Advocacy in the Year Ahead

In this new year of 2022, there are three broad issues I wish to advocate for:

1. SMA's representation in the Multilateral Healthcare Insurance Committee (MHIC).
2. Recognition and prevention of abuse of healthcare workers (HCWs).

3. Ongoing COVID-19 support.

Representation in the MHIC

The SMA, together with the Academy of Medicine, Singapore, continues to represent doctors in the MHIC, advocating for fairness and transparency. Last year's announcement on 9 November 2021 regarding the formation of a Clinical Claims Resolution Process committee was one of the key decisions.¹ A lot more work will be taking place this year, and the SMA will share what we can in our newsletter. Members of the committee² are sworn under the Official Secrets Act and I, for one, find it disheartening to hear whispers of naysayers undermining and downplaying the work that we have collectively put in, without having full information of the entire healthcare landscape.

I urge readers of SMA News, our steadfast SMA Members and supporters, to stay involved and interested in real developments in the complex negotiations. I thank the many friends who have given private and confidential feedback to the SMA Council. These have all been taken into consideration.

Healthcare economics is incredibly complex. There are several Integrated Shield Plan providers; multiple types of insurance products and corporate insurances (also known as employee benefits plans); third-party administrators; several private hospitals, day surgery centres, and a few thousand specialists – they all come with different business models. Truly, Dr Jeremy Lim's Myth or Magic: The Singapore Healthcare System should be a basic entry-level compulsory reading for anyone who wants to venture an opinion, followed by years of engagement and discussions with various stakeholders.

Ongoing developments and changes in response to COVID-19 have also been rapidly evolving, with new insurance products tied to COVID-19 and travel, new medical businesses providing PCR tests and ARTs for travel checks, and telemedicine providers. Concierge services have also been adapting to current needs. For colleagues new to private practice, please be mindful of the Singapore Medical Council (SMC) Ethical Code and Ethical Guidelines³ before signing contracts which promise a fee in return for referrals. You can also refer to the SMA Centre for Medical Ethics and Professionalism's advisory on advertising.⁴

Addressing abuse of HCWs

The Straits Times carried a few articles regarding the abuse of HCWs in Singapore in November 2021.^5,6 Mr Adrian Tan, current president of the Singapore Law Society, shared in a LinkedIn post on 1 December 2021:

"There is a legal way to think about this, but it's not about a patient's human rights, it's about workplace safety. From a legal perspective, a hospital is a workplace. If an employer doesn't provide a safe work environment, legal action can be taken. For example, a nurse could sue a hospital that refused to eject a patient who molested her. She could argue it would be unsafe for her to carry on working in an environment where she could be assaulted again."

I discussed this with several colleagues, and I share below some of our combined views. Healthcare professionals place patients at the heart of all we do – service before self – but when it comes to abuse, it is difficult to express how one feels abused without feeling guilty of being possibly derelict in our duty. If HCWs had the training and organisational support to be able to call out abusive (be it emotional/physical) and manipulative behaviours of patients and/or their families, it will give all of us more protection, peace of mind and the strength to keep on doing what we love best.

Part of the problem is also under-reporting, as some HCWs may not wish to formally make a police report. Healthcare professionals and ancillary workers in public healthcare institutions are categorised as Public Service Workers under the Protection from Harassment Act.⁷ Yet, many HCWs may refrain from making an official report – especially if they feel that it was just a one-off event, if they feel sorry that the patient is sick and not feeling well, or that the families are worried, thereby excusing such behaviour.

Yet another insight is that the type of emotional/verbal abuse that HCWs get can be just as insidious as that in an abusive relationship. We may not always recognise it; we just feel drained and guilty after meeting such patients/families. We are afraid of speaking up because patients hold the power here – a complaint to the hospital's senior management or to their Member of Parliament may bring in undue social pressure to give in to unreasonable demands. For a doctor, an SMC complaint may take months or even years to resolve, and media reports may ruin his/her reputation.

