Vol. 47 No. 4 April 2015

MCI (P) 154/01/2015

MR LEE KUAN YEW1923 - 2015

A Tribute to SMA Honorary Member

CONTENTSVol. 47 No. 4 2015

EditoriAl

4 We RememberDr Tina Tan sums up the issue

iN MEMoriAM

5 A Man of His Time: Mr Lee Kuan Yew (1923 - 2015)A/Prof Chin Jing Jih honours our first prime minister

8 Citation for Mr Lee Kuan YewOriginally delivered at the SMA Annual Dinner 2012

PrEsidENt’s ForuM

10 Making a Meaningful Difference to HealthcareA/Prof Chin Jing Jih passes the torch

11 Continuing the Good WorkDr Wong Tien Hua takes up the baton

CouNCil NEws

13 55th SMA Annual General Meeting

ExECutiVE sEriEs

14 Minimising Occupational Exposure to Hazardous Drugs in ClinicsDr Kong Hwai Loong looks into the issue

ProFEssioNAlisM

18 Oaths and Pledges in Medical Professional CultureDr T Thirumoorthy examines the concepts behind the words

Eulogy

20 A Great Mentor and Colleague Dr Tan Yia Swam pays tribute to A/Prof Vijayan Appasamy

sMA CHArity FuNd

23 Run for a Good Cause!

iNsigHt

24 All in the MindDr Lui Yit Shiang and Dr Soo Shuenn Chiang reflect on their roles as psychiatrists

26 Managing Medical MalingeringDr Tor Phern Chern explains the condition

oPiNioN

28 We All Need Some TLCDr Gillian Lim prescribes burnout “treatment”

FroM tHE HEArt

31 Creating Awareness on Paediatric Brain TumoursAngela Yap and Yvonne Chia recall the joyous young patients

iNdulgE

32 Ready, Set, RelaxDoctors reveal how they stay mentally healthy

36 Photography Tips for Your Next HolidayCanon provides basic pointers on travel photography

ANNouNCEMENt

17 46th SMA National Medical Convention

35 SMA Training Workshop: Core Concepts in Medical Professionalism

46 SMA Seminar: The Utility (Benefits and Limits) of Ethical codes in Teaching and Train-ing of an Ethical Clinician

CAlENdAr

30 SMA Events May - August 2015

AiC sAys

38 Thank You GPs, for Supporting CHAS!GPs, read on!

Opinions expressed in SMA News reflect the views of the individual authors, and do not necessarily represent those of the editorial board of the SMA News or the Singapore Medical Association (SMA), unless this is clearly specified. SMA does not, and cannot, accept any responsibility for the veracity, accuracy or completeness of any statement, opinion or advice contained in the text or advertisements published in SMA News. Advertisements of products and services that appear in SMA News do not imply endorsement for the products 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 the 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 BOARD

EditorDr Tan Yia Swam

Deputy EditorDr Tina Tan

Editorial AdvisorsA/Prof Daniel Fung

A/Prof Cuthbert Teo

Dr Toh Han Chong

MembersDr Martin Chio

Dr Jayant V Iyer

Dr Natalie Koh

Dr Leong Choon Kit

Dr Jipson Quah

Dr Jonathan Tan

Dr Jimmy Teo

EX-OFFICIOSDr Wong Tien Hua

Dr Daniel Lee Hsien Chieh

EDITORIALOFFICE

Senior ManagerSarah Lim

Senior ExecutiveJane Rochstad Lim

Editorial Executives Denise Yuen

Sylvia Thay

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UEN No.: S61SS0168EPhotosiStock: 24, 33; National Museum of Singapore: 1, 5; Shutterstock: 26, 32, 33, 34

4We RememberBy Dr Tina Tan, Deputy Editor

i writE this piece bleary-eyed and foggy-brained after a night of queuing. It was the longest queue I have ever

joined in my life – the queue to see Mr Lee Kuan Yew’s lying-in-state at Parliament House. As we waited in line,

my husband asked me what it was like to watch someone die. A morbid question, yes, but given the context, it

was apt. Unlike my medical colleagues (especially those in palliative medicine and oncology), I have not personally

witnessed the deaths of many patients. However, I’ve had my fair share of the experience as well as other equally

morbid and strange ones, which I will get to in a bit.

Many tributes and eulogies have been written for the late Mr Lee. I am not here to do that, though I have found

myself compelled to compose a more personal and private tribute which I’ve shared with family and close friends.

Instead, what I’m here to do is dedicate this issue to Mr Lee, who had a tremendous impact on our Little Red Dot.

What some may not be aware of, though, were his particular contributions to national healthcare, which SMA

recognised when he was awarded SMA Honorary Membership in 2012. We reprint his citation (which he auto-

graphed), delivered during the SMA Annual Dinner that same year; and A/Prof Chin Jing Jih also shares his eulogy

for Mr Lee.

The passing of someone well known and close to our hearts, even if expected, tends to bring a jolt to our hearts,

and reminds us of the grim reality of our mortal lives. How much more so when that passing is unexpected? Adj

A/Prof Vijayan Appasamy was programme director of the general surgery (GS) residency programme at National

Healthcare Group, and his unexpected death has left many gaps to be filled (both physical and emotional). Our

Editor, Dr Tan Yia Swam, together with various staff members from the Tan Tock Seng Hospital’s GS department,

has penned a eulogy in memory of A/Prof Vijayan for this issue.

Grief is an emotion that many of us are familiar with. It is part and parcel of life. Most times, we deal with our

grief, and then we move on with life. Sometimes, the grief persists, and it becomes depression. Likewise, for any

strong emotions or difficult life circumstances that we encounter, we process and deal with them. Sometimes, that

process goes haywire and our mental well-being becomes jeopardised. We may start to experience unusual things,

and we may cope in unhealthy ways. Likewise, our own patients may tell us that they see, hear, or feel peculiar

things too. That’s why, this month we include a short series of articles pertaining to the mental well-being of our

patients, and for ourselves as healthcare professionals.

Dr Lui Yit Shiang and Dr Soo Shuenn Chiang discuss how we can manage our patients who tell us such strange

things. Dr Tor Phern Chern focuses on how to distinguish patients with genuine problems, from those who may

seek to play the healthcare system for ulterior motives. Dr Gillian Lim contributes a light-hearted article with her

(unofficial) advice on how we can diagnose and treat burnout in ourselves. And finally, our Indulge series features

several of our colleagues and their methods of relaxing and unwinding from work.

So at the end of the day, as I queued to pay my last respects to Mr Lee Kuan Yew, I did wonder about death and

experienced feelings of grief. But what is important for all of us is to go through the process and allow our psyche

to have some closure. The more expressive ones talk or write about their sadness. Others choose to deal with their

emotions in private. However you choose to deal with negativity (grief, anger, stress, etc), remember that there is

a positive side to things. Medication can treat depression and psychosis. Engaging in hobbies and happy pastimes

can help distract one from the burdens of work and commitments. Remembering the achievements of those who

have passed, and continuing on in the same spirit as what they sought to achieve – that helps us to move past the

sadness and grief.

Dr Tina Tan is a psychiatry senior resident with National Healthcare Group. She obtained her medical degree from Duke-NUS Graduate Medical School (Class of 2011). She also has a bachelor’s degree from the University of California, Berkeley.

EDITORIAL

4 • sMA News April 2015

4 Mr lEE KuAN yEw, our founding Prime Minister, left us on 23 March 2015. As a leader and statesman, Mr Lee was unique and to many, a nonpareil. And so are his many achievements for Singapore. Like a magical football team, Mr Lee, with the help of his able teammates, made all the right decisions that transformed this country from a third world entrepot into a first world city state. The achievement, as one commentator put it, was completely disproportionate to the size of Singapore.

Indeed, much has been said and written about Mr Lee’s remarkable achievements and contributions. But a reflection on Mr Lee in SMA News would not be complete without mentioning the pivotal role he played in shaping the

policies responsible for transforming our healthcare system into one of the best and most efficient in the world.

Under his leadership, the Government started off on the right footing by first focusing on basic public health needs such as clean drinking water, proper sanitation, and vaccination programmes for infectious diseases. Appropriate resources were diverted to strengthen and subsidise public primary and acute care services. The overall impact of legislations to curtail tobacco consumption and to criminalise misuse of drugs on the health of Singaporeans is significant but often underappreciated. Developing a 3M system (Medisave, MediShield and Medifund) that emphasised a balance between dependence on the state

A Man of His Time: Mr Lee Kuan Yew (1923 - 2015)

By A/Prof Chin Jing Jih

IN MEMORIAM

April 2015 sMA News • 5

league in the 1960s. The answer went something like this: “You could say it was a sheer miracle – that a group of politicians under the leadership of Mr Lee Kuan Yew came into power and miraculously, none of them were interested in making money for themselves. All they cared for was the survival of Singapore and its people. It was a miracle considering how rampantly institutionalised corruption was in other third world countries at that era. By the sociopolitical norms at that time, this group of incorruptible leaders was simply an anomaly… almost insane!” Mr Lee has ensured that zero tolerance for corruption and nepotism becomes the key guiding principle for anything Singapore, earning the envy and disbelief of other nations.

At the SMA Annual Dinner 2012, when the Association conferred on Mr Lee its highest award, SMA Honorary Membership, we made it clear that it was not just for his achievements and contributions to Singapore, but also for his ideals, values and principles. In the citation for Mr Lee, we listed five of these upon which the success of Singapore has been built – “the rule of law”, “a largely corruption-free society”, “meritocracy”, “interracial and inter-religious harmony” and “affordable political campaigning, election rules and processes where all political parties and aspiring politicians can have a contest of ideas and win the ballot, without raising large amounts of money”. These values, principles and ideals that had become very much a part of Mr Lee and what he represented, will stand the test of time, and will continue to serve and guide the people of Singapore, long after his passing.

Many will recall how, at that annual dinner, Mr Lee was so inspired by the occasion that he delivered an impromptu

and individual responsibility, Mr Lee and his government were successful in persuading the people of Singapore to be accountable for their own healthcare. Many difficult but good decisions at managing cost and patient expectations kept the public healthcare system effective yet sustainable. By being open to talent, the Singapore healthcare system continued to attracted brilliant and dedicated professionals from other countries.

Today, Singapore boasts of a world-class healthcare system which is both safe and effective, while remaining affordable and accessible to every Singaporean. What is perhaps even more remarkable is that many of these fundamental guiding principles laid down by Mr Lee Kuan Yew have remained relevant and important today, even as we begin to tackle a different set of healthcare challenges related to a rapidly ageing population and the consequent need for the integration of healthcare services.

Mr Lee Kuan Yew will always be remembered for his achievements and how he has continuously transformed and improved our lives through one record-breaking statistic after another. But what distinguishes Mr Lee from many other leaders before and after him, goes beyond mere achievements and abilities. A Singapore diplomat was once asked how Singapore was able to be different and became so much more successful in its nation building and economic development than many countries in a similar economic

6 • sMA News April 2015

but no less insightful speech upon receiving his Honorary Membership. He reiterated the importance of bringing home Singaporeans training for their medical degree abroad, and attracting those from countries with similar cultures so as to better serve older Singaporeans. He also exhorted doctors in Singapore to uphold the high standard of professional care and ethical practice, and strive to be the centre for medical excellence in this part of the world. His speech that night showed how proud and satisfied he was in witnessing the journey taken by the medical profession in Singapore since the early days when MRCP was still a rare achievement. It also revealed in him a deep sense of concern for the future of the profession and for Singapore, and a strong determination to strive for the best interests of this nation and her people. This was the hallmark of Mr Lee’s career in the past 60 plus years.

Mr lee’s continuing legacy True to his constant desire to make Singapore a

better place, Mr Lee Kuan Yew has continued to serve the country even after his passing. The outpouring of genuine grief and sadness in the week of mourning following his demise was unprecedented. Singaporeans were galvanised closer together, in a remarkable show of solidarity, as they mourned for their loss. The sheer number of Singaporeans who subjected themselves to hours of queuing under harsh weather conditions just to pay their last respects and to say their last goodbye surprised even the sceptics. Many Singaporeans were genuinely surprised by the degree of sadness and the sense of indebtedness they were experiencing.

