It all started with a letter written to the Straits Times- this lady was concerned about the lack of staff at night. She was promptly rebuffed by a male reader, L, regarding the possible increase in healthcare cost should more staff be hired:
Dear Mdm Goh, do you mind paying more medical fees for more nurses in night shift?More nurses at night requires more manpower and hospital needs to pay them. In turn hospital will have to charge you higher ward fees. Do you want it?Alternatively to be fair to others who do not need so many nurses at night. You can hire a private nurse at your own cost.
This prompted another retort from my junior in medical school, K:
She merely brought up a point of consideration, on top of acknowledging CGH's merits. I believe that her concern warrants attention even if it seems unreasonable to you. We do lack hospital staff. We should think of ways to improve healthcare for all instead of being dismissive. You, me, anyone else, can land up in the hospital one day and our children will be the ones complaining if there are no nurses to pour us a glass of water at night.
This newspaper and its replies made is way to Facebook and a senior of mine, J, a houseman, congratulated the junior on his spirited reply. I caught hold of the thread and went ahead to post my own comments, both on ST and on Facebook. The following conversation ensued:
Characters in the play:
K: My junior who wants to improve the healthcare system
J: My senior, who's already working as a doctor
L: The dismissive member of public who rebutted the original letter writer
G: A Duke NUS student who provided the epilogue
and me
I'd cut away the frills and thrills of the conversation eg. the emoticons and the adulation and get to the meat of it.
Me (posting on ST): Hi K, is there a concrete way we can increase manpower without increasing healthcare cost?
Me (posting again on FB): http://www.straitstimes.com/STForum/Story/STIStory_744592.html
My reply. As dismissive as L's reply sounds, he brought up a valid point. We can envision the ideal healthcare system as much as we want but we have to understand that these resources do not sprout from the ground, but ultimately come from the pockets of the taxpayer
J: Q: Is there a concrete way we can increase manpower without increasing healthcare cost? Ans: Me, at $7.85/h, it costs each of the 40 patients 0.20/h per extra me on duty.Health care economics is an OXYMORON guys.
K: Hi senior. I honestly do not know. Now you are probably thinking then why am I trying to talk here and acting like I know something. I remember an article which was posted some time back. http://online.wsj.com/article/SB121193074899024387.htmlregarding the risks of night shifts and the lack of hospital staff. Admittedly, the article focuses mainly on doctors and it may not a fair comparison. Also, I also concede that hospitals will never be as fully staffed during nights and weekends as compared to weekdays due to resource constraints. However, I merely wish to make the point in the earlier post that it is a valid point of concern that staff shortages can lead to lethal lapses in patient care. This is an implicit point in Mdm Goh's letter but I am sure you agree with it. This is especially so with nurses who happen to be the first point of contact with the patients. Whether or not there is a way to increase manpower without increasing healthcare cost, or for that matter, whether healthcare cost should be increased at all deserves a separate discussion and I am afraid I do not possess the knowledge and experience to discuss this further. :)
Me: Hi all, I know a lot of drs hate to bring in economics into healthcare, but allow me to point out that healthcare costs can be as much a burden to pts and their families as the disease itself. Some pts (eg. cancer pts) even discontinue therapy because of the cost. So, what's the point of practising healthcare without concern for finances? I don't think healthcare economics is an oxymoron, although its true economics isn't the whole point.Well, if you don't mind me quoting what we've learnt before, health is not the absence of disease or infirmity, it is the complete state of biological, psychological and social wellbeing. If we come to the point where healthcare measures put more financial strain on pts in this harsh economical climate, we may have to rethink.Thanks K for the article and I think it is food for thought :) To combat the current problem of fatigued doctors during nigtcall, institutions like NUHS and NHG have implemented the night float system. Drs are presumably fresher and I believe they aren't paid much extra (pls correct me if I'm wrong) since they didn't work extra hours. I'm not sure about the nurses really. Nevertheless, whatever healthcare measure we implement ultimately should be a balance between the pt's physical wellbeing with financial cost
G: Folks, in the absence of actual data, this discussion is no more than idle chatter. Too bad there's nobody actually tracking patient mortality and morbidity at night vs in the day. Or the price point at which patients drop out of expensive long-term therapy (ie, how elastic is demand exactly?). Even if everything is nicely documented in the case notes (har har) there's no overall analysis of data. Such a shame, considering each cluster has a vast treasure pile of patient information that we could potentially exploit to help improve care delivery. :/
If you, the reader, have made your way to the end of this discussion, I'm sure you are pretty saturated by now. Hence, I won't delve into another essay but will just make some quick points:
1) G, the Duke NUS student, has a point. You can't say anything in Medicine unless it is backed up by clinical evidence. Level A and B evidence preferred. In fact, my previous two sentences aren't backed up by evidence so you can believe it at your own risk.
2) The original ST article has a weak argument. The author has not demonstrated that the lack of night staff can prove fatal or injurious to patients.
3) Healthcare CANNOT be about making huge profits BUT
4) Healthcare CANNOT be a source of financial hemorrhage in our already vulnerable economy because a) We do not wish to bankrupt our patients, this defeats the purpose of healthcare and b) We cannot bankrupt Singapore's economy, simple as that. Drs have a duty to the country's economy too. Are you willing to accept this idea?
5) Whatever it is, I'm just glad everyone had a civilised discussion, unlike the hundreds of disgraceful mudslinging angst filled threads you have in cyberspace.
6) Note to FB stalkers: No you can't find this thread on J's, K's, G's or my own FB page. It is on an unlikely source haha you use your IQ to find out
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