Monthly Archives: October 2013

Twilight of the Elites?

Twilight of the Elites: America After Meritocracy

Hayes made an excellent argument why meritocracy is not working in America now. The Elite has found new ways to protect their offspring from dropping out of their group, by employing extensive networks of tutors, coaches and personal connections to make sure their children will join prestigious schools that will lead to them joining prestigious colleges. Opportunity for the poor to climb to the top is becoming scarce. This is very much like the situation in Singapore. The Elite is becoming out of touch with how normal people lives and cannot understand their problems, although they are supposed to represent us. In turn there is erosion of trust in all the major institutions.

Interestingly the solution Hayes proposes is to decrease inequality, the opposite of meritocracy. This is similar to Stiglitz’s proposal on his book.

Singapore is run with the principle of meritocracy. Doctors like me must be considered as part of the “winning” group. Interestingly the same kind of problems described by Hayes is also happening in Singapore. The government is now aware of this erosion of trust and is changing its stance to have more “inclusive” (read; non-meritocratic) growth.

A must read for anyone who is concerned about competition in society.

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Urine Spills in Factories Making Generic Drugs

capsulesPhoto credit: antpkr

I love the US Food and Drug Administration (FDA). They set the standards for generic drug safety, allowing small countries like Singapore to save a lot of time and money to check on the quality of generic drug manufacturing. Unfortunately, what they found in the Wockhardt factory was not pretty: urine on the floor, dirty uniform, moldy storage areas.

Yikes! I would not give my patients these drugs, no matter how cheap they are!

On the other hand, this piece of news creates a problem for doctors and patients. Generic drugs are much cheaper than the originals and allow governments to treat a lot more patients. While the rich patients would of course demand genuine medication, it is not feasible to treat everyone with expensive branded medication. We need the generics and we need to make sure that their standard of quality is good.

The best way to ensure quality compliance is spot checks. Keep up the good work, FDA!

2 Hour wait at Singapore Specialist Clinic

ImagePhoto credit: Ambro

A poor patient has been made to wait at the specialist’s clinic for 2 hours for every visit in a government hospital in Singapore. She did not even dare to go to the toilet for a break because she was afraid that she would miss her turn. The writer quite kindly pointed out that the doctors and nurses at the clinic were doing their best, just that there were way too many patients.

As a doctor I understand the doctor’s point of view, but I had also brought my wife to see her doctor before and we had to wait for 1-2 hours at that same hospital. That was despite the fact that the gynecologist and I were friends (we were made to wait just like everyone else and I thought that was the absolute right thing to do).

How long is too long? One should of course see what other countries are doing. Well researched data are however only readily available for America, where the average wait was 21 minutes. Patients described their wait as about 2 hours in Germany.

Patients feel disrepected when they are made to wait too long and that is the primary reason they would not recommend their doctor. It has gotten so bad that in America, a frustrated patient sued a doctor after waiting for 4 hours and won $250 in a small court.

There are many reasons of long waiting times. The primary reason is of course high demand (many patients) and low supply (lack of doctors/funding/doctors sick). This kind of problems can only be resolved by having more doctors and funding which many governments are reluctant to do because it means higher healthcare spending.

Sometimes patients are late for their appointment. When they arrive later, the doctor is already seeing other patients and they have to be “squeezed in” and this causes longer waits for everyone. On the other hand, it is difficult to expect patients to be on time when doctors make them wait…

Sometimes new medical problems occur. This happens when an appointment is booked for a routine visit lasting 15 minutes, but the patient has a new problem that needs to be addressed. Of course the doctor would need to tend to that problem as well, making other patients wait.

However, another reason is the practice of overbooking. Some patients do not turn up and do not have the courtesy to inform the clinic. To avoid letting the clinic and doctors left idle, it is a common practice for clinics to overbook their patients. However, that creates a long wait when everyone actually turns up. While we can ask patients to tell us early if they decide not to come, technology may be the solution. Most patients usually stick to their appointments, but some don’t. By analyzing past patient behavior, they can predict the total patient volume accurately 95% of the time. Hopefully this will let us manage our resources better and cut down on waiting time for patients.

Problem of Slimming Drugs sold as “Supplements”

ImagePhoto Courtesy: Health Sciences Authority Singapore

If you are taking Oxylite Pro now, stop taking them immediately. The Health Sciences Authority of Singapore had issued an alert after Oxylite Pro had been found to cause liver injuries. An analysis of the ingredients found the potent chemicals 1,3-dimethylamylamine (DMAA) and yohimbine. Those chemicals have caused liver injuries.