Somehow, through Mr Lee’s passing, the virtues of gratitude, altruism and the communal spirit of gotong royong were rediscovered. Mr Lee’s passing also offered many, who until then were either ignorant or disinterested, an intense yet valuable lesson on the history of modern Singapore. Through the biographical account of Mr Lee’s life and political career, viewers were also given a historical narrative of Singapore’s fragile past, and will hopefully learn to appreciate its success story today in the appropriate context.

The revelations and stories read and heard during the week of mourning following Mr Lee’s passing have also given many people a better idea of him beyond the image of an intellectual leader with steely determination. We learnt that like many of us, he enjoyed family life and was the model husband, father and grandfather to his wife, children and grandchildren. Like some of us, he too enjoyed playing golf and a good chocolate dessert after dinner. We learnt that he also had friends, though he generally kept the engagements at an intellectual and professional level. We also learned from reports that he was always grateful and had never forgotten those who had been generous, kind and helpful to Singapore. In a different world or under different circumstances, he

might have chosen to lead a “normal” life like any one of us. That his life was devoted to and occupied solely by concerns for the well-being of this country and her people was a matter of personal choice – a choice that he made decades ago and never looked back. Throughout his life, he was motivated by an intense desire to promote the long term interests of Singapore and her citizens.

Life for this city state without our founding Prime Minister has finally begun. But we should not fear, for his most valuable gift to us, besides the gift of a successful first world nation, are his values, principles and ideals that will help us ride the future waves of challenges and find our way, emerging even stronger and more resilient.

As Mr Lee once said, with much optimism:

“For the young, let me tell you the sky has turned brighter. There’s a glorious rainbow that beckons those with the spirit of adventure. And there are rich findings at the end of the rainbow. To the young and to the not so old, look at the horizon, follow that rainbow, go ride it.”

Thank you Mr Lee Kuan Yew, for the bright sky and rainbow you have given us after years of selfless public service. The best way we can honour you is by picking ourselves up from our grief and becoming more resilient and cohesive as a nation, as we search for the bright sky ourselves, guided by your ideals, principles and values.

May you rest in peace, Mr Lee Kuan Yew.

A/Prof Chin has been President of SMA since 2012. He is a geriatrician in Tan Tock Seng Hospital with an interest in ethics, professionalism and systems of care.

He also exhorted doctors

in Singapore to uphold the

high standard of professional

care and ethical practice, and strive to be

the centre for medical excellence in this

part of the world.”

“

Citation for Mr Lee Kuan Yew

Written by Dr Wong Chiang Yin and A/Prof Chin Jing Jih

Delivered by A/Prof Chin Jing Jih at SMA Annual Dinner 2012

The following speech was first published in the June 2012 issue of SMA News.

IN MEMORIAM

8 • sMA News April 2015

Most oF us are familiar with the facts. Our Guest of Honour,

Mr Lee Kuan Yew’s contributions to the betterment of

Singapore need little elaboration. Many speeches, columns

and even books have also devoted many words and much

time to describing the life and accomplishments of Mr Lee.

These are all on the record and have been delivered with far

more eloquence and completeness than I could ever hope to

achieve this evening.

Instead, I would like to give the less than obvious reasons

why the previous Council, the 52nd Council, where I served

as 1st Vice President, decided to unanimously nominate

Mr Lee Kuan Yew for the SMA Honorary Membership. The

SMA Honorary Membership is the highest honour that the

Association can confer.

The reasons go beyond the physical and statistical

accomplishments that Mr Lee and his team have achieved

in Singapore, for Singaporeans. The reasons transcend the

numbers of GDP per capita, life expectancy and literacy

rates that all countries and political leaders are measured by.

Indeed, Mr Lee has achieved all these in one lifetime, when

many other countries and political leaders have taken several.

But there are more layers to the Singapore story and the

life of Mr Lee Kuan Yew than the figures tell, or the skyscrapers

that dot the skyline of this island suggest. We need to consider

the nuances behind the feat – that Singapore’s independence

was almost unplanned. The medical mind may even

euphemise this country’s independence as “an unexpected

complication” of sorts. And that independence in itself, while

being a cause for celebration, is seldom a reason for success.

Scottish historian and Harvard professor Niall Ferguson

noted that very few among many former British colonies in

Asia and Africa have closed the prosperity and development

gap with their former master since independence, except for

Singapore, Botswana and Malaysia. I might add here that out

of this exact exclusive list, it is obvious which one has come

the furthest. Many of the rest are failed states.

Many facets of Singapore we take as received wisdom

are in fact not indigenous to the cultural norms of ancient

societies, from which the Singapore community is derived

from. I can, from the top of my head, list five such facets that

Singaporeans often take for granted:

1. The rule of law.

2. A largely corruption-free society.

3. Meritocracy.

4. Interracial and inter-religious harmony.

5. Affordable political campaigning, election rules and

processes where all political parties and aspiring

politicians can have a contest of ideas and win the ballot,

without raising large amounts of money.

To us in the SMA Council, these are the cornerstone

beliefs, values and principles that the success of Singapore

is built on. Mr Lee Kuan Yew has been often described as

the consummate pragmatist. But the SMA Council also

recognises that these are the ideals that Mr Lee has held on to,

and continues to defend even as he ran Singapore with a large

dose of pragmatism. And we deeply appreciate that these are

the values that Mr Lee have come to represent. The bricks

and mortar as well as the record shattering statistics are but

the consequences of these values, beliefs and principles.

We live in a world now of little conviction and much

expediency. Politicians say what is politically correct. Political

messages are often now managed through the varnished

veneer of media consultants. Leadership is but often a

reaction to opinion polls.

But Mr Lee Kuan Yew is an exception. He has always been

a politician with a message delivered with deep conviction

and robust intellect. And his message will demand your

consideration and response, whether in agreement or

otherwise. On this alone, Mr Lee already stands unique

and tall as a statesman. To quote Dr Mahathir Mohamad:

“But I think he will go down in history as a very remarkable

intellectual and politician at the same time, which is not a

very often thing.”

Fellow SMA members, guests, ladies and gentlemen, it is

my great honour and indeed, the honour of the SMA to confer

the Honorary Membership on Mr Lee Kuan Yew – not just for

his achievements and contributions to Singapore, but for his

ideals, values and principles.

I present to you, SMA Honorary Member Mr Lee Kuan

Yew.

April 2015 sMA News • 9

PRESIDENT’S FORUM

After serving three terms as

President of SMA, I have now stepped

down and passed the baton to a new

President. This will therefore be my

last contribution to the President’s

Forum, after 35 consecutive monthly

articles. I suspect the editorial staff is

secretly delighted, as I have struggled

over the last three years to meet

the monthly deadlines. I do wish to

offer a sincere apology here to them

for the anxieties and headaches I

have put them through with my late

submissions and long sentences,

respectively. These three years of

compulsory writing have been a

valuable journey for me, as I have

learnt much from the reflections,

research and engagement needed to

shape my views and writings.

improving the healthcare landscape

As I look back, I am grateful for

the opportunity to have led and

shaped the future of SMA and the

medical profession, together with

my dedicated and capable council

members. I am appreciative of the

trust and support that they have

given me. It is my sincere wish that

our collective vision and industry

have contributed towards making a

meaningful difference in the lives and

health of our patients. A few areas and

strategies that we adopted deserve

special mention here.

One of the challenges we

constantly face, and will continue

to face in the future, centres on the

issue of trust between the medical

profession and society, and between

doctors and patients. In Singapore

today, patients rarely doubt the

clinical competency of doctors, but

quite a few lack confidence in their

integrity and conduct. In the last few

years, SMA, through the positions

that we take regarding relevant issues

and the provision of educational

activities that equip our doctors in

ethics, professionalism and health law,

consolidated its efforts in advocating

and nurturing the trustworthiness of

doctors and the medical profession.

Our efforts in promoting doctor-

patient communication serve to

improve engagement, understanding

and finally trust between our doctors

and patients.

Another challenge that confronts

all Presidents of SMA, past and

present, is the heterogeneous

membership that we have to

serve and lead. Unlike many other

professional bodies, members of SMA

include specialists from different

tertiary specialties, primary care

practitioners, doctors from private

and public sectors, and doctors from

diverse age groups. These different

subgroups often present with varying

perspectives and needs. In managing

such diversity, the SMA President

has to first consider what is good for

patients and the profession. Doing the

right thing often required me and my

council to see ourselves as more than

mere representatives of our members.

Strong and courageous leadership

for SMA means being able to convince

our members to also do the right

thing, even if it involves a sacrifice

of self-interest. It is therefore my

Making a Meaningful Difference to HealthcareBy A/Prof Chin Jing Jih

A/Prof Chin has been President of SMA since 2012. He is a geriatrician in Tan Tock Seng Hospital with an interest in ethics, professionalism and systems of care.

The Association’s

priority will always

be to serve and work

alongside patients,

thereby guaranteeing

the long term relevance

of the medical

profession to society.”

personal hope that, through our

consistent messaging and actions,

the public and patients have come to

accept and appreciate the Association

first and foremost as a patient-centric

professional organisation, contrary

to the common misnomer of SMA

as a doctors’ union. While many of

its projects and efforts do lead to

improvement in the lives and working

environment of doctors, SMA’s

ultimate objective as a professional

organisation is to improve patient

care. The Association’s priority will

always be to serve and work alongside

patients, thereby guaranteeing the

long term relevance of the medical

profession to society.

voice of the ProfessionI have always maintained that

doctors are most effective and

trusted by their patients when

equipped with high professional

morals and morale. During my three

terms as President, striving for a

reasonable and supportive practice

environment for doctors has always

been a core mission for SMA. We took

the position that SMA must serve as

the Voice of the Profession, which

naturally and ultimately includes

advocacy for patients. We took great

pains to ensure that SMA does not

become a loud Voice known for its

“sound and fury, signifying nothing”.

Rather, we have always aimed to

earn the respect and recognition of

policy makers, regulators and other

relevant agencies by being a calm

and reasonable Voice, distinguished

for its maturity, credibility, and

constructiveness. This philosophy of

the SMA leadership underlies many

patient and astute behind-the-scenes

negotiations and engagements that

has quietly but successfully earned

its recognition as a credible source of

independent and objective opinion.

Such an approach makes SMA a far

more effective advocate for patients

and doctors than one known only for

the stirring of emotions and banging

of tables.

I hope that my council members

and I have in the past three years,

made SMA a more effective and

resilient professional organisation

with a clear vision of what needs to

be done in the years ahead. I urge

all members to give the incoming

President and his team the necessary

support and encouragement to

continue the endeavour, so that

doctors are able to devote their

professional time and energy to the

ethical provision of effective cure and

compassionate care.

May we all uphold the spirit of

Jasa Utama, putting Service before

Self.

Continuing the Good WorkBy Dr Wong Tien Hua

it is a great honour for me to take

over from A/Prof Chin Jing Jih,

who had led SMA for the past three

years. On behalf of the Council,

the Secretariat and the general

membership of SMA, I would like

to thank A/Prof Chin for his term

as President. We hope to continue

the good work that he has done

especially in the area of ethics and

professionalism. A/Prof Chin’s

monthly President’s Forum in SMA

News written over the past three

years provides ample material for a

textbook on the subject. I certainly

have big shoes to fill and much to

learn.

I have been a member of the

SMA Council since 2004. Since

then I have witnessed how SMA has

transformed itself through active

engagement with our members, from

medical students to GPs, specialists

and special interest groups; offering

more educational programmes for

both our profession and the public;

and increasing our exposure in the

public domain as well as on social

media platforms.

We look forward to a year already

packed with events. The secretariat

staff is planning a wide variety of

activities for almost every weekend

throughout the year.

