of
those meetings I attended, I do not trained non-medical colleagues to great interest to doctors and patients.
04 AUG 2018 SMA News
FEATURE
Text by Dr Wong Tien Hua,
SMA Representative on the MOH Diabetes
Prevention & Care Taskforce
Dr Wong is the
Minister for Health Mr Gan Kim Yong public to visualise and understand.
1st Vice President declared a “War on Diabetes” in his Compared to pictures of a heroin-
of the 59th SMA budget speech in parliament on filled syringe, an ulcerating tumour,
Council. He is a 13 April 2016. To declare war on a lit cigarette or an infective microbe,
family medicine
physician practising
a chronic disease is remarkable diabetes is an abstract illness.
in Sengkang. because it has not been done before. The factors that can lead
Dr Wong has an As I had written in the May 2017 to diabetes include genetic
interest in primary edition of SMA News (http://bit.
care, patient predisposition, diet and lifestyle.
communication
ly/2LshIZx), the US had previously These are notoriously difficult
and medical ethics. declared war on drugs and war on issues to manage especially in
cancer, with similar declarations in the perspective of population
other healthcare systems against health. Take for example, dietary
tuberculosis (an infectious disease) factors and the problem of sugar
and tobacco (a carcinogen). and carbohydrates. The public has
These other “wars” tend to be long been aware that sweetened
agent- or disease-specific. Diabetes, soft drinks are high in sugar and
on the other hand, is an invisible therefore bad for health, but recent
disease with multifactorial causes and attention has shifted to the role of
is thus difficult for patients and the refined carbohydrates in the diet,
AUG 2018 SMA News 05
such as that in white rice and white one of the world’s highest rates of necessary because diabetes onset
bread. These refined carbohydrates lower extremity amputations. There is insidious and asymptomatic
have a high glycaemic index, are projections that estimate that at the early stages. Patients
which means that they are rapidly close to one million Singaporeans may not volunteer themselves
absorbed into the blood stream and may suffer from diabetes by 2050. for early screening especially if
could cause sugar spikes associated Singapore’s diabetes prevalence there is no incentive to do so.
with the development of diabetes. rate (10.5%) is higher than those in GPs will by now be familiar with
Singaporeans typically consume a Japan (5.7%), Finland (6.0%), Taiwan the enhanced Screen for Life (SFL)
few portions of white rice a day; it’s (8.4%) and Hong Kong (8.0%).3 programme that was rolled out
a cultural heritage that has been The Diabetes Prevention and by HPB on 1 September 2017.
passed down the generations. Care Taskforce is a high-level inter- This programme enables
Changing such deeply ingrained ministerial committee that was eligible Singaporeans to screen
habits is no doubt a challenging task. set up in June 2016 to spearhead for five conditions: hypertension,
In 2016, the Health Promotion Board efforts to address diabetes in hyperlipidaemia, diabetes mellitus,
(HPB) highlighted white rice as a three key areas: healthy living and cervical cancer and colorectal
concern in the fight against diabetes, prevention, screening and follow- cancer. HPB has sent letters to the
which was reported in our local up, and disease management. patients’ homes and recommended
press.1 A follow up story seemed to You would recall that Prime a visit to a nearby participating clinic
suggest that this led to some alarm Minister (PM) Lee Hsien Loong, for health screening. These active
in the community, reporting that during his National Day Rally on 20 reminder letters help to create
targeting white rice “has created a awareness and encourage at-risk
August 2017, singled out diabetes
storm of protest from rice lovers”.2 individuals to go for screening tests
as one of three key long-term issues
early at a highly subsidised rate,
for Singapore. This underscores the
An urgent problem before the onset of symptoms.
importance of diabetes in a whole-
Minister Gan reported in his 2016 of-nation effort to tackle the disease However, diabetes screening under
budget speech that about 400,000 and further emphasises the urgency SFL applies only to individuals aged
Singaporeans are diabetic and the and seriousness of the problem. 40 years and above. For those below
lifetime risk of developing diabetes this cut-off age, screening should be
is 30%. Of the Singaporeans Key initiatives thus far considered at an earlier age if other
who have diabetes, one in three risk factors are present, such as obesity
has not been diagnosed. And Early screening and a family history of diabetes.
among those diagnosed, one Early screening is a key initiative In response to this, HPB has
in three has poor control of the of particular relevance to primary also rolled out the Diabetes Risk
condition. Additionally, we hold the care doctors who are the points Assessment (DRA) tool for those aged
unfortunate distinction of having of first patient contact. It is 18 to 39 years old. The tool comprises
a set of five questions including the
respondent’s age, gender, height
and weight, BMI, family history of
diabetes and history of hypertension.
Based on the information, the online
tool tabulates the risk level for
diabetes. Singaporeans found to
be at risk of diabetes through the
tool can enjoy the same subsidised
rate of S$5 for diabetes screening
and one follow-up consultation
at the participating GP clinic.
Encouraging exercise
The National Steps Challenge is
another initiative by HPB to leverage
06 AUG 2018 SMA News
on the smartphone and wearable dial down the percentage of sugar in packaged food products indicates
technology to encourage Singaporeans sweetened drinks. Channel NewsAsia that they are the healthier options to
to be more physically active. Fitness reported that seven major soft drink help consumers to make informed
trackers measure the number of steps manufacturers have agreed to reduce choices during grocery shopping.
taken and reward the wearer when the sugar content in all their drinks in Food products awarded the HCS
they reach certain defined physical Singapore to 12% and below by 2020.4 are generally lower in fat, saturated
activity milestones. Participants are Another way to change habits fat and/or trans fat, lower in sodium,
encouraged to walk at least 10,000 is to provide drinking water lower in sugar, higher in calcium and
steps a day and stand to redeem freely across the country. Public higher in dietary fibre. The number
shopping and grocery vouchers. The consultation and feedback has called of such products has grown steadily
third season of the challenge that for a “drink plain water” campaign. from an initial 300 in 2001 to 2,500
concluded in April 2018 reached out The feedback panel asked for more across 70 food categories today.
to more than 690,000 individuals. water coolers to be installed in public
Preventing diabetes areas, such as within community
centres. Minister Gan announced References
The Taskforce has been exploring in June 2018 that plain water will 1. The Straits Times. Hooked on white rice,
measures to reduce sugar in sugar- be provided at all Government but some ready to change diet. 6 May
sweetened beverages. PM Lee and People’s Association functions. 2016. Available at: http://bit.ly/2Jz01FX.
mentioned in his National Day Rally Drinking points will also eventually 2. The Straits Times. Fighting diabetes:
that some countries impose a sugar be made available freely in public Why the target is white rice. 12 May 2016.