Oxylite Pro is marketed as a magic weight loss supplement. Looking at the ingredient from its website, it probably works to some extent, as it contains DMAA and yohimbine which are stimulants and caffeine that increases the metabolic rate, and certain plant extracts that increases thyroid hormone which in turn increases the metabolic rate.

Mainstream Western medication can be toxic if taken inappropriately. That is why even paracetamol (Panadol) in overdoses can harm the liver. That is the reason only doctors can prescribe registered medication as we need to carefully weigh the potential pros and cons of any single medication. We must help, not harm patients.

A healthy diet (low in saturated fat and refined carbohydrates, high in good protein and fibre) and regular exercise is the best way of weight loss. Please discuss with your doctor before you want to take any of the over-the-counter supplements that promise quick fixes for weight loss.

Counterfeit Drugs a problem in Indonesia

fake drugsPhoto courtesy:  Victor Habbick,

I am sometimes asked about the huge price difference of drugs between Indonesia and Singapore. Rent, labor, the strong Singapore dollar, and differential pricing are all factors. However, there is one very important factor – fake or counterfeit drugs. Counterfeit drugs have become a huge problem in Indonesia. The pharmacies used to buy drugs from “independent medication sellers”, but are now buying them simply online.

I had come across instances when I simply switched medication from overseas to Singapore ones, and saw huge differences in the effect of lowering blood pressure and blood sugar. I can only surmise that the “strengths” of the medications are different.

Part of the problem reported was that the pharmacies find it difficult to differentiate between genuine and fake medication. I totally agree. There is no way for even pharmacists and doctors like us to differentiate between the fake and real thing, since boxes, logoes can all be faked. The only way to ensure that the drugs are genuine is to buy direct from the Big Pharmaceutical Companies themselves.

Pharmacists and doctors must realize that fake drugs may not contain any active ingredients, and can also contain harmful ingredients. They must make a stand to sell the real thing to their patients. Patients must also buy medication from registered pharmacies and not from dodgy ones.

Tom Hanks has Type 2 Diabetes

Tom Hanks 2009

Photo credit: Wikipedia

I love Tom Hanks. From Forrest Gump to Angels & Demons, I have always enjoyed watching him perform. He is professional, willing to gain or lose 20kg just to fit into the look of a role.

He has just declared that he has developed type 2 diabetes mellitus at age 57. Also, he has been having “high sugars” (likely prediabetes) from age 36.

Type 2 Diabetes mellitus is a disease of high blood sugar, when the body cannot make enough insulin to bring the sugar down in the blood. It happens especially in people who are overweight and obese, because when they gain fat tissue, their body becomes resistant to the effect of insulin. At first, the pancreas makes more insulin to overcome this resistance and their blood sugar is still normal. Over time, however, the pancreas becomes weak and blood sugar starts to rise a bit (prediabetes) and then a lot (frank diabetes).

8.3% of Americans have diabetes, and 11.3% of Singaporeans have diabetes. The high blood sugar wreaks havoc in the body, getting attached to everything in the body, preventing their normal function. If uncontrolled, diabetes can lead to blindness, kidney failure, amputations of the lower limbs, heart attacks and strokes. Fortunately, good control of diabetes can prevent all these complications.

The most important thing is through lifestyle modifications. The most important thing is to control the amount of carbohydrate intake and exercise regularly. Tom Hanks has said that he would not be taking on roles that require weight gain any more. Well he is someone that can lose 26 pounds (12kg) just through sheer determination, so I think he can do it.

Indeed, Tom Hanks has had quite a good run with his prediabetes. He only “graduated” from prediabetes to diabetes after 21 years! In Singapore, a study done by Prof ES Tai showed that 35% of patients with prediabetes develop diabetes in 8 years. So Mr Hanks have largely avoided developing diabetes at a much earlier age, and should be congratulated.

It is also very encouraging to know that celebrities like Tom Hanks would openly admit their chronic medical condition. It can lead to better recognition of the illness by the public, and lead to healthy discussion by patients at risk and their doctors. Well done Mr Hanks!

H1N1 in the news in Singapore

Child receiving Vaccine

Image courtesy of  David Castillo Dominici / FreeDigitalPhotos.net

It has just been reported that 6 children in 2 kindergartens have come down with the H1N1 virus (used to be called swine flu). The H1N1 first came to news in 2009 when it killed many people in Mexico. Fortunately the virus had turned out to be much milder than it first appeared, and all the current influenza vaccines protect against the H1N1 virus.

The Singapore’s Health Promotion Board provides useful information on the seasonal influenza virus.

How to avoid the flu? Frequent washing of hands is important. People who are sick should rest at home, and when they go out, they should wear a mask and cover their mouth with tissue paper when sneezing. However, the best protection is to get vaccinated.

I am going to vaccinate my children tonight. Hope they are not going to be too cranky after that.