Some major highlights in the

coming months include:

Presidents’ Messages

“

April 2015 sMA news • 1110 • sMA news April 2015

Standing (from left) Dr Noorul Fatha As’art, Dr Woon Yng Yng Bertha, Dr Tan Yia Swam, Dr Wong Chiang Yin, A/Prof Tan Choon Kiat Nigel, Dr Tan Tze Lee, Dr Toh Han Chong, Dr Chong Yeh Woei, Dr Lee Yik Voon, Dr Lee Pheng Soon, Dr Anantham Devanand, Dr Ng Chee KwanSitting (from left) Dr Loo Kai Guo Benny, Dr Chan Teng Mui Tammy, A/Prof Chin Jing Jih, Dr Wong Tien Hua, Dr Toh Choon Lai, Dr Lee Hsien Chieh Daniel, Dr Lim Kheng ChoonNot in picture A/Prof Tan Sze Wee

55th SMA Annual General MeetingBy Lee Sze Yong, Manager,

Council Support

Dr Wong tien HuA was elected as the new SMA

President during the SMA Annual General Meeting (AGM),

held in the Arthur Lim Auditorium at the Alumni Medical

Centre on 12 April 2015.

Outgoing President A/Prof Chin Jing Jih started the

proceedings by thanking members for attending the AGM.

He also expressed that SMA is fulfilling its position as a

rational, reasonable, and fair organisation that engages

with various policymakers, by taking a longer and broader

perspective.

A/Prof Chin concluded by thanking his fellow council

members, volunteers in SMA’s various committees, and the

secretariat staff.

Honorary Secretary Dr Chan Teng Mui Tammy referred

members to the 55th SMA Annual Report 2014/2015,

highlighting that Dr Ng Chee Kwan and A/Prof Tan Choon

Kiat Nigel had been co-opted to the SMA Council, after Dr

Abdul Razakjr Omar and Prof Wong Tien Yin stepped down

from the Council in 2014. Dr Ng and A/Prof Tan made brief

introductions to those present at the AGM.

Next, Dr Lee Hsien Chieh Daniel, Honorary Treasurer,

presented the accounts for SMA, SMA Pte Ltd (SMAPL)

and SMA Trust Fund, underlining various key elements of

the financial statements, as well as SMA’s approach to its

finances.

Dr Wong Chiang Yin, one of the directors of the SMA

Charity Fund (SMACF), provided a brief on SMACF’s

objectives, past projects and activities, and upcoming

plans. SMACF successfully renewed its Institution of a

Public Character status for another two years. Dr Wong

encouraged members to donate to SMACF, highlighting the

300% tax benefit for the year 2015.

Members present affirmed the SMA Council’s proposal

to elect Singapore President Tony Tan Keng Yam as SMA

Honorary Member.

Members present also affirmed the appointment of

A/Prof Cheong Pak Yean and Dr Lee Pheng Soon, taking

over from Dr Khoo Chong Yew and Dr Low Lip Ping, as

trustees of the SMA Trust Fund. A/Prof Chin thanked Dr

Khoo and Dr Low for their service to SMA. A/Prof Cheong

Pak Yean, Dr Lee Pheng Soon, Prof Low Cheng Hock, Dr Tan

Kok Soo and Dr Tan Yew Ghee will serve on the SMA Trust

Fund for a three-year term from 2015 to 2018.

Members present also affirmed the appointment of Prof

Chee Yam Cheng, to take over from Dr Yong Nen Khiong,

as trustee of SMAPL. A/Prof Chin thanked Dr Yong for his

service to SMA. Prof Chee Yam Cheng, Prof Low Cheng Hock,

and Dr Tan Cheng Bock will serve as trustees for SMAPL for a

five-year term from 2015 to 2020.

Elections for the SMA Council were then conducted. In

addition to Dr Wong’s election as SMA President, A/Prof

Chin Jing Jih and Dr Toh Choon Lai were named 1st and 2nd

SMA Vice President respectively. The new SMA Council

looks forward to being of service to the members of SMA, the

medical community, and the betterment of healthcare for all

Singaporeans.

56th sMA Council 2015 - 2016

President Dr Wong Tien Hua

1st Vice President A/Prof Chin Jing Jih

2nd Vice President Dr Toh Choon Lai

Honorary Secretary Dr Lee Hsien Chieh Daniel

Honorary Assistant Secretary Dr Lim Kheng Choon

Honorary Treasurer Dr Chan Teng Mui Tammy

Honorary Assistant Treasurer Dr Loo Kai Guo Benny

Council Members

Dr Anantham Devanand A/Prof Tan Sze Wee

Dr Chong Yeh Woei Dr Tan Tze Lee

Dr Lee Pheng Soon Dr Tan Yia Swam

Dr Lee Yik Voon Dr Toh Han Chong

Dr Ng Chee Kwan Dr Wong Chiang Yin

Dr Noorul Fatha As’art Dr Woon Yng Yng Bertha

A/Prof Tan Choon Kiat Nigel

COUNCIL NEWSPRESIDENT’S FORUM

Dr Wong Tien Hua is President of the 56th SMA Council. He is a family medicine physician practising in Sengkang. Dr Wong has an interest in primary care, patient communication, and medical ethics.

1. sMA Annual Dinner At our Annual General Meeting held on 12 April 2015,

we nominated the President of the Republic of Singapore

Dr Tony Tan as the SMA Honorary Member for 2015. Dr Tan

will be receiving SMA’s highest award at this year’s Annual

Dinner to be held at the Grand Copthorne Waterfront Hotel

on 16 May. I hope that you will be able to attend and look

forward to seeing you at the event.

2. sMA Council retreatAs we have a few new council members with us this year,

the SMA Council will hold a planning retreat from 30 to

31 May, to come together for team building and to review

our work plan for the year ahead. We will be looking at our

core mission and objectives as an organisation, to rebrand

SMA in line with our purpose, and to better streamline our

activities.

3. sMA national Medical ConventionThe 46th SMA National Medical Convention, focusing

on the topic of urology, will be held on 25 July at Sheraton

Towers Singapore.

4. international relations

The SMA is the secretariat for the Medical Association

of South East Asian Nations (MASEAN). This year, the

midterm MASEAN meeting, with the theme of “Challenges

in training our future healthcare workforce”, will be hosted

by the Brunei Medical Association, in Bandar Seri Begawan

from 1 to 3 May.

I look forward to serving SMA, to represent our

membership of doctors in the medical community, and to

reach out to the public to promote trust in the profession.

April 2015 sMA news • 1312 • sMA news April 2015

introductionA number of drugs that are used in

the clinics are potentially hazardous

to individuals who are inadvertently

exposed to them. These at-risk

individuals are primarily the clinic

healthcare workers who handle these

drugs, although patients and their

caregivers may also be exposed to

these drugs through environmental

contamination.

One definition of “hazardous

drugs” is: drugs which are potentially

genotoxic, carcinogenic, teratogenic, or

toxic to body organs, when individuals

are exposed to them at relatively low

concentrations. By this definition, many

of the chemotherapeutic agents that are

used in the clinics to treat cancers are

hazardous drugs. This article shall focus

primarily on these cancer therapies,

although the principles discussed in this

article would have general applicability

to non-chemotherapeutic hazardous

chemicals as well. “Hazardous drugs”

and “hazardous chemicals” shall be used

interchangeably in this article.

Toxicity from occupational exposure

to hazardous drugs may arise through

acute, large-dose exposures, or through

chronic, low-dose, repeated exposures.

This article explains some pertinent

facts about occupational hazardous

drug exposures, and outlines some

Minimising Occupational Exposure to Hazardous Drugs in Clinics

relevant preventive measures to

minimise such risks.1

Modes of exposure to hazardous drugs in the clinic

The three principal modes of toxic

exposure are:

1. Inhalation of drug aerosols.

2. Direct skin or mucosal contact with

hazardous chemicals.

3. Accidental inoculation of hazardous

chemicals through the skin.

By far, the greatest risks of

occupational exposure to hazardous

drugs are probably the chronic

inhalation of drug aerosols and

repeated dermal contact with

hazardous drugs. Concentrations of

5-fluorouracil ranging from 0.12 to

82.26 ng/m3 have been found during

monitoring of drug preparation

without a biological safety cabinet

(BSC). Administration of drugs, such

as pentamidine, via aerosolisation can

lead to measureable air concentrations

in the breathing zone of healthcare

workers providing treatment.2 Wipe

samples of workstation surfaces

in oncology pharmacies have also

demonstrated the presence of traces

of cyclophosphamide, indicating the

opportunity for dermal exposure.3 It

is, however, difficult to quantify the

amount of systemic absorption that

results from repeated low-dose airway

and dermal exposure to such hazardous

chemicals.

deleterious effects of inadvertent exposures

Animal studies have amply

documented the carcinogenic,

mutagenic and teratogenic effects of

hazardous drug exposure in animals. The

clearest evidence relates to alkylating

agents such as cyclophosphamide and

nitrogen mustard. The American Society

of Hospital Pharmacists recommends

that all pharmaceutical agents that

are animal carcinogens be regarded as

human carcinogens.

In humans, many hazardous

drugs are known to be carcinogenic

even when used at therapeutic

levels. Chemotherapy use has been

associated with the development of

future secondary malignancies, such

as leukaemia, lymphoma, and bladder

cancer. Chemotherapy drugs have been

shown to induce chromosomal damage,

and the risks increase with the dose and

duration of therapy. Chemotherapy,

especially alkylating agents, is also well

known to cause gonadal dysfunction.

Does occupational exposure to low-

level chemotherapeutic agents lead to

By Dr Kong Hwai Loong

This is part of a series on workplace safety and health for healthcare institutions.

EXECUTIVE SERIES

14 • sMA News April 2015

significant harm to healthcare workers?

This question is not easy to answer.

It is inconceivable that a randomised

trial will ever be carried out to provide

a definitive answer to this question.

Indirect evidence provides some clues

though. Occupational exposure to

chemotherapeutic agents has been

demonstrated to correlate with urine

mutagenicity in healthcare workers.4

With improved handling practices, a

decrease in mutagenic activity could be

demonstrated. Another study showed

that urinary mutagenic activity was

increased in pharmacy personnel when

they were handling chemotherapeutic

drugs, but the activity fell to level of

unexposed controls within two days of

stopping drug handling.

Taken together, the animal and

human data suggest that cellular

damage and tissue harm may result

from “sufficient” exposure to hazardous

drugs, either therapeutically or

inadvertently through occupational

exposures. However, it is unclear if “safe

minimal levels” of such exposure exist.

The risks are likely a continuum.

At-risk nursing and pharmaceuti-cal procedures1

Inadvertent occupational exposure

may occur during drug preparation,

drug administration, and drug and waste

disposal.

Drug preparation

During drug preparation, certain

manipulations may cause splattering,

spraying and aerosolisation. Examples of

such manipulations include:

1. Withdrawing needles from drug

vials.

2. Transferring drugs using syringes

and needles.

3. Breaking open ampoules.

4. Expelling air from drug-filled

syringes.

5. Preparing aerosolised drug therapy.

Employee activities such as smoking,

eating, drinking and applying cosmetics

where these drugs are prepared, are

associated with increased risks of

inadvertent drug exposure.

Drug administration

Clearing air from syringes or

infusion lines, and leakage at tubing,

syringe, or stopcock connections

present opportunities for dermal

contact with hazardous drugs and

aerosolisation.

Drug and waste disposal

Materials used during drug

preparation, such as syringes, needles

and gloves, contain varying amount of

hazardous drugs. Their disposal may

present chances for healthcare workers

to come into contact with these

drugs. The urine of patients receiving

cyclophosphamide and cisplatin

contain large amounts of these drugs.

Inappropriate handling of urine or

urine-soaked clothing and bedding may

pose risks of occupational exposure.

Measures to minimise inadvert-ent occupational exposure 1, 5, 6, 7

Staff education and training

The risks of inadvertent

occupational exposure should be made

known to all healthcare workers who

come into contact with such drugs.

Regular reminders would be helpful.

Where appropriate, formal training

should be given before the employee

is declared competent to carry out

at-risk activities such as chemotherapy

preparation and administration.

Safe work area

The use of dedicated BSCs, where

only hazardous drugs are prepared,

is highly recommended. These cabi-

nets should be regularly serviced and

certified fit for use by trained techni-

cians. High-efficiency particulate air

(HEPA) filters of these cabinets should

be changed regularly. Appropriate

decontamination procedures should be

carried out after each drug preparation.

Safe work equipment

Syringes and intravenous sets

with Luer-Lok fittings should be used

for hazardous drugs. The syringe size

should be larger than the amount of

drug volume that will be administered,

to prevent the plunger from accidentally

dislodging. Properly labelled plastic

bags and sharps containers should be

used for disposing hazardous drugs.