Available at: http://bit.ly/2uHl6IL.
tax in a bid to reduce the intake of areas, such as hawker centres,
dietary sugar. Other measures being 3. International Diabetes Federation.
parks and even bus stops. Age-adjusted prevalence (20 – 79
considered include warning labels years) estimates for 2015. In: IDF
and advertising restrictions. This route Healthier food choices Diabetes Atlas 7th Edition (2015).
may be a bit hard for consumers to The Ministry of Education and HPB 4. Channel NewsAsia. 7 major soft drinks
swallow, but it certainly goes to show have been running the Healthy Meals
manufacturers in Singapore to reduce
how far perceptions toward sugar have sugar content in drinks. 22 Aug 2017.
in Schools Programme since 2011, Available at: http://bit.ly/2NYmWxR.
shifted – it is as if sugar has become serving healthier meals with less fat,
the “new tobacco”. The Taskforce is also sugar and salt, with a serving of fruit 2
negotiating with industry players to in schools. The Taskforce has extended
this concept to demonstrate a whole-
1 of-Government commitment, by
implementing the Healthier Catering
Policy (April 2017) and Healthier
Drinks Policy (November 2017) as
the default in Government premises
and at Government-organised
events. Under the policy, caterers
must provide wholegrains and plain
water, use healthier oils for all food
preparation and limit the number of
deep-fried items per order. Lower-
sugar drinks will also be the default in
government premises, while freshly
prepared hot coffee and tea must
be served with no added sugar. You
will notice that sugar and syrups are
now provided as a side option.
Legend
The range of Healthier Choice 1. All freshly prepared drinks are now served
Symbol (HCS) products has seen an with no added sugar at hospital canteens
increase in recent years. This distinctive 2. Drinks with the Healthier Choice Symbol,
red pyramid symbol stamped on with some containing no sugar
AUG 2018 SMA News 07
PRESIDENT'S FORUM
A National Campaign,
a National Effort Text by Dr Lee Yik Voon
A national campaign National Family Planning Campaign
(Stop at Two), and Keep Singapore Clean,
In 2016, the Ministry of Health (MOH),
but none of them have been on such
led by Minister for Health Mr Gan Kim
a large scale and hence its term “War
Yong, declared a War on Diabetes.
on Diabetes”. The Diabetes Prevention
We had about 400,000 diabetics then;
and Care Taskforce is made up of
one in three diabetics did not know
inter-ministerial committee members to
that they have the disease and for
those who knew, one in three had coordinate our war efforts in the other
Dr Lee is a GP practising poor control of their chronic disease. aspects of our economy other than
in Macpherson. He healthcare. Just as in any war, we need
is also a member of This is no ordinary health campaign to mobilise the public, who are often the
the current National nor is it like any other health campaigns victims, to get them to achieve a healthy
General Practitioner we have had in the past. When we state so as to not be susceptible to the
Advisory Panel. He is a declare war on a disease that affects a
pet lover at heart who onslaught of hyperglycaemia. We need
large number of people, every Singapore to gather the resources which would
is the proud owner of
a dog, and regularly citizen should be committed to the normally be employed elsewhere, to be
feeds neighbourhood war effort. To date, we have already allocated to focus on our war. I recall
community cats. He also committed more than 1 billion SGD a seeing frequent running commercials on
enjoys playing online war year to our war (against diabetes). This
games and thinks that the Pioneer Generation campaign, but
playing Pokemon Go is a
year, prediabetes has been included the current television advertisements on
good form of exercise. as one of the chronic conditions in diabetes look more like snippets from
our Chronic Disease Management a Chinese kung fu movie. Perhaps the
Programme (CDMP) that is covered advertisement for diabetes-prevention
by the Community Health Assistance is more erudite but I think I would have
Scheme (CHAS) and Medisave. preferred to have kept it simple and easy
We all recall many national to understand, so that it would improve
campaigns, such as Save Water, the retention with the requisite repetition of
National Courtesy Campaign, the the campaign message to our citizens.
08 AUG 2018 SMA News
Nationwide efforts heart disease, kidney disease, limb perhaps the zoo and Sentosa could
amputation and mental illness, as well offer cheaper entrance fees on certain
This is not just a Government campaign
as lead to inflated healthcare costs with days to promote outdoor activities.
though; we need to round up our
spirals into poverty and bankruptcy.
Government agencies, private sector, Another target to achieve is the
healthcare personnel, patient advocacy prevention of complications. I believe
groups, caregivers and case managers
Tools of war more public education in the print
to fight this war. We need to make The good news is that, of late, we have media, social networks and public
lifestyle changes and we need to persist better armamentarium to fight this war – outreach can reduce the onset of
till preventing diabetes is a way of life. we have new drugs that not only control complications. We know that many
For those who are already afflicted, we diabetes but also the complications of conditions, such as microalbuminuria
need to educate them to prevent their diabetes such as those that damage and prediabetes, can be reversed early
condition from further deterioration the heart and our vital organs. The bad on through a healthy diet and lifestyle.
and to treat complications early. We news, however, is that our medical
The War on Diabetes is a very good
also hope to see more media and colleagues are still battling the usual
opportunity for us doctors to practise
propaganda messaging, as these are problems in managing our patients, such
team-based holistic care. It is good to
vital to motivate and educate our public, as ignorance, poor awareness and poor
know that chronic disease management
to empower them to be less dismissive insight leading to poor compliance.
is not our burden to carry alone; we
and ignorant, and to reduce their Who should we set as a target have multiple healthcare partners to
susceptibility to the attack of diabetes. group and when do we institute the bear the load and share their expertise
There have been many other ideas recommended changes? We know that to better manage our patients.
