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3 ............................. The Year in Retrospect VOLUME 35 NO.4 APRIL 2003
7 ............................. Lessons from SARS M I TA ( P ) 2 8 8 / 0 2 / 2 0 0 3
8 ............................. Every Bit As Human
SMA
9 ............................. A GP’s Take on SARS
10 ............................. Courage Under Fire
11 ............................. SARS (and You)
15 ............................. HO Seminar 2003 N E W S
17 ............................. Eulogies
How Our Lives, and Medical Practice,
have Changed in 2 Short Months EDITORIAL BOARD
By Dr Lee Pheng Soon, President, 44th SMA Council
Editor
Dr Wong Tien Yin
S
ARS has been described both as the medical event of
Deputy Editor
the decade, and the greatest challenge facing Singapore
Dr Daniel Fung
since independence. This new infection of high morbidity IN MEMORIAM: DR ALEXANDRE CHAO
Members
and mortality, that spreads relentlessly the moment we let 22 APRIL 2003, ICU, SGH. – 1900 HOURS
Dr Chan Kah Poon
down our guard, has made all of us pause to think. It’s now
And Then The Line Went Meekly Straight Prof Chee Yam Cheng
become clear that the disease is not going to disappear
like a bad dream. And it is also clear that medical practice – Dr John Chiam
And then the line went meekly straight,
whether in the hospital, in the humble HDB GP’s clinic, No more punctuations of peaks and troughs; Dr Jon Goh
or from the helicopter cockpit of Ministerial Policy – is now The final cut between life and death. Dr Lee Pheng Soon
I blinked past the wetness of white and lights,
very changed, compared to even as recent as 2 months ago. Some sat down, some slumped against walls, Dr Terence Lim
Many of these changes are probably forever. Choking as all spirit fled us, Dr Oh Jen Jen
The Outgoing President’s Forum features the many achievements Unable to stand and muster a farewell to Dr Toh Han Chong
This gentle soul into the night.
of the team he led, in the past 12 months. As the incoming Ex-Officio
President you elected, I will instead speak about change – forced And then the line went meekly straight, Dr Lee Pheng Soon
upon us, and upon the practice of medicine in Singapore, by SARS I looked upon he who laid ashen,
Dr Tham Tat Yean
and related recent events. We need to think about these unpleasant Still as the gripping cold of the room.
Behind him the machines wept and breathed, Executive Secretary
points, because even if we do not want to change, the world Into veins curdled, Ms Chua Gek Eng
around us already has – and we cannot avoid being impacted Into lungs drowned.
The sickle had reaped Editorial Manager
by the consequences. The ostrich may stick his head into the
This gentle soul into the night. Ms Krysania Tan
sand, but his action will not alter swiftly approaching events.
And then the line went meekly straight,
OUR ATTITUDES TOWARDS LEARNING NEED TO CHANGE As it should have some time ago,
Compulsory CME, started just before the SARS epidemic, If not for comrades that have kept the semblance
Of a living heart, with tired arms and bent backs.
emphasized the need for continuous learning. CME is usually We have seen more deaths than we care to know.
about updates and “new science”, and learning about this is essential. But, we men and women, now pained to the pith,
However, SARS has shown many of us how much we have Will always remember the passing of The views and opinions
This gentle soul into the night. expressed in all the articles
forgotten of first-principles – in this case, those relating to are those of the authors.
microbiology, immunology, and infection control. Patients now Written by a doctor who was in the ICU These are not the views
of the Editorial Board nor
routinely ask us very basic but specific questions: about the possibility at the time of Dr Chao’s passing the SMA Council unless
*line - ‘line’ of ECG trace on patients monitors in ICU specifically stated so in
of airborne infection, the ability of viruses to survive and be brought writing. The contents of
home on clothing, the value of specific hand-wash soaps or specific the Newsletter are not to
be printed in whole or in
air-ionizers. They demand clear answers because they need to part without prior written
dismiss both folklore myths and scientifically-couched untruths approval of the Editor.