Personal protection equipment (PPE)

Latex gloves must be worn at all

times when handling hazardous drugs.

Research has shown that thickness

of gloves is important when used in

handling hazardous drugs. Double-

gloving is preferred if it does not

interfere with the tasks. Gloves should

be changed frequently (at least hourly).

Gloves must be changed at once in the

event of glove tear or drug spillage.

Staff should be familiar with the proper

technique of removing contaminated

gloves.

Gowns are recommended for

healthcare workers when they are

handling hazardous drugs. In the event

of spillage, the use of respirator masks

is recommended. Surgical masks

are inadequate against drug aerosol

inhalation.

Sound work practices

Many existing nursing practices

already reduce the risk of healthcare

worker injuries in the course of their

work. Some practices that particularly

relate to the handling of hazardous

drugs are listed here:

1. Aseptic techniques must be

observed in all drug preparations.

2. The drug preparation area should

not be cluttered.

3. All items necessary for drug

preparation should be placed within

the BSC before work is begun.

4. All PPE should be donned before

work is started in the BSC.

5. The handling of drugs inside BSC

should be deliberate, careful and

not rushed.

6. All syringes and intravenous bags

containing hazardous drugs should

be marked with distinctive warning

labels.

April 2015 sMA News • 15

Dr Kong is a private medical oncologist working in Paragon Medical and Novena Medical Center. He remains an adjunct associate professor in National University Health System. He was formerly the executive director of

Biomedical Research Council, Agency for Science, Technology and Research. He was a past recipient of the National Day Awards and twice winner of the Singapore Youth Award.

7. Sharps containers must be placed

within the BSC and within easy

reach in the general chemotherapy

administration area.

8. Needles should not be recapped.

9. As far as possible, priming of the

administration set should be done

within the BSC. If priming must occur

at the site of drug administration, the

intravenous line should be primed

with non-drug-containing fluid.

10. The use of extremes of positive

and negative pressures when

accessing medication vials should

be minimised. Vial preparations that

allow easier access are preferred.

11. Ampoules with dry materials should

be gently tapped down before

opening to minimise aerosolisation.

Wrap a sterile gauze pad around an

ampoule’s neck before breaking it.

Diluents should be introduced into

the open ampoule slowly down its

inside wall.

12. Hazardous drug bags should be

wiped with moist gauze on the

outside. These bags should be

transported with care to avoid

damaging them inadvertently. If the

drug bags are being transported

between the clinic and another

health facility, an appropriately

sized and properly labelled plastic

container should be used. Staff

handling these bags and boxes should

don gloves.

13. During intravenous drug

administration, fittings should be

carefully observed for leakage.

14. Personnel dealing with the urine

of patients who have received

chemotherapy in the past 48 hours,

should don gloves and disposable

gowns. Frequent glove changing and

hand washing is strongly encouraged.

15. Thick plastic bags with distinctive

colours and appropriate labels should

be used as trash bags to collect

materials that may be contaminated

with hazardous chemicals. Needles,

syringes and breakable items should

be collected in sharps containers.

Commercial waste disposal should

be carried out by licensed companies.

Management of spills of hazardous

chemicals

1. Emergency procedures for managing

spills of hazardous chemicals should

be developed and staff educated on

them.

2. Spills should be cleaned up

immediately by trained and properly

attired personnel. The spill should be

documented and personnel exposed

noted.

3. Personnel who have spills on their

gowns or gloves should immediately

remove these PPE, and cleanse the

affected skin with soap and water.

Eye exposure should be managed by

water or eyewash irrigation for at

least 15 minutes. Expert eye consult

is advisable.

4. “Small spills”, less than five mililitres,

should be cleaned up immediately

by personnel wearing gowns,

double latex gloves and splash

goggles. Liquids should be wiped

with absorbent gauze pads. Solids

should be wiped by wet absorbent

gauze. The spill areas should then be

thoroughly cleaned with detergent

solutions followed by clean water.

5. “Large spill” areas should be isolated

and aerosol generation limited.

Larger absorbent materials will be

needed to wipe up the spillage.

6. After a large spill in a BSC, consider

changing the HEPA filters by trained

personnel.

7. A spill kit, clearly labelled, should be

kept near the drug preparation and

administration areas. Its content

should include: goggles, gloves, gown,

absorbent materials, scoop to collect

glass fragments, and hazardous

material disposal bags.

ConclusionHazardous chemicals are

frequently present in clinics. Many

of them, such as chemotherapeutic

drugs, are used daily in some clinics

to treat patients. Awareness of

the hazardous properties of these

chemicals, establishment of sound

work processes, and familiarity

with their proper handling, are the

cornerstones in their safe usage in

clinics. The true safe limit to exposure

to these hazardous drugs is unclear.

It is prudent to err on the safe side

by limiting inadvertent occupational

exposure to these agents as much as is

practical.

References1. Appendix I: Controlling occupational

exposure to hazardous drugs. In: Wilkes GM, Barton-Burke M, eds. Oncology Nursing Drug Handbook. Massachusetts: Jones and Bartlett, 2011:1185-219.

2. deWerk NA, Wadden RA, Chiou WL. Exposure of hospital workers to airborne antineoplastic agents. Am J Hosp Pharm 1983; 40(4):597-601.

3. McDevitt JJ, Lees PS, McDiarmid MA. Exposure of hospital pharmacists and nurses to antineoplastic agents. J Occup Med 1993; 35(1):57-60.

4. Falck K, Grohn P, Sorsa M, et al. Mutagenicity in urine of nurses handling cytostatic drugs. Lancet 1979; 1(8128):1250-1.

5. Alexander M, King J, Bajel A, et al. Australian consensus guidelines for the safe handling of monoclonal antibodies for cancer treatment by healthcare personnel. Intern Med J 2014; 44(10):1018-26.

6. Chaffee BW, Armistead JA, Benjamin BE, et al. Guidelines for the safe handling of hazardous drugs: consensus recommendations. Am J Health Syst Pharm 2010; 67(18):1545-6.

7. Maede E. Avoiding accidental exposure to intravenous cytotoxic drugs. Br J Nurs 2014; 23(16):S34, S36-9.

16 • sMA News April 2015

Oaths and Pledges in Medical Professional Culture – Does Analysing and Reflecting on

the Words Matter?By Dr T Thirumoorthy, Executive Director, SMA Centre for Medical Ethics & Professionalism

Concepts easy to recognise and apply Several lines in the pledge are easy to recognise as part

of contemporary professional and clinical ethics. “Make the health of my patient my first consideration” fits in well with the

principle of primacy of patient welfare and the importance of

managing conflicts of interest (especially financial conflicts).

The principle demands accepting that the interest of the

patient be held above that of the clinician and other third

parties, and is an essential component of building trust in the

doctor-patient relationship.

“Respecting the secrets which are confided in me” lends

easily to the principle of upholding medical confidentiality.

This was easier to uphold when a single family physician

was responsible for the majority of a patient’s medical care.

In present day medicine, when the average elderly patient

may have more than three medical co-morbidities managed

by multiple teams and both healthcare professionals and

patients zipping in and out of hospitals, it is a challenging

task to maintain medical confidentiality and privacy. With

electronic medical records that are accessible to many, and

the rise of public interest and interest of medical payers

(managed care and medical insurance) in the happenings in

doctor-patient relationship, this principle has been diluted

with many ethical and legal exceptions.

introductionOn Saturday 28 February this year, I had the privilege of taking the Singapore Medical Council (SMC) Physician’s Pledge

for the first time, with over 300 other physicians, in the presence of medical dignitaries like the Minister of State for Health,

and both the President and Registrar of SMC.

This pledge has its origin in the Declaration of Geneva1 adopted by the World Medical Association (WMA)2 in 1948.

After undergoing several modifications over the years, the declaration is now accepted as an oath to be taken at the time of

admittance as a member of the medical profession. It is also considered a public professing by the profession of the values

that it stands for.

In Singapore, doctors are required to take the SMC Physician’s Pledge to qualify for full registration in the SMC Register

of Medical Practitioners.

For many taking the pledge that day, it was not their initial entrance to the profession, as they were senior doctors and

consultants who had been foreign-trained. The ceremony was sombre, while the people in the hall were cosmopolitan and

international, representing a diversity of cultures.

Some may call it a purely symbolic or allegorical ceremony. Whatever the significance attached to such ceremonies, it is

worth reflecting on the words of the pledge and examining its relevance to today’s medical practice.

The SMC Physician’s Pledge“I solemnly pledge to:

dedicate my life to the service of humanity;give due respect and gratitude to my teachers;

practise my profession with conscience and dignity;make the health of my patient my first consideration;

respect the secrets which are confided in me;uphold the honour and noble traditions

of the medical profession;respect my colleagues as my professional

brothers and sisters;not allow the considerations of race, religion,

nationality or social standing to intervene between my duty and my patient;

maintain due respect for human life;use my medical knowledge in accordance

with the laws of humanity;comply with the provisions of the Ethical Code; andconstantly strive to add to my knowledge and skill.

I make these promises solemnly, freely and upon my honour.”

PROFESSIONALISM

18 • sMA News April 2015

“Not allow the considerations of race, religion, nationality or social standing to intervene between my duty and my patient”

is encompassed by the principle of justice with regard to

eliminating discrimination and ensuring fair access to the

benefits of medical care. The Declaration of Geneva includes

explicit and extended considerations: “I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient”.

This segment of the principle of justice now also calls for

physicians to be “culturally competent” in today’s medical

practice, so they can be aware of and sensitive to every

individual patient’s needs.

“Constantly strive to add to my knowledge and skill” is a professional commitment to competence, and to

advancement of medical knowledge by promoting scientific

research and standards. This is also the ethical basis for

promoting evidence-based medicine and practice. Scientific

evidence gives credibility to current medical practice,

although much of medical practice lacks good evidence.

Commitment to scientific principles also aims to remove

arbitrariness, which was the legacy of medical charlatans of

the past.

“Respect my colleagues as my professional brothers and sisters and give due respect and gratitude to my teachers” is

a remnant of the Hippocratic Oath, and the concept of

medicine as a brotherhood/sisterhood has received much

criticism as being exclusive, elitist, monopolistic and even

self-serving. However, the current professionally accepted

concept of collegiality is of utmost importance, considering

that multiple teams of specialists are providing care to

today’s patients who have multiple morbidities. Collegiality

encompasses the principles of collaboration and cooperation

in the common purpose of serving patients’ welfare.

“Comply with the provisions of the Ethical Code” reaffirms

our commitment to ethics and virtues as one of the three

important pillars of medical professionalism, together with

clinical competence and altruism.

general aspirations and concepts easy to recognise“Practise my profession with conscience and dignity; uphold

the honour and noble traditions of the medical profession” describes the essence of attributes expected of a medical

practitioner in carrying out his work and in carrying himself

in society. It describes the virtues and character of honour,

integrity, selflessness and nobility. Upholding the noble

traditions of the profession requires the doctor to rise above

the temptations of materialism and not use his professional

status in merely seeking status, position, rank and power. The

doctor should earn a respected position in society by clinical

and ethical competence, conscientiousness, humility and

selfless dedication to the service of humanity.

Aspirations and concepts difficult to appreciate and apply

“Dedicate my life to the service of humanity; maintain due respect for human life; use my medical knowledge in accordance with the laws of humanity” – there is no doubt that the practice

of medicine in essence is an ethical and social humanitarian

enterprise. Medicine aims to relieve human suffering caused

by illness and injury.

It is difficult to conceive of the practicalities of maintaining

due respect for human life, and much easier to uphold the

principle of respect for persons. Respect for persons is

defined as respect for their welfare and their wishes. Part of

the difficulty stems from the controversy on determining the

definition of life. When does it start and when does it end?

Or it never ends but just changes its form? Looking for the

“laws of humanity” is even more difficult. However, as one

peruses the history of the Declaration of Geneva, this refers

to avoiding the application of medical knowledge and skills

in human torture, capital punishment, cruel or inhumane

treatment (eg, genital mutilation). Doctors are expected to

advocate for the right to health of children and women and

other rights that preserve the dignity of humans. Illness robs

humans of their autonomy and dignity, and medical practice

aims to restore these to them by relieving the illness.