from the community, such as the with the elderly group and their years of
We hope to catch those with
Running Society’s mass run every neglect, it is difficult as it may seem like
complications early so that there is a
weekend with the involvement of a lost cause. We need to focus on our
chance of reversal. We hope to catch
Residential Committees, and the Health younger citizens. In fact, we should start
with pregnant women and maybe even those who are susceptible at an early
Promotion Board’s introduction of stage to prevent them from contracting
earlier at the preconception stage. After
exercise programmes in parks and diabetes and to encourage a general
delivery, we should continue our efforts
malls on weekends. Perhaps we could healthy lifestyle among our citizens. We
for both mother and child. The mothers
extend the ActiveSG funds to create a hope to move our patients away from the
will need to understand that gestational
better environment for cycling and get hospitals and back into their community.
diabetes is an early warning signal for
students to do Community Involvement We aim to look beyond healthcare and
them to pursue preventive measures.
Programmes associated with these instead into the health of our citizens.
For the children, we should start them
activities as well, instead of selling
early, guiding them by various means After that, we still need to constantly
flags. Could we extend the Individual
to achieve a healthy lifestyle. More ask ourselves these questions:
Physical Proficiency Test to all gender
health education efforts should be put
and ages, beyond reservist liability, 1. Are we fighting a limited war or
in place in schools and for school-going
with incentive of more subsidies if they a total war? Have we mobilised
children. There was even a suggestion
achieve gold standard? Making bus enough of our nation?
to make it compulsory as part of Primary
stops further apart could be helpful, so School Leaving Examination scores. 2. Who else has the public authority in this
people will choose to walk more; and war? Certainly, it is not only our MOH?
more shelters to encourage walking There are talks of legislation to curb
under all weather conditions. The use the sugar intake and sugar tax. Punitive 3. If this is intended to be a long-drawn
of information technology and the measures and negative reinforcements war, what are the key sustainability
Internet of Things to manage wearable should not be a standalone. We objectives for the nation?
devices should also be considered. should incentivise and give positive a. Quality-adjusted life year;
reinforcement to encourage correct
The war against diabetes also behaviour. However, when our existing b. saving health dollars; or
involves our allied health professionals, healthy food choices are considerably c. not to bankrupt the nation?
like physiotherapists, occupational more costly to consume than junk
therapists, podiatrists and medical social 4. Are the current communication and
food, we need to set it right so that
workers. As for the doctors, it is not just outreach methods enough? If they
the flow in behaviour will go along the
the responsibility of endocrinologists are enough, has the community been
correct gradients. Instead of gourmet
or diabetologists; every doctor is influenced? If so, how do we secure the
holidays, we could change them to
involved as diabetes is a multi-systemic commitment of the citizens, employers,
trail-walking and camping vacations.
organ disease. The complications are Instead of massive buffet feasts when National Trades Union Congress, food
devastating and reach into every nook we gather, we should have simple and beverage sectors, and more?
and cranny of our bodies. Diabetes refreshments. Families should be getting After all, we are not only for doctors
can result in coma, stroke, blindness, together for activity-based events and but indeed, we are for our patients.
AUG 2018 SMA News 09
SMA’s Letter and MOH’s Reply on
council news
Doctors’ Duty to Report
Unfit-to-Drive Cases
In October 2017, SMA received feedback from members regarding Fitness to Drive, specifically on how a doctor can highlight unfit-
to-drive cases to the Traffic Police, especially in scenarios where the patient refuses consent for disclosure.
The SMA Council deliberated and sent a letter to the Ministry of Health (MOH) in November 2017, highlighting that:
1. there was no mechanism to report unfit-to-drive cases to the relevant authorities;
2. there was no means to require a second (or specialist) opinion on continuing fitness to drive; and
3. there was no assurance of absolution from a breach of patient confidentiality, if a doctor unilaterally reports an unfit-to-drive case.
MOH responded via email in November 2017, indicating that it was collating responses from the Traffic Police, Land Transport
Authority and other stakeholders.
In March 2018, MOH provided an official response on the matter. Both SMA’s letter and an extract of MOH’s official response are
reproduced below.
SMA’s letter to MOH
14 November 2017
A/Prof Benjamin Ong
Director of Medical Services
MINISTRY OF HEALTH
Dear A/Prof Ong,
Fitness to Drive: duty to report/warn
Doctors have the responsibility of certifying persons as fit to drive at intervals required by relevant Acts or Regulations.
However, in the interval between such statutory examinations, we sometimes encounter patients who because of specific
acute conditions, have become unfit to drive with immediate effect.
Examples are previously-well patients upon suffering their first epileptic seizure or their first episode of severe psychosis,
or diabetics whose remaining good eye had acutely deteriorated from retinopathy so much that safe driving can no
longer be assured.
Such patients are clearly a hazard to themselves and to other road-users, and should be prevented from driving with
immediate effect, i.e. even before their next statutory examination. While some such patients would voluntarily stop driving
following medical advice, others remain in denial, lack sufficient insight to comply or simply refuse outright. At the present
there is no mechanism by which doctors can alert the relevant authorities to revoke the driving license of those unfit to drive,
and in fact no assurance of absolution from a breach of patient confidentiality if he unilaterally takes either measure.
Although we have identified this gap that results in public hazard, the SMA has no authority with which to bridge it. We
therefore bring this to the attention of your Ministry for consideration of any necessary action. Doctors would greatly
appreciate a single point of contact to inform the relevant authority, as well as the assurance of absolution from breach
of patient confidentiality when doing so, as they support public safety by identifying drivers no longer able to do so safely.