I offer some examples of abusive cases below, which include those personally encountered as well as others' anecdotes:

1. After a routine, uneventful surgery, a patient's children demanded on the day of discharge that the ward staff arrange for daily food delivery to the patient at home, because they were all too busy to do so, and "if anything should happen, it'll be your fault". The nurse was flabbergasted, but luckily one of the doctors in charge was around and took over that conversation, telling them firmly that no one has ever requested for such a service, and the hospital staff are in no way obligated to fulfil their request.
2. A patient may ask a doctor to falsify their clinical information for insurance purposes and threaten to leave a bad review if it is not done.
3. A patient may have a large family with complex relationships (eg, children from two different spouses), which may not be made known to the managing doctor. The main spokesperson who has been kept updated may not be accepted by another set of relatives. The second set of relatives may then bring their familial conflicts and dynamics into the discussion of medical care.

4. As a junior doctor, I once had to call a patient's son to explain why a surgery had to be postponed again (once due to salt imbalance, and again due to unexpected fever). The son said, "You are lucky I am not there, otherwise I will hang you, every single one of you." My heart froze and I almost burst into tears. I was prepared for unhappiness and complaints, but to be threatened with death? I cannot remember how I ended that phone conversation. After calming down, I told my then-Head of Department, who asked me to document it and make a police report. I did, and in the follow-up, the officer informed me that they had visited the man and warned him. Subsequently, the patient apologised profusely, and arranged for another child to take over as the main correspondent.

I am certain that many HCWs would have their own stories of abuse to share, which our professionalism has mostly kept in check, and thus we have not posted them on social media. This is probably why there is such a skewed representation of lapses in healthcare – HCWs would do open disclosures when a medical error has been made; yet, when the abuser is the patient, who can we talk to? Who will believe us?

The "denial of service" to abusive patients/families is such a foreign concept to most local HCWs. A few friends who have worked overseas have shared that their hospitals have such provisions in place (typically for drunks or known drug addicts who come into the emergency department not for medical conditions, but are being abusive; eg, screaming/shouting/spitting at staff, demanding drugs) to turn away such visitors.

Maybe COVID-19 has indeed made it timely for there to be stronger legislation to protect HCWs against bullying and harassment.

Support amid COVID-19

In my November 2021 column (https://bit.ly/5311-PF), I described life with COVID-19 as an ongoing siege. Most of our front-line HCWs are now used to donning personal protective equipment and the twice-weekly self-administered ART for baseline screening of asymptomatic COVID-19 infections.

The national roll out of vaccine-differentiated measures in public areas has given vaccinated people additional peace of mind. With the announcement on 10 December 2021 that the Pfizer-BioNTech vaccine has been approved by the Health Sciences Authority for use on children aged five to 11,⁸ parents who are keen have additional assurance of protection from COVID-19 infections.

At the time of writing, vaccinated travel lanes have been established and people are travelling internationally. We will be watching the Omicron variant carefully, and how effective our border precautions are.

A voice for the profession

As always, even though the SMA may not have any legislative power, being a non-governmental organisation made up of volunteers in our role as advocates for patients and for doctors allows us to have an independent opinion of healthcare issues. This voice does not have to shout to be heard. A quiet word in the right ears may be all it takes.

I leave this as food for thought, and I wish all of you a healthy and smooth 2022.

1. Clinical Claims Resolution Process. About CCRP. Available at: https://bit.ly/3oUqZja.
2. Ministry of Health. MOH appoints Multilateral Healthcare Insurance Committee. Available at: https://bit.ly/3mMmpAZ.
3. Singapore Medical Council. Ethical Code and Ethical Guidelines 2016 Edition. Available at: https:// bit.ly/3ubNYqq.
4. Singapore Medical Association. SMA CMEP advisory on advertising standards for doctors. Available at: https://bit.ly/3GsblBP.
5. Chua N. More healthcare staff facing abuse: Patient asked S'pore hospital nurse if she provided sexual services. The Straits Times [Internet]. 28 November2021. Available at: https://bit.ly/3J2I96v.
6. Chua N. More healthcare staff facing abuse: 'I hope your parents die,' patient's son tells S'pore hospital worker. The Straits Times [Internet]. 28 November 2021. Available at: https://bit.ly/3m7Y49z.
7. Ministry of Home Affairs. List of PSWs in the Schedule of the PSWO. Available at: https://bit.ly/322aKI9.
8. Ministry of Health. Expert Committee on COVID-19 vaccination recommends using the paediatric dose Pfizer-BioNTech/Comirnaty vaccine for children aged 5 –11 years and extending booster vaccination to persons aged under 30years. Available at: https://bit.ly/3dVeOMR.