ConclusionTaking medical oaths and pledges are long-standing

rituals in the medical tradition and culture. Questions have

been raised as to whether the concepts in traditional medical

oaths are relevant for the current doctor-patient relationship

and medical practice.3 Revisiting these oaths from time to

time to reflect on their words and concepts helps keep them

relevant and alive.

References1. World Medical Association (WMA). WMA Declaration

of Geneva. Available at: http://www.wma.net/en/30publications/10policies/g1/. Accessed 11 March 2015.

2. WMA. Medical Ethics Manual. Available at: http://www.wma.net/en/30publications/30ethicsmanual/index.html. Accessed 11 March 2015.

3. Dickstein E, Erlen J, Erlen JA. Ethical principles contained in currently professed medical oaths. Acad Med 1991; 66(10):622-4.

Dr Thirumoorthy has been an associate professor in the Education Programme at Duke-NUS Graduate Medical School since 2007. His teaching responsibilities include subjects on professionalism, medical ethics, communications, and healthcare law. He has been practising medical dermatology at Singapore General Hospital since 2002.

April 2015 sMA News • 19

i writE this with great heaviness. March 2015 was a

month of losses. Singapore lost our founding father. An

even more personal loss was the unexpected and sudden

passing of Mr V.

A/Prof Appasamy Vijayan was born on 15 August

1953, and passed away on 19 March 2015, aged 61. A/Prof

Vijayan obtained his medical degree at the University of

Madras, India. He served as a specialist medical officer in the

Singapore Armed Forces, and trained in the fields of diving

and hyperbaric medicine, and disaster medicine. Following

his career in the armed forces, he completed his surgical

training and obtained fellowships from the Royal College of

Surgeons of Edinburgh (in 1997) and the Royal College of

Physicians and Surgeons of Glasgow (in 1998). He was later

admitted as a fellow of the Academy of Medicine, Singapore

in 2003. At the time of his passing, he was president-elect of

the College of Surgeons.

He was also awarded the Public Service Medal (PBM)

in 2000 and the Public Service Star (BBM) and Long

Service Medal (PBS) in 2011, as National Day Honours

by the Singapore Government. He received the inaugural

Singapore Courage Fund Healthcare Humanity Award

in 2004 and the National Healthcare Group (NHG)

Outstanding Citizenship Award in 2010. In that same year,

he was awarded the Health Manpower Development award

to pursue a master’s programme in medical education.

He was the patient safety officer in the Division of

Surgery, and he took the role very seriously. He came up

with improvements in the time-out checklist and for every

lapse in safety, he investigated with fairness, insisting on

knowing the how and why, without ever attaching individual

blame. He was always willing to listen and invited input

from everyone; never discounting opinions from nurses or

junior staff. He was the programme director of the General

Surgery Residency Programme of the NHG - Alexandra

Health Pte Ltd (AHPL) cluster of hospitals; a role that took

up most of his time in the past few years. He handpicked the

residents, with input from the consultants and registrars.

He planned their curriculums and postings, and he met them

regularly on a one-to-one basis (out of office hours) to get

and give direct feedback on their performance and progress.

We called him “Mr V” affectionately – though I don’t

remember how it started. He had always been a passionate

and energetic man, and was truly committed to lifelong

learning. Whenever I had to call him in the middle of the

night for a trauma consult, he would be alert and sprightly

(even if it was 3 am!). When he needed to come in to the

emergency operating theatre, he was always fresh as a daisy

and cheerful; while the rest of us were running haggard

and falling asleep on our feet. His commitment to teaching

showed whenever he quizzed and questioned us on various

aspects of the case (in the middle of the night!).

Mr V was a warm and friendly man, and genuinely cared

for his trainees. He had always maintained up-to-date with

the “young” folks – becoming computer savvy and holding

private talks with the registrars and residents to get to

know us on a social basis. When we were invited to his elder

A/Prof Appasamy Vijayan – A Great Mentor and ColleagueBy Dr Tan Yia Swam, Editor

EULOGY

daughter’s wedding, I was extremely honoured to be part of

the happy occasion. He welcomed us like his favourite nieces

and nephews, and even invited all of us to stay and dance the

night away! But we were too shy to.

Mr V also had a great sense of humour – there was

one memorable HOI (hour of inspiration – a Tan Tock Seng

general surgery tradition) where the housemen caricatured

him in the manner of “Z for Zorro”: Mr V slashing a V on

a “bad” houseman who could not meet his expectations.

He laughed the hardest. He was also a talented player of

traditional Indian drums – which I regret not having had the

privilege to see.

My greatest regret though, is not having the chance to

know him better as a friend; as previously, I have always felt

he was so many years my senior. He has left such big shoes

to fill: clinical work; medical education with the Lee Kong

Chian School of Medicine; directorship of the residency

programme; medical leadership with the College of

Surgeons. Yet while we scramble to close up these gaps, the

holes in our hearts will always remain empty.

Personally, I think the best way to honour him is to live

life to the fullest, and to always work for the betterment of

our patients and the profession; something that Mr V had

always done.

Dr Tan is currently an associate consultant with the Breast Department of KK Women’s and Children’s Hospital. She recalls the advanced specialist training years at Tan Tock Seng Hospital fondly, for the friendships that stood the test of time and on-call hardships! She continues to juggle the commitments of being a doctor, a mother, a wife, and the increased duties of SMA News Editor. She tries to keep time aside for herself and friends, both old and new.

From leftConclusion of a successful training session: Dr Vijayan (sitting, centre) with his team of trainers (surgical consultants and registrars), as well as residents and nurses

Dr Vijayan in his element: teaching! He used newer techniques of simulation and case scenarios for teams of junior doctors to manage, with immediate feedback and critique

From topMr V in awesome dress up at the photo booth at the NHG-AHPL Residency Open House, with current chief resident, Dr Tan Ming Yuan

Mr V sharing finer points of surgery with medical students during a break

LIFE IN PIXELSSMA NEWS PHOTO COMPETITION

The winner of each theme will take home a Crumpler camera bag and a Canon Digital Ixus lanyard with 16GB thumbdrive.

The winning entries will also be featured in the pages of SMA News.

Send us your best photos along with your name and MCR/matriculation number at lifeinpixels@sma.org.sg, with the

name of the theme as email subject. All images must be in JPEG format, and sized to at least 2,480 x 3,508 pixels. Include a

short descriptive legend (maximum 20 words) with each picture.

This contest is open to SMA members in good standing only. Before submission, check out the contest details at

https://www.sma.org.sg/lifeinpixels.

Calling all photography enthusiasts! Life in Pixels is back for 2015! To celebrate Singapore’s 50th year of independence, we’re releasing a series of themes which reflect the richness of life on this little red dot.

theme* Closing date release of results

1. “Nation Building” – a play on words: members of the pioneer generation and buildings of historical significance

28 June End July

2. “Singapore by Night” – capture the bright lights of our city after the sun goes down

23 August End September

3. “Culinary Heritage” – the best local gastronomic delights that are a feast for the eyes

25 October End November

*SMA will be holding relevant photo workshops in conjunction with each of the four themes. For more info, go to http://goo.gl/6Wg3mv.

Organised by In celebration ofImaging partner

date:12 July 2015

time:6.30 am

Venue:Kallang Practice Track

registration Closing date:21 June 2015

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*The unique SMA code is reserved exclusively for the first 500 SMA members who register for the race. SMA members who sign up thereafter will have to pay the

full published rate.

Run for a Good Cause! In commemoration of SG50, Pocari Sweat Run 2015 will be raising

funds to benefit the healthcare community, and the SMA Charity Fund

(SMACF) is one of the charity beneficiaries for the event. Pocari Sweat

Singapore will donate $5 to SMACF for every SMA member who

participates in the race.

Pocari Sweat Singapore’s brand ambassador, Dr Mok Ying Ren, 2013 SEA

Games men’s marathon gold medallist, will also be present at the event to

interact with runners and share valuable tips on running during a stage

presentation.

Support SMACF by signing up for the Pocari Sweat Run with the unique

SMA promo code and enjoy 15% off!

To obtain the special promo code, please contact Ms Jennifer Lee (SMACF)

at email: jenniferlee@sma.org.sg or tel: 6223 1264. For more information

about Pocari Sweat Run 2015, and to register, please visit their website at

http://www.pocarisweatrun.com or scan the QR code below.

dr MoK yiNg rEN

Pocari Sweat SingaporeAmbassador

Official Charity Beneficiary:

INSIGHT

tHEsE sNiPPEts (above) from our patients are mere

snapshots of their intense and immense struggles to keep

in touch with reality. We are liaison psychiatrists working

in a local hospital, and are very much deeply rooted and

entrenched in our culturally rich and multireligious society.

Frequently, we are called to question our own clinical

judgements, not just by spiritual healers, mediums or fellow

colleagues steeped in religious beliefs, but even by the

macabre nature of what these phenomenological experiences

reveal.

diagnosing mental disordersFor uninitiated readers stepping into psychiatry, these

may come across as frightening to most, strangely alluring

to some, and perhaps curiously prickly to the mind. Most

of our patients will attempt to understand, rationalise

or even disavow them. Then some will seek to receive

meanings or answers from their deities, some may derive

solace from psychedelics or OTC drugs to drown out these

“voices” or “visions”, and even a smaller number may just

turn to trusted healthcare practitioners to “believe them”,

without realising this area of practice falls under the

All in the Mind

“Why am I seeing my grandfather standing

there? He died last year!”

By Dr Lui Yit Shiang and Dr Soo Shuenn Chiang

“Shhh... don’’t keep doing that.”

“This is a message from God, yes?”

“I can feel a presence...

but I don’t see anyone...

“You aren’’t real.

Are you?”

24 • sMA News April 2015

domain of mental health. “Hallucinations” are what most of

our learned colleagues from general practice, emergency

medicine or internal medicine will tell their patients with

a certain sense of triumph (“aha, I know what you have!”),

followed by a rapid referral to us.

Viewed with scepticism by sufferers or perhaps

even by our own peers (owing to stigma and why we can

diagnose without laboratory or imaging confirmation),

but we will still proceed to inquire inquisitively, gently,

comprehensively and empathetically about these

encounters and other possibly associated symptoms

sufficient to meet syndromic criteria or features of

a particular disorder. Of course, if indeed these are

hallucinations (perceptions in the absence of actual

stimuli), we will delve into their aetiologies and wonder

how we can begin to relieve them of these phenomena.

One very useful model is the stress-vulnerability pathway

and dopamine hypothesis to illustrate the emergence and

evolution of these symptoms, hence paving the way for the

discussion to move towards treatment acceptance.

More often than not, non-psychiatric conditions will

present with hallucinations. Acute delirium can present

with such extraordinary perceptual disturbances, owing

to a variety of insults to the brain. Unfortunately, delirium

is a less popular yet considerably lethal diagnosis among

hospitalised patients because of fluctuations in cognitions

(eg, attention span, amnesia) at different times in a day

to different members of the medical team, disguising as a

depressive reaction to distract them from the underlying

causes like sepsis, metabolic derangements or an insidious

bleed somewhere. Dementia of Lewy body subtype will

present with complaints of disturbing visions and noises

which worsen with initiation of antipsychotic medication.

Charles Bonnet syndrome is a phenomenon in which

patients who suffer visual impairments experience graphic

and elaborate visual images.

Thereafter, pertaining more to psychiatric conditions

would be schizophrenic disorders, psychotic depression,

drug-induced states or even dissociative states (just to

name a few). To absolutely describe or contrast these

disorders is beyond the scope of our prose and we believe

readers will be stimulated to pursue other texts of

psychiatry on their own. Of the lot, patients diagnosed with

schizophrenia often display other symptoms like blunted

affect, language loss and social deterioration. Very much

amenable to medication and rehabilitation, this condition

also lends visibility to the disease in the public eye, when

the emergence of socially unsanctioned positive symptoms

and neglect of self-care occur due to non-compliance of

treatment or escalated negative expressed emotions from

disconcerted family members or misinformed faith-based

practitioners.