Yours sincerely,
Dr Wong Tien Hua
President,
Singapore Medical AssociationMOH’s Reply [Extract] MOH’s response: Although there are no expressed
provisions in the Road Traffic Act (Cap. 276) related to
There was no mechanism (e.g. single point of contact) by which protection for the doctor in reporting patients fitness status to
doctors can alert the relevant authorities to revoke a patient’s drive, there are the following legal provisions and guidelines,
driving license; on the grounds of public interest, to protect doctor in the event
that a patient reports confidentiality breach:
MOH’s response: MOH has followed up with [Ministry
of Home Affairs] MHA and Traffic Police (TP) on this point. (a) First, section 17(3) of the Personal Data Protection Act
To facilitate ease of voluntary reporting, TP has agreed for (PDPA), read with the Fourth Schedule, provides exceptions
SMA to publish the email address, SPF_TP_Medical@spf.gov. for disclosure without consent. The Fourth Schedule,
sg, in SMA’s guidelines. This email will be in addition to the paragraph 1, states that: “An organization* may disclose
postal addresses and fax numbers in SMA’s current medical personal data about an individual without the consent
guidelines on fitness to drive. of the individual in any of the following circumstances: …
(g) the disclosure is to a public agency and such disclosure
There was also no policy to require a second (or Specialist) opinion is necessary in the public interest.” (*”organization” is
on continuing fitness to drive; defined in the PDPA to include individuals.)
MOH’s response: Currently, as indicated in the SMC’s Ethical (b) Second, the SMC ECEG provides guidance on the
Codes and Ethical Guidelines (ECEG), it is the doctors’ clinical circumstances related to defensible disclosure without
and ethical responsibility in providing appropriate advice to consent. C7(5) of the ECEG states that “Disclosure
patients on their medical conditions and implications of the without consent is generally defensible when it is
conditions. SMC’s ECEG A3(4) also states that: “If you cannot mandated by law, it is necessary in order to protect
provide services that are necessary for your patients, or most patients or others from harm, when the involvement of
beneficial for your patients, you must offer to refer them to parents and legal guardians is beneficial to minors or
other doctors or institutions which can provide the most where such disclosure is in patients’ best interests.”
appropriate service.”
(c) Furthermore, if the patient brings a civil suit against the
Lack of assurance of absolution from a breach of confidentiality if doctor for breach of confidentiality, the doctor can rely on a
the patient who refused to stop driving was reported even when defence of public interest if there are clear facts to indicate
this was done in the interest of public safety. that the patient had posed a danger to the public.
AUG 2018 SMA News 11council news
Forging Ties
acr ss the Causeway
Text and photo by Dr Wong Tien Hua
The Malaysian Medical Association Chulan Kuala Lumpur hotel in the heart the workload of his Ministry’s staff,
(MMA) was formed in 1959 and seeks to of the city, within a stone’s throw of the especially for the junior doctors. He
represent all doctors, as well as medical iconic Petronas Twin Towers at Suria KLCC. also spoke of bolstering public-private
students, in Malaysia. It is interesting to The culmination of the three-day partnerships in the healthcare system
note that both the MMA’s and SMA’s event was the gala dinner held on the and of looking into the provision of
crests bear the same motto of “Jasa evening of 30 June. The dinner was universal health coverage.
Utama” or “Service before Self”. graced by the Sultan of Perak, Sultan Finally, the newly minted MMA
Being a large country, it is logistically Nazrin Muizzuddin Shah, and his wife president, Dr Mohamed Namazie
challenging to bring all its members Raja Permaisuri Tuanku Zara Salim. Ibrahim, also delivered a speech in which
together at once. As such, the MMA The guest of honor was Dr Dzulkefly he requested for quicker placements of
holds an annual national convention Ahmad, a toxicologist by training, who housemen and a revision of the medical
together with its annual general meeting was named the Health Minister in the new fee schedule.
and annual dinner, providing a platform Cabinet of Prime Minister Tun Dr Mahathir We would like to thank the MMA for
to bring together continuing medical Mohamad in May 2018. In his speech, their hospitality and for the insights
education, networking and social events. Dr Dzulkefly stated that he wanted gained during the convention and
This year, the National MMA to address the “toxic work culture” of congress. We wish the MMA all the best
Convention and Scientific Congress was healthcare practitioners, put an end to in their endeavours to improve the
held from 28 to 30 June 2018 at Royale bullying and look into ways to reduce nation’s healthcare landscape.
Legend
1. Dr Wong with foreign guests at the MMA
annual dinner in Kuala Lumpur
Dr Wong is the
Photo: Malaysian Medical Association
1st Vice President
of the 59th SMA
Council. He is a
family medicine
physician practising
in Sengkang.
Dr Wong has an
interest in primary
care, patient
communication
and medical ethics.
12 AUG 2018 SMA NewsHonouring Excellence
COUNCIL NEWS
LTC (NS)(DR) Tang Chien Her A/Prof Tan Thai Lian
The 59th SMA Council warmly Deputy Commanding Officer Senior Consultant
congratulates our Members who are 1 Medical Squadron Tan Tock Seng Hospital
Republic of Singapore Air Force National Healthcare Group
recipients of the National Day Award 2018.