If you have something to share on SARS or other
found in half-page advertisements in newspapers. Many of us Published by the Singapore
issues, please email us at krysania@sma.org.sg Medical Association,
stumble, unable to provide clear and confident responses, and Level 2, Alumni Medical
our credibility as healthcare professionals suffer. We are thus We welcome your opinions, Centre, 2 College Road,
Singapore 169850.
reminded that CME is not just learning new things, and also comments and observations. Tel: 6223-1264
about reviewing forgotten first-principles from dusty textbooks. Fax: 6224-7827
The Editor Email: news@sma.org.sg
And there is no shame in acknowledging this. URL: http://www.sma.org.sg
Page 2
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Page 1 – How Our Lives... have Changed... loss of income, to cover operating expenses for the days
OUR ATTITUDES TOWARDS OUR PATIENTS’ NEED or weeks that he would need to close his clinic – should he
FOR TIME, MUST CHANGE fall slightly ill, be served a Home Quarantine Order, or be
Gone are the days of spot diagnoses, fast consultations, and hospitalized as a patient himself. And we need to review
quiet pride in seeing 45 patients in a morning GP clinic. GPs our life-insurance policies, to ensure we have adequate cover
now need much longer per patient – both because we need for our family should the ultimate sacrifice ever be called.
to exercise more care during history and clinical examination,
and also because the patient needs more reassurance about OUR THOUGHTS ON INFECTION CONTROL NEED
himself or a relative with a persistent cough. Every patient TO CHANGE
who is unwell and febrile now needs more time – for us to For each of our different medical practices, we need to
nail down a “safe” diagnosis confidently, and to exclude reassess according to the risk we perceive – what is enough
the possibility of a concurrent, more sinister, infection. Our to prevent self- and cross-infection? Do we need only mask
hospital colleagues in the chronic-care wards have it even and gloves, or do we also need a gown, hair and shoe
tougher – they know that current illnesses and prescribed covers? How frequently should we wash our hands? Even
medications may sometimes obscure the signs and symptoms in the simple GP’s clinic, what about the shared BP cuff,
of early SARS. Suddenly, we find that patients need much and the need to swab the stethoscope diaphragm after
more time, even for the “simple” outpatient consultation. each patient? Clearly, carrying on in the same old way will
We need to guard against seeing these patients as “a pain”. not do.
Later on, we will also need to find some way of mitigating the
cost of this new (but very necessary) extra attention. WE NEED TO LISTEN TO OUR PATIENTS MORE
The single pleasant change – balancing the number and In this age of very personal uncertainty, do we hear them
duration of MCs issued against pressure from HR managers out enough? Do we understand their concerns that new
or screening for malingering – now belongs to the past. disposable ear-probe covers are critical to them, because
As several SARS cases seemed to have presented early to Chinese Medicine emphasizes that the ear, oro- and
GP clinics with non-specific signs and symptoms, a GP needs nasopharyx, are cavities that communicate with the
to ask instead if all such patients should be kept from work respiratory tract? Or do we too easily dismiss their fears
till their clinical picture is clearer. After all, there is the risk that when they show unease as we strap on the common-use
one of these non-specific patients may over several days BP cuff?
develop SARS.
THE COST-STRUCTURE OF PRACTISING MEDICINE IS
OUR ATTITUDES TOWARDS OUR COLLEAGUES NEED GOING TO CHANGE
TO CHANGE It is clear that staff considerations in hospitals need to
44TH SMA COUNCIL All of us want to be the best possible help to our colleagues, change. If entire teams are quarantined 10 days at a time,
Dr Lee Pheng Soon especially when the team is understaffed. Our culture has and if team members are to stay home every time they
President been to drive ourselves hard, and to routinely work through have a fever, it is clear that spare capacity must be built into
minor illnesses. Things have changed so much that we now hospital staff numbers. It’s even more difficult for GPs,
Dr Wong Chiang Yin
know that by so doing, we risk being a source of infection, some of whom work in solo practice. If it is considered
1st Vice President
maybe even of disaster, to the team. We thus need to change unacceptable – dare I say “unethical”? – for him to continue
Dr Toh Choon Lai our work-ethic, and accept that the most important help we to work once he has a detectable fever, the cost of
2nd Vice President can offer our team-mates is to stop working immediately, employing a locum on an emergency basis must be
Dr Tham Tat Yean once we feel unwell. Similarly, our attitude towards our factored into the cost of running a clinic. Do we even dare
Honorary Secretary colleagues who leave in the middle of the work-day should think what would happen when the cough-and-cold
be one of gratitude rather than of disdain. season starts?