Of particular interest is the increasing attention cast

on substance use in our local scene, where amphetamines

or other psychedelics are becoming rampant. Their

consumption may signal a way of coping with these

symptoms or may be a tip of the iceberg of a bigger problem

of drug-induced psychosis. Ice (methamphetamine),

Ecstasy (MDMA) or “power pills” (dextromethorphan)

users often describe acute or delayed onset symptoms and

their hallucinations may present in various modalities in

a myriad of frequencies and intensities. One approach is

definitely a direct enquiry since most users would admit

to drug use so as to derive some form of rescue from

these undesirable effects (as all users are looking for

the cognitively enhanced state and not these unwanted

consequences) and immediate cessation to ameliorate

progression of the symptoms.

Final thoughtsAfter the assessments and investigations, some

patients blatantly respond by saying that psychiatry is of

little or no value in their self-management, but this actually

rarely adds angst to our own clinical experience. The most

grievous is instead insightless attribution to spiritual

explanations, especially when risk is imminent in the

absence of treatment or containment. Just as it is critical to

ensure treatable causes of hallucinations are being looked

into (and hence the general hospital psychiatrist is an

invaluable ally), we cannot help but also mention that there

is a role for involuntary institutional care in view of the

risks to sufferers and caregivers.

Otherwise, in our attempts to empathise and build

rapport with sufferers and their caregivers, we will wear

many hats as clinician, advocate and fellow believer even,

so as to marry medical models, religious concepts and

traditional values into a feasible treatment plan that would

put our patients’ care and mental wellness in good stead

for the years ahead. Simple as these words may seem, but

in real practice, it will take full immersion into the culturally

steeped world of deities, supernatural customs and

paranormal experiences with patients, before your voice as

a psychiatrist shimmers into their clarity of mind to guide

them back into reality.

Yit Shiang is a consultation-liaison psychiatrist in National University Hospital (NUH), who enjoys great fellowship (ie, co-share challenging patients) with his colleagues. In his spare time away from the madding crowd, he loves running, singing and immersive bollocks sharing with his fellow psych colleagues at Wala Wala.

Shuenn Chiang works in the NUH consultation liaison service and neuroscience clinic. His professional interests are in psychotherapy work and mindfulness practice. In his leisure time, he jogs, sings and drinks away with his fellow psych colleagues at Wala Wala as well.

April 2015 sMA News • 25

By Dr Tor Phern Chern

iN A typical doctor-patient relationship, the clinical history provided by the

patient is often key for both diagnosis and management. What happens if he is

deliberately feigning symptoms? And why should the average clinician worry

about malingering patients?

The main reason is that such behaviour is both more common than most

clinicians imagine and the potential ramifications can be adverse for both

the patient and clinician. Mistakenly diagnosing and treating a patient will

expose him to all the potential risks of the treatment with essentially no

potential benefits. The clinician is then left with the possibility of being sued

for defamation of character and malpractice. Extreme cases of successful

litigation include patients who claimed to have cancer and managed to obtain

repeat prescriptions of oncological drugs (and then suffered the predictable

negative effects) from physicians who did not confirm the diagnoses. In

a paediatric population, overlooking malingering-by-proxy in children by

parents can be potentially disastrous.

understanding malingeringDeliberately feigning symptoms is often medicalised either as malingering

or a factitious disorder. Malingering is defined in the fifth edition of the

Diagnostic and Statistical Manual of Mental Disorders as “the intentional

production of false or grossly exaggerated physical or psychological

symptoms, motivated by external incentives such as avoiding military duty,

avoiding work, obtaining financial compensation, evading criminal prosecution

or obtaining drugs”. The difference between malingering and factitious

disorders is the motivation for the symptom production. In malingering, the

motivation is defined as an external incentive; for factitious disorders, the

external incentives are absent.

Most practising doctors in Singapore would have considered these two di-

agnoses when seeing patients with potential secondary gains (external motiva-

tion for seeking help rather than positive internal motivations). Such patients

often elicit strong negative countertransferences from the doctors treating

them. Nevertheless, it is useful for medical practitioners to be aware of some

common myths regarding malingering.

Malingering is often thought of as rare and seen mostly in forensic

settings. However, research shows that malingering is not unusual in clinical

settings where the outcome of an evaluation has important consequences

(eg, insurance claims) and some degree of symptom exaggeration may be

present in up to 60% of the patient population. Similarly, malingering is not

evidence of deeper psychiatric issues (eg, antisocial personality disorder) and

is often an adaptive response to the situation. Malingering is also not a static

rigid response pattern (once a malingerer, always a malingerer), but is often

behaviour governed by a cost-benefit analysis.

Deception is often associated with malingering, but deception is a

universal and normal social human behaviour, and is thus not a telltale sign

MANAGING MEDICAL

MALINGERING

INSIGHT

26 • sMA News April 2015

Dr Tor is a psychiatrist working in the Mood Disorder Unit in the Institute of Mental Health. He has a special interest in treating patients with electricity and magnetism. In a previous life, he spent his time treating stressed young men in uniform.

of malingering. Lastly, clinical interviews are often not

sufficient to determine malingering. A highly respected senior

colleague once shared the experience of being entirely fooled

by a patient presenting consistently with classic symptoms of

schizophrenia. This patient was only exposed after a private

investigator showed the clinician videographic evidence of

the patient performing acts in her daily life that were entirely

inconsistent with her provided history. As it turned out, the

patient’s behaviour was due to a secondary gain that was not

made known to the clinician.

detection of malingeringWhy do some patients malinger? As with much human

behaviour, the reasons are complex and multifactorial, but

one significant factor is the potential benefits of the sick role

in a society that accepts the ill more easily than emotional

disorders or problems of living. An unemployed person in

debt with a headache is a patient who requires treatment

and support, while an unemployed person in debt may be

seen as merely needing to get a job. Why a particular person

malingers also depends on his previous experiences of being

ill, family influences, developmental factors, and mental

model of his life situation and resources.

So how can the practising clinician detect malingering?

The first step is to recognise the possibility of malingering

in scenarios where there is potential for secondary gain (eg,

insurance claims or military duty). Other situations to be

more sensitive in include patients who present inconsistent

histories and have sought medical care from many treatment

centres with atypical courses of their conditions. Patients

with large number of investigations or predict worsening

of their conditions are also at higher risk of malingering. In

addition, patients with diagnosis of post-traumatic stress

disorder, brain injury and pain conditions are more likely to

display malingering behaviour.

If a clinician suspects malingering, what should he do? The

first thing is to acknowledge that a routine clinical assessment

is inadequate to detect malingering and the cornerstone

of detection is a well-prepared clinical assessment with all

available documents reviewed and apparent inconsistencies

marked out for clarification. Notes from other healthcare

providers should be obtained and reviewed in advance, and

firm evidence of fabrication sourced. Consultation with a

psychiatric colleague should be arranged if possible and the

actual assessment should be conducted in a non-judgemental

and non-punitive fashion, with continued support included.

Future management of the patient should be based on a

shared understanding of the diagnosis. It is important not

to jump to the conclusion that the patient is malingering

despite minor inconsistency or deception, as even patients

who malinger can still have entirely genuine treatment needs.

The prognosis of such cases is variable, and many patients

will drop out of treatment when confronted by evidence of

malingering by the treatment team.

Managing malingering A memorable case I encountered was of a young man in

his 20s who had been admitted for several months in an acute

ward at a restructured hospital, and had done more blood

tests and radiographic investigations than most patients with

cancer. The young man had been admitted 46 times before,

while his family was well known to be highly vocal about his

treatment needs and routinely showed newspaper cuttings

of their previous encounters with healthcare staff who failed

to take his complaints seriously. He also routinely cited his GP

whom he claimed supported his complaints.

By that time, the general management strategy

was to simply accede to the patient’s requests for more

investigations and tests. It did not help that the patient had

so many investigations that some were mildly abnormal (eg,

possible mild kinking of ureter or that his urine production

was so large as to defy belief). Eventually the management

team reviewed all his previous 46 admissions, his extensive

investigations and spoke to his private GP. It was apparent

that his complaints over the 46 admissions were not

consistent with any known medical condition and seemed

to evolve in tandem with whatever abnormal investigation

was available at the time. The GP also did not recall giving

the kind of support the patient reported. Lastly, the reported

symptom severity was inconsistent with his otherwise

healthy clinical appearance.

The team then held a family session where they

confronted the patient and family with the entire

chronological history and evidence, and strongly suggested

the need for appropriate outpatient care. Predictably the

patient and family became upset but instead of complaining,

they simply discharged him that same day. The team felt that

the reason the patient left was because they were trying to

put all the pieces of the story together rather than just taking

his word for it, so he and his family decided to go to a new

treatment setting where they would not face such challenges.

Unfortunately he was admitted to another hospital the same

night. He was later sent to a psychiatric unit in that hospital

which diagnosed malingering and I was told his condition

improved eventually.

ConclusionThe lesson here is to keep malingering as a possible

scenario when the circumstances suggest it, and manage it

actively via a well-prepared assessment with a view towards

appropriate sympathetic management of the patient’s

needs.

April 2015 sMA News • 27

lEgENd HAs it that it happens to

everyone. Even the most respected

professors have weathered through

it. What is it, you ask? I am talking

about burnout disorder (cue dramatic

music). Please note that this can be

further classified into minor burnout

disorder and major burnout disorder in

the “Diagnostic Manual of I-Made-This-Up”. It’s the most dreaded condition

a physician could be plagued with,

transforming the most enthusiastic,

bubbly, caring, and conscientious

doctor into a shadow of his or her

former self.

Like any condition in our Oxford

Handbooks, we need to be familiar with

the basic aspects of this ailment. This

article will thus provide a crash course

on minor/major burnout disorder.

We All Need Some

By Dr Gillian Lim

{

Epidemiology This condition has equal

prevalence among all genders and

races. However, it has the highest

incidence in the 23 to 30 years age

group – ie, house officers, baby medical

officers (MOs), and all the way to

senior MOs nearing the end of their

bond.

diagnostic criteria 1. Three or more of the following in a

two-week period:

a. Complaints of lethargy.

b. Changes in mood from baseline

(low, irritable, or overly elated).

c. Poor sleep and large eye bags.

d. Dealing with existential issues.

e. Restlessness in job.

f. Hair loss.

g. Transient thoughts of “why am I

not a banker/businessman?”

h. Hopelessness of “why am I on

call again?”

2. Displays evidence of functional

impairment in one or more

domains of life:

a. Reduced social interaction with

humans of choice.

b. Poorer quality of handwriting in

notes.

c. Decreased ability to meet Joint

Commission International

standards.

d. Lesser interaction with journals

and textbooks.

3. No evidence of other more

serious conditions such as major

depressive disorder, anxiety

disorder, substance use disorders

or a general medical condition.

4. Specifiers:

a. Minor burnout criteria are met

if impairment is localised to one

domain.

b. Major burnout if you can’t even

be bothered to count.

treatmentMy guess is that most people with

burnout won’t be reading this, but in

case you are, or you know of someone,

suffering from this disorder, the

following methods are some woolly,

non-evidence-based ways to achieve

remission.

TLC {

OPINION

28 • sMA News April 2015

Using a biopsychosocial approach

to treatment:

1. Biological:

a. Initiation of regular low dose

oral ethanol-based or non-

ethanol-based beverages of

choice (my preference is Meiji

Chocolate Flavour Milk 1L, if I

am feeling hardcore).

b. For breakthrough agitation,

consider Haribo gummy sweets

or chocolates as needed.

c. Start low and go slow.

d. Beware of toxicity especially

with alcohol.

2. Psychological:

a. Cognitive behavioural therapy

(to tackle negative cognitions

such as “I am a useless doctor”

or “I am never going to pass my

exams”).

b. Assertiveness training (in

cases where burnout is due to

inability to say “no” to arrows).

c. Korean drama therapy (usually

more effective in the female

gender).

d. Cartoon therapy (don’t judge!).

e. Music therapy (have found

results with Ellie Goulding,

negative effects with certain

Disney stars).

f. Bibliotherapy.

3. Social:

a. Consider planned or

impromptu trips abroad that

are not for the purpose of

exams.

b. Schedule meals and gatherings

that are not related to exams

with loved ones.

c. Stay up late doing random

non-exam stuff (eg, computer

games? YouTube!).

d. Take up a hobby that is not

related to work or exams (eg,

knitting, cooking, baking or

painting).