A/Prof Chong Phui-Nah
The Long Service Medal
Chief Executive Officer
The Public Service Star (Bar) Adj Prof Lee Chien Earn National Healthcare Group Polyclinics
Deputy Group Chief Executive Officer National Healthcare Group
Dr Kee Wei Heong Regional Health System
Chairman Dr Gregory Kaw Jon Leng
Singapore Health Services
Drug Rehabilitation Centre Senior Consultant
Review Committee (2) Chief Executive Officer Tan Tock Seng Hospital
Changi General Hospital National Healthcare Group
Member
(seconded from Ministry of Health)
BOVJ & BOI Adj A/Prof Benedict Tan Chi'-Loong
A/Prof Pang Weng Sun Senior Consultant
The Public Administration Medal (Silver) Deputy Group Chief Executive Officer Changi General Hospital
(Population Health) Singapore Health Services
A/Prof Aymeric Lim Yutang
National Healthcare Group
Physician-in-Chief and Group Chief A/Prof Pek Wee Yang
Human Resource Officer Executive Director Chairman Medical Board/
National University Health System Geriatric Education and Senior Consultant
Research Institute Khoo Teck Puat Hospital & Yishun Health
Dean
Ministry of Health National Healthcare Group
Healthcare Leadership College
MOH Holdings Dr Christopher Khor Jen Lock Adj A/Prof Fabian Yap Kok Peng
Senior Consultant Head and Senior Consultant
A/Prof Mabel Yap Mei Poh
Singapore General Hospital Endocrinology Service
Director
Singapore Health Services KK Women's and Children's Hospital
Professional Training and
Assessment Standards Division Dr Seet Chong Meng Singapore Health Services
Ministry of Health Senior Consultant Adj A/Prof Arjandas s/o Mahadev
Sengkang General Hospital Pte. Ltd. Head and Senior Consultant
The Public Administration Medal (Silver) Singapore Health Services Department of Orthopaedic Surgery
(Military) KK Women's and Children's Hospital
Adj A/Prof Ng Kee Chong
COL (DR) Edward Lo Hong Yee Chairman Medical Board Singapore Health Services
Chief Army Medical Officer KK Women's and Children's Hospital A/Prof Cheow Peng Chung
Headquarters Army Medical Command Singapore Health Services Senior Consultant
Singapore Armed Forces Singapore General Hospital
A/Prof Koh Tse Hsien
Senior Consultant (Head) Singapore Health Services
The Public Administration Medal (Bronze)
Singapore General Hospital A/Prof Ian Yeo Yew San
A/Prof Tan Suat Hoon Singapore Health Services Deputy Medical Director (Education)
Director Head and Senior Consultant,
National Skin Centre A/Prof Melvin Leow Khee Shing
Senior Consultant Medical Retina Department
National Healthcare Group Singapore National Eye Centre
Tan Tock Seng Hospital
Prof Wong Peng Cheang National Healthcare Group Singapore Health Services
Senior Consultant A/Prof Soh Chai Rick
National University Hospital A/Prof Daniel Fung Shuen Sheng
Chairman Medical Board Senior Consultant
National University Health System Singapore General Hospital
Institute of Mental Health
A/Prof Koo Wen Hsin National Healthcare Group Singapore Health Services
Senior Consultant Dr Ng Lay Guat
National Cancer Centre Singapore Dr Chow Mun Hong
Director Senior Consultant
Chairman Quality Management Singapore General Hospital
Division of Medicine Singapore Health Services
Sengkang General Hospital Pte. Ltd. Senior Consultant
SingHealth Polyclinics Dr Lee Wee Yee
Singapore Health Services Senior Consultant
Singapore Health Services
Changi General Hospital
The Commendation Medal A/Prof Jackie Tan Yu-Ling Singapore Health Services
Dr Eugene Shum Jin-wen Senior Consultant
Chief Community Development Officer Tan Tock Seng Hospital
Corporate Development National Healthcare Group This list may not be exhaustive. If we have
Changi General Hospital Prof William Hwang Ying Khee inadvertently omitted the name of any recipient,
Singapore Health Services Medical Director we sincerely apologise for the oversight.
National Cancer Centre Singapore
The Commendation Medal (Military) SingHealth Headquarters
Singapore Health Services
LTC (NS)(DR) Jonathan Choo Tze Liang
Chief Physician A/Prof Edmund Wong Yick Mun
192/193 Squadron Deputy Medical Director (Clinical Services)
Republic of Singapore Navy Head & Senior Consultant
Surgical Retina Department
Singapore National Eye Centre
Singapore Health Services
AUG 2018 SMA News 13council news
Report by Dr Lim Kheng Choon
Dr Lim is the
SMA office relocation SMJ impact factor rises to 1.08
Honorary We would like to inform our Members We are pleased to announce that the
Secretary of and partners that the SMA office has Singapore Medical Journal (SMJ) has
the 59th SMA
Council. He relocated to the following address improved in its impact factor for the 2017
is currently with effect from 3 August 2018. citation year, from 0.67 (2016 citation
an associate
2985 Jalan Bukit Merah year) to 1.08, and now ranks 100 out
consultant of 154 journals under the “Medicine,
at Singapore #02-2C, SMF Building
General and Internal” category of
General Hospital. Singapore 159457
the 2018 Journal Citation Reports.
Our telephone: (65) 6223 1264 and email:
The SMA Council would like to
sma@sma.org.sg remain unchanged. extend our heartiest congratulations
However, our fax is discontinued to Editor-in-Chief A/Prof Poh Kian
temporarily. Keong, the SMJ Editorial Board and the
The three professional bodies (PBs), ie, secretariat for achieving this notable
SMA, Singapore Dental Association and milestone. We wish the journal every
Pharmaceutical Society of Singapore, success as it aims to expand the body
were informed by the Alumni Association of scientific knowledge in medicine and
(AA) of a rent hike upon the expiry of improve patient care through publishing
impactful high-quality papers.
the lease at 2 College Road on 2 August
2018. Protracted negotiations between
the three PBs and AA extended into Joint survey on NEHR
the middle of July 2018 and the three SMA, Academy of Medicine,
PBs were unable to afford the new Singapore and College of Family
rent demanded by AA (ie, $4.80 psf for Physicians Singapore collaborated
a three-year lease, with $4 psf for the and funded a survey to study the
first three months). On 17 July 2018, AA public's understanding of the National
informed the three PBs that a Notice to Electronic Health Record (NEHR) and
Quit would be served and upon failure collate relevant feedback. The survey
also approached specific groups of
of the three PBs to vacate the premises,
individuals who may not routinely access
AA would proceed to impose a default
social media, various media platforms
rate of two times the existing rental rate. or public feedback mechanisms via
That being the case, SMA informed face-to-face interviews, to solicit their
AA on 25 July 2018 that it will vacate 2 opinion and thoughts. The report is
College Road by 2 August 2018. Members published in this month's SMA News
who are interested in the events that (see page 15). Preliminary results and
led to our decision to move out of 2 findings were shared with the Ministry
College Road are urged to visit http:// of Health who also took the opportunity
to provide their response on the
bit.ly/2LAWHjp to access the summary
survey in a companion statement.
of events and important documents
between the three PBs and AA, as well
as with the relevant authorities.