Dr Tan Sze Wee
The standard of medical services in Singapore has
Honorary Treasurer
OUR ATTITUDES TOWARDS OURSELVES NEED TO CHANGE made huge strides in past years. However, calculating the
Dr Foo Chuan Kit Though this is probably not rigorously documented enough manpower costs of providing these services had presumed
Honorary Assistant Secretary to be “evidence-based medicine”, we need to accept that that doctors – from the humble GP to the sub-specialized
Dr Chong Yeh Woei long hours, inadequate rest, food without thought of nutrient Professor – are more dedicated, have more stamina, and are
Honorary Assistant Treasurer quality, physical and psychological stress – all contribute to more robust than ordinary human beings. SARS has made
lowering our personal resistance to disease. We need to one thing clear. It is not just the doctor’s dedication that
change and accept that we are just as human as those we is the deciding factor – it is whether society can afford
Members
treat, and consciously take care not to over-stretch ourselves. the risk of him being an “infector” when he pushes himself
Dr John Chiam Yih Hsing Indeed, we should deliberately make a little time each day to while unwell. Will society then accept that the doctor
Dr Chin Jing Jih exercise, and if possible and in addition, to find a little pleasure. needs to put aside more time to rest, to stop work earlier
Prof Low Cheng Hock This should be part of the daily prescription for ourselves. once he starts feeling unwell or has a fever, to earn enough
Dr Soh Wah Ngee to save for hospitalization and protect against the risk
ON A RELATED NOTE, OUR THOUGHTS ABOUT of premature death? If so, it is clear that the manpower
Dr Tan Chue Tin
PRACTICE UNCERTAINTY NEED TO CHANGE cost of medical practice cannot remain the same.
Dr Tan Kok Leong
It used to be adequate for a doctor just to do his best
Dr Ivor Thevathasan professionally and ethically, and remember to renew his HOW THE SMA WILL TRY TO HELP ALL OF US
Dr Wong Tien Yin medical defence insurance. In the age of SARS, this is clearly Our first priority is to ease the difficulty of practice during this
Dr Yue Wai Mun not good enough. He has to save enough to provide for time of immense change. In these first few weeks following
Page 5
S M A N e w s A p r i l 2 0 0 3 Vo l 3 5 ( 4 )
Page 2 – How Our Lives... have Changed... ONE PROFESSION
the outbreak of this disease, we have tried our best to ensure When we look at the healthcare providers infected by SARS,
that the humble GPs, who stand alongside hospital staff at we realise that this grim virus did not differentiate between
the front-line of the SARS epidemic, have adequate supplies of doctor and porter. Even among doctors, SARS did not
masks and gowns. We have clarified with the MOH, the protective differentiate between the specialist, the trainee, or the GP.
measures needed to permit a clinic to carry on functioning, after Maybe it is because as a profession, we had responded
diagnosing a SARS patient. We are currently working with the like a city-state in siege – with ministry officials, hospital
Ministry of Manpower to try to modify the requirements for administrators, heads of clinical departments, physicians
certifying Employment Pass holders from “SARS-affected countries”, senior to the most junior, doctors in private practice whether
to make them practical. We have tried hard to strike a balance specialists or GPs alike, all stepping forward as one to man
between continuing with important work that cannot be the firing line.
delayed (e.g. the HO’s pre-posting Seminar) and the small risk of Some may comment wryly that it took an epidemic to
infection, by seeking advice from experts on reasonable “anti-SARS” unite us in this way. Even so, if at the end of this decade,
measures that will let us continue. We will be re-looking at if indeed SARS in retrospect had turned out to be the medical
our current locum register, to see if there is a better way to help event of the decade, we will be able to say with pride that
GPs source reliable locums at short notice, should they feel unwell. we responded as One Profession, and continued to serve
In time to come, when the acute emergency is over, when in the memory of those who fell. At this point, though,
we are starting to learn to live with SARS, there will be many, we cannot even say how long or tough this fight against
many more issues to address. Just as one example, if SARS SARS will be, or who among us will be next struck ill. I
continues to rumble on, when might it be appropriate for our suspect that we have a long way to go yet. But while we
colleagues in private hospitals to be allowed back to seeing have the strength, be it SARS or other matters, this 44 th
patients in more than one hospital? The SMA will work with the Council of the SMA will fight on, representing you, alongside
relevant authorities to ensure that we address the remaining you, in this time of change. We only ask for your continued
changes in a representative manner. support and encouragement, because we are human, too. s
S M A N e w s April 2003 Vol 35 (4)