Prognosis Fair. Most people are able to see

positive responses within one to two

weeks of treatment. More persistent

cases may require use of multiple

modalities of therapy simultaneously

and more co-therapists.

ConclusionI think the bottom line is that

we are not alone. We enter this

profession bright-eyed and bushy-

tailed; full of hope and good intentions

to dedicate our lives to serve others –

mayhap a tad too idealistic.

Along the way, we meet obstacles

and challenges that lower our morale,

and send us crashing down to earth.

We get burned out, jaded, and weary.

We wonder why we ever started on

this journey and how we can carry on.

If I were a betting sort of person,

I’d put my money on the legend being

true. Burnout is unfortunate, but

perhaps an inevitable part of learning

to be an effective physician. It is a

terribly unpleasant feeling that may

make us question our purpose in this

field.

Can we get past it? Yes, we just have

to look around us and see that there

are seniors among us who remain

passionate about their work and their

patients. There is hope for us yet.

So what can we learn from it? Maybe

burnout is a way for our body to tell us

that the balance of our lives is wrong.

It is true, we may have examinations,

insane calls, unreasonable patients

or demanding workloads; but there

is life and family outside work, and

we are responsible to ourselves for

maintaining this equilibrium. A journey

is a long one, a marathon if you like. We

need to pace ourselves and take breaks

to complete it safely. We are doctors,

but we are still humans. Before caring

for others, we need to first care for

our own bodies. So why not start by

showing yourself a little TLC today?

Dr Gillian Lim is currently embarking on her fourth year of the National Healthcare Group Psychiatry Residency Programme. In her spare time, she enjoys singing, marvelling at nature, and being pleased with little things in life.

April 2015 sMA News • 29

DATE EVENT VENUE CME POINTS WHO SHOULD ATTEND? CONTACT

CME Activities

10 MaySunday

BCLS CourseAlumni Medical Centre

2Family Medicine and All Specialties

Siti Nurhuda or Lin Shirong 6223 1264cpr@sma.org.sg

27 MaySaturday

SMA Seminar: The Utility (Benefits and Limits) of Ethical Codes in Teaching and Training of an Ethical Clinician

Health Sciences Authority (HSA) Auditorium

TBCDoctors and Healthcare Professionals

Denise Tan 6223 1264denisetan@sma.org.sg

2 JuneTuesday

Mastering Professional InteractionsSheraton Towers Singapore

2Family Medicine and All Specialties

Margaret Chan 6223 1264 margaret@sma.org.sg

3 JuneWednesday

Mastering Your Risk The Elizabeth Hotel 2Family Medicine and All Specialties

Margaret Chan 6223 1264 margaret@sma.org.sg

6 JuneSaturday

SCS-SMA Cancer Education Series 2015: Cervical Cancer

Health Promotion Board

TBCDoctors and Healthcare Professionals

Denise Tan 6223 1264denisetan@sma.org.sg

8 JuneMonday

Mastering Adverse OutcomesSheraton Towers Singapore

2Family Medicine and All Specialties

Margaret Chan 6223 1264 margaret@sma.org.sg

29 JuneMonday

Mastering Difficult Interactions with Patients

Sheraton Towers Singapore

2Family Medicine and All Specialties

Margaret Chan 6223 1264 margaret@sma.org.sg

30 JuneTuesday

Mastering Shared Decision MakingSheraton Towers Singapore

2Family Medicine and All Specialties

Margaret Chan 6223 1264 margaret@sma.org.sg

1 JulyWednesday

Mastering Your RiskSheraton Towers Singapore

2Family Medicine and All Specialties

Margaret Chan 6223 1264margaret@sma.org.sg

2 JulyThursday

Mastering Difficult Interactions with Patients

Sheraton Towers Singapore

2Family Medicine and All Specialties

Margaret Chan 6223 1264margaret@sma.org.sg

4 JulySaturday

Mastering Adverse OutcomesSheraton Towers Singapore

2Family Medicine and All Specialties

Margaret Chan 6223 1264margaret@sma.org.sg

4 JulySaturday

SMA Training Workshop: Core Concepts in Medical Professionalism

Ramada Singapore at Zhongshan Park

TBCDoctors and Healthcare Professionals

Denise Tan 6223 1264denisetan@sma.org.sg

11 JulySaturday

Mastering Adverse Outcomes The Elizabeth Hotel 2Family Medicine and All Specialties

Margaret Chan 6223 1264margaret@sma.org.sg

20 JulyMonday

Mastering Difficult Interactions with Patients

Sheraton Towers Singapore

2Family Medicine and All Specialties

Margaret Chan 6223 1264margaret@sma.org.sg

25 JulySaturday

46th SMA National Medical ConventionSheraton Towers Singapore

TBCDoctors, Healthcare Professionals and General Public

Margaret Chan 6223 1264margaret@sma.org.sg

Non-CME Activities

16 MaySaturday

SMA Annual Dinner 2015Grand Copthorne Waterfront Hotel

NASMA Members and Guests

Mellissa Ang 6223 1264dinner@sma.org.sg

12 JulySunday

Pocari Sweat Run Kallang Practice Track NASMA Members (special promo code available)

Jennifer Lee 6223 1264jenniferlee@sma.org.sg

19 AugustWednesday

SMA Annual Golf Tournament TBC NASMA Members and Guests

Azliena Samhudi 6223 1264liena@sma.org.sg

SMA EVENTS MAY - AUGUST 2015

CALENDAR

30 • sMA News April 2015

Creating Awareness on Paediatric Brain Tumours By Angela Yap and Yvonne Chia

For A full 15 minutes, the sound of car engines filled the

driveway of KK Women’s and Children’s Hospital (KKH).

A crowd had gathered around and onlookers were busy

whipping out their handphones and snapping pictures. Upon

advancing closer, one could see the culprits responsible for

drawing such attention. Transforming the usually peaceful

Saturday morning at KKH into a place packed with excitement

were two dozen Lamborghinis neatly lined up along the

driveway. These sports cars and their drivers were not

simply cruising through KKH. In fact, they were intentionally

waiting there, as part of the inaugural Paediatric Brain

Tumour Awareness (PBTA) Day held on 1 November 2014,

to receive 24 special children who have been through more

suffering than their peers have experienced: brave young

survivors of brain tumour.

Amid the throng was also another important group of

people – the Duke-NUS Graduate Medical School students

behind PBTA Day. In end 2013, Dr David Low (consultant

paediatric neurosurgeon at KKH) and Dr Joshua Chua

(recent graduate from Duke-NUS), two individuals who

were moved by the sufferings of the paediatric brain tumour

survivors, came up with the idea of organising an annual

event to celebrate the lives of these young fighters. They

brought together a group of second year Duke-NUS students

to form the PBTA group, and the very first public awareness

event for paediatric brain tumour patients in Singapore was

born.

We hoped that PBTA Day could provide the young

patients with a day of fun and laughter, enabling them to

momentarily forget their suffering from the various medical

treatments they had been subjected to. Thus, the celebrations

at KKH included a mini carnival featuring game and balloon

sculpting booths for the children’s enjoyment. In addition,

we also wanted this occasion to provide an opportunity for

family members to demonstrate mutual support for one

another and rally together for the difficult journey ahead. To

achieve this aim, educational talks, about recent advances

in paediatric brain tumour research and social platforms

available for families to seek aid from, were also organised.

The main highlight of the event, however, was the joyride,

in which the 24 car owners volunteered not only their cars

but also their time to drive the young patients from KKH

to Kallang Leisure Park. The significance of this event to

the children could be exemplified by the account of one

participant who fell ill on the morning of PBTA Day, and had

to be temporarily warded at KKH. But this young survivor

was unwilling to allow his illness to defeat him and eventually

regained his strength to attend the joyride.

This heart-warming story reminds us that despite the

suffering these paediatric brain tumour patients face, their

condition is simply just one part of their lives. The treatment

regimens these patients undergo often leave them with

fragile health and other side effects, such as scars from

surgery or hair loss from chemotherapy. However, in showing

our support and care for these children, we can encourage

them and their family members to look beyond the illness

and its devastating effects; and recognise instead that they

too are capable of living a meaningful life outside the illness.

our thanksPBTA Day 2014 was made possible through collaboration

with the Brain Tumour Society Singapore (BTSS) who rallied

support from the Lamborghini Club Singapore for the joyride

segment. BTSS is a newly founded non-profit organisation

that celebrated its launch on 1 November as well. To show

their support for brain tumour patients, BTSS successfully

organised their own Brain Tumour Awareness Day with the

Brainy Car Rally event, for adult sufferers, on the same day.

We would also like to thank our various partners – KKH,

Children’s Cancer Foundation, VIVA Foundation for Children

with Cancer, and Science Centre Singapore. With the love

and support that our first event had garnered, we look

forward to its next edition this November, to bring smiles and

laughter to these children again.

You can find out more about PBTA at our website, http://

pedsbta.wix.com/pbta, or our Facebook page, https://www.

facebook.com/pedsbta.

Ph

oto

: PB

TA G

rou

p

Angela Frances Yap and Yvonne Chia (Duke-NUS Class of 2017) are the chairperson and vice chairperson for PBTA Day 2014, respectively.

FROM THE HEART

The PBTA Group

April 2015 sMA News • 31

We asked five physicians how they upkeep their mental wellness amid their busy schedules. Be it personal improvement,

leisure activities with family and friends, or simply having time to themselves, these doctors show us how it’s done.

My sporting background and personal experience with managing

busy work schedules as a doctor in institutional practice, and now in

private practice, have been valuable in my advice to patients, who

range from elite athletes to busy executives.

I participated in triathlons as a junior doctor, and went on to

complete the Ironman Western Australia during my registrar days,

raising funds for the Handicaps Welfare Association. However, my

exercise regimen had to be adapted since I started a family.

Long hours of training (including bike rides at 3 am) in preparation

for the gruelling Ironman Triathlon has now given way to shorter

and more varied workouts. In order to be more family-friendly, my

training was modified to include my children so we could inculcate

sports as a regular family bonding and fitness activity.

My children will cycle or kick-scoot alongside when I go for

my weekly runs, which can vary from endurance to tempo runs,

once or twice a week. For variation and greater intensity, I

combine high intensity interval training (running intervals

around a park with slopes) with circuit training on the

pull-up bars and chest dips on parallel bars in between.

We also practise agility ladder drills to help my kids, who

are learning tennis, improve their footwork, balance and

coordination.

Varying the exercise routine and moderating the

intensity reduce the risks of injury and keep it from getting

monotonous. Finding activities where we can exercise

together as a family is also more inclusive and fun.

On top of that, I also learn from exercising with my

children. Seeing their recreational gymnastic routines has

reminded me that core strength training and flexibility should

be incorporated into any individual’s fitness programme.

Dr David Su is an orthopaedic surgeon at The Orthopaedic Centre Novena, Farrer and Orchard. He has a special interest in foot and ankle conditions. A once-avid triathlete, he has completed the Ironman Langkawi, Ironman Western Australia, Escape from Alcatraz triathlons, among others. He is married with three children.

From topTempo runs with children as they kick-scoot on the park connector

Circuit training at the exercise corner in between running intervals

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32 • sMA News April 2015

My favourite way to de-stress, after a full day of

convincing patients to take their statins, is to gather a few

friends and have a game of Settlers of Catan or Balderdash.

Competitive board and card games have always been a

breath of invigorating air for me. I enjoy the challenge of

thinking out of the box and figuring out the best route to

a goal that is five to ten steps ahead. If you’ve ever read

Ender’s Game, you’ll understand how mental stimulation in

one realm can have applications in real-life situations.

The other way I relax is making desserts. I have a sweet

tooth, and it annoys me when a dessert that looks nice

in a shop’s display ends up tasting terrible. If you want

something done right, sometimes you just have to do it

yourself. My best recipes are not from cookbooks or the

internet. Instead, they are from my mother’s well-worn

notebook and hand-me-down recipes shared among my

domestic goddess friends. Thanks to them, my kitchen has

given birth to some really yummy goodies like tiramisu, sticky

date and toffee pudding, carrot cake, ultra rich and creamy

vanilla and chocolate ice cream, and the piece de resistance

– my mother’s chocolate box gateau (think rocky road sans

marshmallows). Now you know why I’m a fan of statins.