14 AUG 2018 SMA NewsJOINT SURVEY ON THE
Public Sentiments towards the
SURVEY
National Electronic Health Record
by College of Family Physicians Singapore,
Academy of Medicine, Singapore and Singapore Medical Association
“Singaporeans are generally supportive of the NEHR, This survey was carried out over a six-week period from
and want more control over their data.” 9 March 2018 to 15 April 2018. A total of 2,100 responses
were collected, comprising 2,000 online submissions and 100
In early 2018, in reviewing the proposed Healthcare face-to-face interviews. The face-to-face interviews were done
Services Act (HCSA), and the implications for the nationwide
to reach out to non-IT-savvy respondents aged 60 years and
implementation of mandatory contribution to the National
above, with these respondents being recruited in the town
Electronic Health Record (NEHR), the College of Family
Physicians Singapore, the Academy of Medicine Singapore and centres, key districts and heartland areas.
the Singapore Medical Association agreed to conduct a joint The subject pool comprised 90.4% (1,899 of 2,100) Singapore
survey on the public sentiments towards the NEHR. citizens, with 79.8% (1,676 of 2,100) living in public housing.
The objectives of the survey were to: 58.0% (1,217 of 2,100) were females, with the ethnic distribution
Evaluate the general public’s sentiment and awareness of being representative of the Singapore population (see Figure 1).
the NEHR; The summary of the results of the survey is as follows:
Understand the perceptions and misconceptions of the We found that 1,936 of 2,100 (92.2%; “Somewhat Support” /
public towards the NEHR; and “Support” / “Strongly Support”) of the study cohort were
Identify any concerns they might have. supportive of the NEHR (see Figure 2).
Education Occupation
0.1% None: 1.5%
0.6% 1.5% PSLE: 5.9%
5.9% ITE: 4.1%
11.9% 4.1% 23.0% PMETs (Private Sector): 49.0%
GCE 'N' Level: 3.8%
3.8% PMETs (Civil Service): 11.3%
GCE 'O' Level: 13.3%
Non-PMETs
GCE 'A' Level: 3.9% 49.0%
(Private Sector): 13.1%
3.6%
13.3% International Non-PMETs
Baccalaureate: 0.1% (Civil Service): 3.6%
33.1% Unemployed
13.1%
Diploma: 21.7%
(Housewife, Student/NS/Youth,
3.9% Degree: 33.1% Retiree, etc.): 23.0%
11.3%
Postgraduate Degree: 11.9%
21.7%
0.1%
Others: 0.6%
Did Not Specify: 0.1%
Figure 1
Overall, I would _____ the implementation of the NEHR.
92.2%
1,936 out of 2,100
Strongly Oppose 1.3% Oppose 1.8% Somewhat Oppose 4.7% Mean: 4.55
Somewhat Support 36.7% Support 43.1% Strongly Support 12.4%
Figure 2
AUG 2018 SMA News 15581 of 2,100 (27.7%) definitely wanted to have their records of the NEHR was lowest amongst those aged 21 to 29 year
maintained in the NEHR. olds (62 of 170; 36.5%) and those above 60 years old (141
of 320; 44.1%) (see Figure 4).
1,175 of 2,100 (56.0%) would like their records maintained in
the NEHR but did not want any healthcare provider to access 1,979 of 2,100 (94.2%) of the respondents felt that their
it without their explicit consent except during emergencies doctors would be able to make better informed diagnoses
(see Figure 3). and decisions with the NEHR, and it would also raise patient
safety (1,993 of 2,100; 94.9%) (see Figure 5).
314 of 2,100 (14.9%) were fully aware of the NEHR, and
1,045 of 2,100 (49.8%) had not heard of it at all. Awareness
Which of the following best describes your intention towards the NEHR? %
I would definitely like to have my records maintained in the NEHR. 27.7
I would like to have my records maintained in the NEHR BUT do not want any healthcare provider to
56.0
access it without my explicit consent except during emergencies.
It does not matter to me whether my records are in or out of the NEHR. 5.0
I would like to opt out of the NEHR presently, BUT still have my records uploaded in the NEHR
6.0
(with access blocked for now) so that they can be viewed in the future should I choose to opt in again.
I would like to opt out of the NEHR presently AND do not want any records stored in the NEHR.
3.3
Should I change my mind and opt in in the future, I accept these permanent gaps in my record.
I would like to opt out of the NEHR and am unlikely to opt in in the future. I would not want to store
2.0
my data in the NEHR at all.
Note: This analysis was based on all respondents, n = 2,100.
Figure 3
Have you heard of the National Where have you heard / received
n %
Electronic Health Record (NEHR)? information on the NEHR?
Printed media (e.g. Straits Times) 325 30.8
Television 222 21.0
Online news 210 19.9
Word-of-mouth (e.g. friends, families, relatives) 184 17.4
Ministry of Health (MOH) website 174 16.5
Social media 114 10.8
My GP / Doctor 92 8.7
Online Search Engines 84 8.0
Yes, heard of it and fully
understand what it is. 314 (14.9%) Radio 77 7.3
Yes, heard of this term but do not fully Others (e.g. Workplace, Hospitals) 58 5.5
understand what it is. 741 (35.3%)
Flyers / Brochures 50 4.7
No. 1,045 (49.8%)
Exhibitions / Roadshows 22 2.1
Note:
1. This analysis was based on all respondents, n = 2,100.
2. Analysis on "Where have you heard / received information on the NEHR?" was based on all respondents who answered "Yes" for the question "Have you heard of
the National Electronic Health Record (NEHR)?", n = 1,055.
Figure 4
16 AUG 2018 SMA NewsOn a scale of 1 to 6, where 1 means "Strongly Disagree" and 6 means Top 3
"Strongly Agree", please rate your extent of agreement with the n Mean Boxes
following statements. (%)
With the NEHR, my doctor(s) will be able to make better-informed diagnoses and decisions for 2,100 4.86 94.2
the best course of treatment to improve my health.
25.0% 42.3% 26.9%
1.8% 1.1% 2.9%
The NEHR will raise patient safety by enabling medical professionals to access critical medical 2,100 4.90 94.9
information (e.g. name of medication prescribed, diagnoses) in an emergency.
23.7% 42.4% 28.8%
1.6% 0.9% 2.6%
Strongly Disagree Disagree Somewhat Disagree
Somewhat Agree Agree Strongly Agree
Note: This analysis was based on all respondents, n = 2,100
Figure 5
Majority of the respondents were willing to disclose
general information, such as doctor’s general diagnoses
Given a choice, which of the following type of
(1,719 of 2,100; 81.9%), allergies (1,661 of 2,100; 79.1%) personal data would you be willing to make
and general medication history (1,629 of 2,100; 77.6%). available in the NEHR?
However, when it came to “sensitive” information, the support Doctor's Diagnosis – General 81.9%
was lower [medication history (1,061 of 2,100; 50.5%),
Allergies 79.1%
laboratory and radiology results (946 of 2,100; 45.0%), doctor’s
more specific diagnoses (914 of 2,100; 43.5%) and operation/ Medication History – General 77.6%
procedure notes (876 of 2,100; 41.7%)] (see Figure 6).
Vaccination History 71.5%
77.5% (1,627 of 2,100) of the respondents were confident
that their data in the NEHR was secure, and 70.8% Laboratory and Radiology
69.8%
Reports – General
(1,487 of 2,100) were confident that their data would not
be misused by others (see Figure 7). Nevertheless, there Operating Theatre Notes and 60.8%
were specific concerns: Procedures – General
Hospital Discharge Summary 59.0%
1 70.9% (1,489 of 2,100) were concerned about
Visit History 56.0%
their medical information being uploaded
onto a cloud (secured online storage). Medication History – Sensitive 50.5%
2 82.9% (1,741 of 2,100) were concerned that their Laboratory and Radiology 45.0%
medical information would be used for matters of Reports – Sensitive
public interest by the Ministry without their consent.
Doctor's Diagnosis – Sensitive 43.5%
3 81.7% (1,715 of 2,100) were concerned that the
Operating Theatre Notes
NEHR is not subjected to the requirements of the 41.7%
and Procedures – Sensitive
Personal Data Protection Act (PDPA) (see Figure 8).
Others (e.g. Dental Records) 3.1%
Note:
1. This analysis was based on all respondents, n = 2,100.
2. Percentages may not add up to 100% as this is a multiple response question.
Figure 6
AUG 2018 SMA News 17On a scale of 1 to 6, where 1 means "Strongly Disagree" and 6 means Top 3
"Strongly Agree", please rate your extent of agreement with the n Mean Boxes
following statements. (%)
I am confident that my data in the NEHR is secured. 2,100 4.02 77.5
14.7% 49.3% 21.4% 6.8%
2.8% 5.0%
I am confident that my personal information in the NEHR would not be misused by others. 2,100 3.88 70.8
7.1% 18.5% 46.3% 17.7% 6.8%
3.6%
Strongly Disagree Disagree Somewhat Disagree
Somewhat Agree Agree Strongly Agree
Note: This analysis was based on all respondents, n = 2,100
Figure 7
On a scale of 1 to 6, where 1 means "Very Concerned" and 6 Bottom
means "Not Concerned At All", how concerned are you with the n Mean 3 Boxes
following statements: (%)
Your medical information being uploaded into a cloud (i.e. secured online storage). 2,100 2.98 70.9
17.0% 18.6% 35.3% 12.9% 10.9%
5.3%
Your medical information being seen by all your attending doctors. 2,100 3.67 45.3
8.8% 12.0% 24.5 23.5% 20.8% 10.4%
Your medical information being used for matters of public interest by the Ministry without 2,100 2.24 82.9
your consent.
42.8% 18.0% 22.1% 8.9%
5.2% 3.0%
NEHR is not subjected to the requirements of the Personal Data Protection Act (PDPA). 2,100 2.41 81.7
34.4% 20.1% 27.2% 9.2%
6.2% 2.9%
Very Concerned Concerned Somewhat Concerned
Somewhat Not Concerned Not Concerned Not Concerned At All
Note: This analysis was based on all respondents, n = 2,100
Figure 8
18 AUG 2018 SMA NewsIn conclusion:
1 About half (1,055 of 2,100; 50.2%) of the respondents were aware of the NEHR, with 14.9% (314 of 2,100) “fully understanding”
what NEHR is.
2 More than 90.0% of the respondents agreed that with the NEHR, “their doctor(s) would be able to make better-informed
diagnoses and decisions for the best course of treatment to improve their health” (1,979 of 2,100; 94.2%) and that “the NEHR
would raise patient safety by enabling medical professionals to access critical medical information (e.g. name of medication
prescribed, diagnoses) in an emergency” (1,993 of 2,100; 94.9%).
3 Most of the respondents were confident that their data in the NEHR was secure (1,627 of 2,100; 77.5%), and that their data
would not be misused by others (1,487 of 2,100; 70.8%). Nevertheless, there were still concerns with data confidentiality with
regard to their “medical information being used for matters of public interest by the Ministry without their consent” (1,741 of
2,100; 82.9%) and that “NEHR is not subjected to the requirements of the PDPA” (1,715 of 2,100; 81.7%).
4 In a nutshell, while 92.2% of the respondents supported the implementation of the NEHR to varying extents, about a
quarter of all the respondents (581 of 2,100; 27.7%) mentioned that they “would definitely like to have their records
maintained in the NEHR”. More than half of the respondents (1,175 of 2,100; 56.0%) “would like to have their records
maintained in the NEHR but do not want any healthcare provider to access it without their explicit consent except
during emergencies”.
The survey results have helped us to better understand the public perceptions of the NEHR, and the sensitivities regarding the
privacy and confidentiality issues of personal medical records that concern the members of the public. With this insight, we hope
that it will help to shape how the NEHR will develop especially in the light of the forthcoming HCSA.
MINISTRY OF HEALTH’S STATEMENT ON THE EP
RIN
TED RE
PR
Joint Public Sentiment Survey
R
IN
TE
REPR
D
INTED
A
UG
on NEHR by AMS, CFPS and SMA
UST
2
The Ministry of Health (MOH) would like to thank the Academy of Medicine, Singapore (AMS), College of Family Physicians
Singapore (CFPS) and Singapore Medical Association (SMA) for providing additional valuable feedback on the National
Electronic Health Record (NEHR).
The survey validates much of the feedback that we had gathered during MOH’s public consultation sessions in early 2018
from various stakeholders, including current and prospective licensees, professional bodies, and members of the public.
The survey indicates broad support for the NEHR as an enabler to facilitate care continuity as patients move across
healthcare settings. We are also heartened that respondents agreed that the NEHR will raise patient safety by enabling
medical professionals to access critical medical information during emergencies.
The survey findings reiterate concerns similar to those raised during the public consultation, such as patient
confidentiality and data security. MOH plans to enact legislations to protect patients’ healthcare data and usage in NEHR.
As patient confidentiality is of utmost importance to us and in view of the recent major cyberattack on SingHealth’s
database, MOH has directed the Integrated Health Information Systems (IHiS) to conduct a thorough review of the
robustness of the cyber safeguards of our key IT systems. These include the NEHR, which is different and separate from the
affected system at SingHealth. While we conduct this review, we will take a pause on our plans on mandatory contributions
of healthcare information to NEHR. This will allow us to review and strengthen our cybersecurity measures where necessary
before proceeding.
MOH recognises that doctors and dentists, as future users of NEHR, play a critical role in ensuring that electronic medical
records are used safely, effectively, and ethically for the benefit of our patients. We thank AMS, CFPS, and SMA once again
for sharing their survey findings with us.
AUG 2018 SMA News 19INSIGHT
A Viable Way to Manage and Reverse Type 2 Diabetes Mellitus?
Text by Dr Tan Tze Lee, Deputy Editor
Diabetes mellitus has always been a However, evidence has begun energy balance alone. After a
major health challenge for Singapore, to emerge of the potential reversal week of dietary restriction, fasting
and it has become such a big problem of T2DM in patients undergoing glucose had reduced from 9.2+/-
in recent years that our Government bariatric surgery, with normalisation 0.4 mmol/l to 5.9+/-0.4 mmol/l
declared war on diabetes in 2016. As of blood glucose levels within days of (p=0.003). The first-phase insulin
of 2014, there were already 440,000 the procedure long before any major response increased from 0.19+/-
Singapore residents aged 18 years weight loss had occurred. There 0.02 mmol/min/m2 to 0.46 +/-0.07
and above who had diabetes, and was also evidence that moderate mmol/min/m2 (p100% DiRECT clearly demonstrated that
Odds Ratio (per kg weight loss): 1.32
T2DM of up to six years’ duration
(95% CI: 1.23, 1.41) 86.1%
PERCENTAGE ACHIEVING REMISSION AT 12 MONTHS
could potentially be reversed.
PProfessional
SMA CMEP – MEDICAL ETHICS
Accountability
[PART 2]
Text by Dr Peter Loke
service, the patient accepts this offer The Bolam test: The test is the
This is the second instalment of a two-part with the consideration of the fees standard of the ordinary skilled man
series. The first instalment was published in (money) and there is an intention to exercising and professing to have
the July 2018 issue of SMA News create the relationship. The doctor has that special skill; it is sufficient if
(http://bit.ly/2Mn2vte). an implied duty to exercise reasonable he exercises the ordinary skill of an
care and skill, and falling below this can ordinary competent man exercising that
be construed as a breach of contract. particular art. A doctor is not guilty of
The remedy for breach of contract negligence if he has acted in accordance
Professional accountability
is to place the “innocent party” in a with a practice accepted as proper by a
and the law
position as if the contract had not been responsible body of medical men skilled
While professional self-regulation as breached. There is no need for harm to in that particular art. Putting it the other
enforced by the Singapore Medical have resulted to the patient. A doctor way round, a doctor is not negligent, if
Council (SMC) is empowered by can also be held to a breach of contract he is acting in accordance with such a
legislation (the Medical Registration if a specific outcome is promised for practice, merely because there is a body
Act [MRA]), the law also has a direct of opinion that takes a contrary view.
a treatment (eg, this treatment is
role in enforcing accountability on the
guaranteed to deliver 10 kg of weight The Bolitho addendum: A defendant
medical profession. This is separate
loss in two weeks) and the outcome doctor cannot escape liability for
and administered differently from
is different from what is promised. negligent treatment or diagnosis
the SMC disciplinary process. While
In reality, the principle area in law simply because he leads evidence
disciplinary matters in the SMC are
that the medical professional is held from a number of medical experts who
ultimately judged by a Disciplinary
accountable for is the tort of negligence. are genuinely of the opinion that the
Tribunal, matters in relation to law are
In this context, quantifiable harm that defendant’s treatment or diagnosis
decided by the courts of the land. The
directly results from falling below the accorded with sound medical practice,
penalty also differs; the SMC can fine
minimum standard of care expected because what is required is that the
or suspend a doctor, or revoke his/her
practice must be accepted as proper by
licence, whereas the remedy in legal in law is actionable against the doctor.
responsible, reasonable and respectable
cases in tort is a claim for damages There are three key elements that must
professionals, and the court must be
(money), and in contract in the medical be fulfilled for the tort of negligence
satisfied that the exponents of the body
context would commonly be money. to occur. There must be a duty of care
of opinion relied upon can demonstrate
A licenced doctor can potentially (a “given” in the normal doctor-patient
that such an opinion has a logical basis.4
face a complaint in the SMC and a relationship), breach of this duty and
lawsuit for the same matter. A simple quantifiable harm that directly flows The Bolam-Bolitho test (summary):
way of looking at them is that they from this breach. The restitution for The minimum standards are not
are two parallel, separate systems of this harm is damages in the form of breached if a respectable, responsible
answerability and administration. money, which is paid to the person and reasonable body of professionals
harmed. The test to determine minimum considers the practice as proper,
Two areas in law that a medical
standards is different for diagnosis so long as this opinion is able to
professional can be held accountable
and treatment (Bolam-Bolitho test),1 withstand the scrutiny of logic, is
for are breach of contract or tortious
for provision of information and internally consistent and has taken
negligence. When a patient pays
a doctor for medical services, the advice (Hii Chi Kok test)2 and for SMC account of recent advances.
essential elements of a contract are cases when the charge is professional The Hii Chii Kok test: Also known as
fulfilled; the doctor offers the medical misconduct (Low Cze Hong test).3 the modified Montgomery test, this entails
22 AUG 2018 SMA NewsYou can also read