Dr Anandan Gerard is a family physician in Queenstown Polyclinic. He loves witty conversation, smiley patients and double cheeseburgers. Best thing he learned this year: practice makes perfect, so be careful what you practise.

call, instead of crashing way before my normal bedtime,

also helped to reset my body’s biological clock. Over the

weekends, I would try to do longer runs in the mornings. This

routine took my mind off work and kept me going strong.

Last year, I took a year off my residency training to do

a medtech innovation fellowship with Singapore-Stanford

Biodesign, where I spent six months at Stanford University.

Coincidentally, I was also expecting our little one then. With

the amazing weather in California, I continued jogging (in

moderation) throughout my pregnancy up till about 30

weeks. Our daughter is now ten months old, and though

I wish I had the energy to continue my previous running

routine, I could only try my best to slot in at least three quick

sessions a week.

Nevertheless, as the saying goes, “Runs end. Running

doesn’t.” So keep running!

Dr Rena Dharmawan is currently a third year general surgery resident with SingHealth. She obtained her medical degree as part of the inaugural batch of Duke-NUS Graduate Medical School. She also has a bachelor’s degree in biomedical engineering from the University of Michigan, Ann Arbor.

I fell in love with running during my freshman year at the

University of Michigan, Ann Arbor. Due to the cold weather,

I was mainly restricted to running indoors on the treadmill.

When I returned to Singapore in 2007 for medical school,

I discovered the greatness of outdoor running. Not only

does the run seem shorter, with goals of reaching a certain

destination or completing a certain route instead of merely

hitting a targeted distance, but I also get to indulge in my

other favourite pastime of people watching. Additionally,

I enjoy the scorching sun and humidity. There is this

unexplainable sense of accomplishment completing a run all

drenched in my own sweat.

On weekdays, I used to either do a quick run in the

mornings before ward rounds or in the evenings, on the

occasional days when I got off early. Doing a run post-

An intense game of Settlers of Catan cools off nicely with a bowl of home-made chocolate ice cream

April 2015 sMA News • 33

I embarked on wine studies for the challenge – the

Master Sommelier Exam is known to be one of the toughest

assessments ever. There are only about 200 people who

have earned this qualification in the world, and none of them

are from Singapore.

Contrary to popular belief, wine classes consist of more

than just drinking glass after glass of (insert most expensive

wine you know here). Wine studies encompass a broad

knowledge base, including chemistry (the technical details

of how wine is made, how much sulphur needs to be added,

or the chemical reaction behind malolactic fermentation);

biology (the Latin names of the various grape species);

geography (the different wine regions in the world and soil

types of each region); law (the wine laws of various countries);

and even some medicine (the effects of alcohol on your body).

While I know now that I cannot be a wine master who is

able to announce the wine’s grape varietal, region of the world

and vintage from just a single swirl, sniff and sip from a glass of

wine, at least I am no longer intimidated by the dizzying array

of wine on a supermarket shelf!

Dr Derrick Lian is a histopathologist at KK Women’s and Children’s Hospital. He is also a Certified Specialist of Wine (Society of Wine Educators), Introductory Sommelier (Court of Master Sommeliers), and has the Wine and Spirits Education Trust Level 1 and Level 2 Certifications.

Hoping my kids will support Manchester United so we can enjoy watching football matches as a family very soon!

Learning the Geography of Spain, with bottles of social lubricant in the foreground (with permission from Lim Hwee Peng School of Wine)

Dr Alvin Ng is a consultant respiratory physician and intensivist with Changi General Hospital. He is also the deputy chief surgeon of the St John Brigade Singapore. He was awarded the United Nations Peacekeeping Medal and the Force Commander Letter of Commendation for medical services rendered in Timor Leste.

When I was single, I pursued many interests like

watching movies, reading comics, playing video games,

building Gundam model kits and collecting toys. Now,

with the joy of raising young children in the house, these

activities had to take a back seat while I balance my family

life with a busy work schedule. My boys come first, so

important family time begins once my hospital work ends.

When my eldest son recently turned five, the

opportunity arose for me to morph my old pastimes into

quality indoor time with my boy. Our shared hobbies have

now evolved into watching animation movies, reading

children’s comics, playing multi-player kids’ video games,

building Lego sets, and opening once-treasured collectable

toys to have fun with together.

Our biggest motivation for working hard is to provide a

better future for our children. Sometimes work becomes all-

consuming and we forget to prioritise quality time with our

family instead. I will never lose sight of that goal, and even

if I did, my wife would remind me that family comes first.

Being an outgoing person, she will organise frequent family

field trips to the beach, skate-scooting at Bishan Park, outings

to Universal Studios Singapore, and overseas trips.

A balanced lifestyle is important. A successful family life

ensures a healthy state of mind to tackle work challenges. A

good working life ensures work stressors do not overflow into

family time. With the right equilibrium, the most important

part of our lives – our family – can be enjoyed.

34 • sMA News April 2015

Please return this slip for SMA Training Workshop: Core Concepts in Medical Professionalism to Denise Tan, Singapore Medical Association, 2 College Road, Level 2, Alumni Medical Centre, Singapore 169850. Tel: 6223 1264, fax: 6224 7827 or email: denisetan@sma.org.sg. A confirmation email will be issued to all applicants.

Name: MCR no.:

Email: Handphone no.:

Profession/Specialty: SMA member: Yes / No

Registration fees (inclusive of GST)

☐ SMA member: $100

☐ Preferred partners (AMS, MLS, CFPS): $150

☐ Non-member: $200

Mode of payment

☐ Credit card

Visa/MasterCard no.: - - -

Expiry date: / CVV2/CVC2 no.: ☐ Cheque (payable to Singapore Medical Association)

Bank: Cheque no.:

Signature: Date:

By registering for this event, you consent to the collection, usage and disclosure of personal data provided for the purpose of this event, as well as having your photographs and/or videos taken by SMA and its appointed agents for the purpose of publicity and reporting of the event.

sMA training workshop: Core Concepts in Medical Professionalism

Date: 4 July 2015, Saturday

Time: 8.30 am to 5 pm

Venue: Ramada Hotel, Zhongshan Meeting Room (16 Ah Hood Road, Singapore 329982)

Number of CME Points: Pending approval from the Singapore Medical Council

To register, visit https://www.sma.org.sg/academy or fill in the form below.

The workshop will touch on the important concepts of professionalism, allowing participants to gain a deeper understanding and acquire skills on this subject. Topics to be covered include: collegiality, conflict of interest, confidentiality and privacy, doctor-patient relationship, professional accountability and governance, and ethical case analysis. Speakers will also share about the challenges of teaching and evaluating professionalism in trainees.

The target audience are clinical directors; heads of departments; programme directors and medical school faculty involved in the education and evaluation of residents and medical students for ethics and professionalism; leaders of professional organisations; and members of ethics and complaints committees.

time Programme Faculty

8.30 am Registration

Dr T ThirumoorthyExecutive Director, Centre for Medical Ethics & Professionalism (CMEP), SMA

Dr Devanand AnanthamDeputy Director, CMEP, SMA & Senior Consultant, Department of Respiratory and Critical Care Medicine, Singapore General Hospital

Dr Gerald ChuaDeputy Director, CMEP, SMA; Head of Department and Senior Consultant, Department of Medicine, Alexandra Hospital

Dr Peter LokeTeaching Faculty, CMEP, SMA & Partner, Mint Medical Centre A/Prof Jason YapTeaching Faculty, CMEP, SMA & Associate Professor, Saw Swee Hock School of Public Health

8.50 am Introduction

9 am Professionalism

9.50 am Collegiality

10.20 am Tea Break

10.50 am Confidentiality and Privacy

11.35 am Professional Accountability and Governance

12.35 pm Lunch

1.30 pm Consent

2.30 pm Conflict of Interest

3 pm Tea Break

3.15 pm Doctor-Patient Relationship and Ethical Case Analysis

4.20 pm Interactive Discussion on Evaluation of Professionalism in Trainees

4.50 pm Reflection and Feedback

5 pm End

VACAtioNs ArE exciting times filled with new tastes,

sounds, smells, and most importantly, sights! If you are keen

on immortalising your holiday memories in high quality

images, here are some basic and helpful tips to keep in mind

before you embark on your journey!

gearing up: items to packFirst, it would be helpful to consider the equipment to

bring:

• Depending on the nature of your trip, would you prefer

to travel with a digital single-lens reflex (DSLR) or a

compact camera? If you’d like the best of both worlds, you

could also consider smaller and lighter DSLR models.

• If you’d like to travel light, you might not wish to bring

along too many lenses. Consider bringing just two

versatile lenses that would cater to most situations.

• Do remember to bring along spare camera batteries,

especially if you’re travelling to colder climates since

lower temperatures mean that your batteries would run

out of juice faster. On top of bringing additional cells,

keep them warm by placing them in an insulated pouch

or simply carrying them close to your body while you’re

on the go. Extra memory cards would come in very handy

if you’re a trigger-happy photographer. These would

help ensure that you would never miss a brilliant photo

opportunity because of a dead battery or a full memory

card.

Exploring small worlds: macrophotography A holiday album wouldn’t be complete without some

lovely close-ups. While you snap away at vast landscapes

on your next holiday, don’t forget to pause and smell the

flowers, or in this case, take a close-up photo of them! Casual

macrophotography has been made readily accessible to us

today, with most point-and-shoots equipped with an inbuilt

macro function. But if you want to take it to a higher level

with a DSLR, consider using macro lenses. Another tip: make

sure that your subject is well lit to achieve the best colour

vibrancy and clarity.

going for gold: autumn photographyWhile winter particularly captures our attention and

wonder, we often forget that autumn too is beautiful with

all its glorious hues, providing numerous opportunities for

vivid photographs. Try capturing autumn foliage during

the magical hour: the first half hour following sunrise, and

the last half hour just before sunset. The golden rays of

the sun would not only complement, but also enhance the

colours of the leaves. If lighting conditions aren’t favourable,

fret not! Many newer camera models come with inbuilt

creative filters. Simply snap away and the cameras would

automatically apply the best-looking filters to suit your

images.

taking astronomically beautiful pictures: astrophotography

Capturing heavenly bodies is particularly difficult in

Singapore due to the bright city lights. This is known as light

pollution and it affects both you and your camera’s ability

to capture the complete details of the night sky. As a rule

of thumb, get as far away as possible from the city lights.

While astrophotography would typically require some

technical know-how, a new generation of compact cameras

now comes with a special shooting mode designed for such

photography. You can achieve beautiful photos and videos

such as star trails and even a breathtaking time-lapse movie,

simply by activating said mode.

defying convention with unique perspectives: be experimental

Unless you’re a documentary-maker, feel free to let

loose your creative juices in capturing your shots! Literally

bend reality by using wide-angle lenses to capture towering

skyscrapers. This creates a unique effect of distortion. Look

out for lenses with built-in image stabilisers to suit this

purpose. Additionally, these lenses would help you capture

more details in one shot, and work well in taking amazing

landscape shots.

lighting the fire in your images: photographing fireworks

The first and simplest thing to do in preparation for

capturing fireworks is to scout out a good location. Go for

spots where you can get a clear, unobstructed view of the

skies where the fireworks would be released. To achieve

a pretty “trailing” effect, increase your shutter speed.

Following that, tune down the lens aperture (eg, f/11) and

lower your ISO settings (eg, 100 or 200). Finally, use a

tripod! While cameras come with inbuilt image stabilisers,

Photography Tips for Your Next Holiday

Text and photos by Canon Imaging Academy, Canon Singapore

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36 • sMA News April 2015

this special type of photography requires utmost stability to

capture the best images.

Capturing movement in stills: long exposure photography

Photographs taken with long exposures can create an

effect of movement within the frame. To showcase that

movement, it is important to feature still subjects against

moving objects. Setting moving objects, such as people

or cars, as the background against still subjects would

create an almost 3D-like effect, with the static subjects

popping out from the images. Long exposures also have an

interesting and “smoothening” effect, giving even rough

water a calm, glassy look.

Making a mark: geotag your pictures to revisit your journey

An unconventional and enjoyable way to reminisce

about wonderful trip is to map the places that you’ve

been to. With the unique feature of being able to geo-tag

your photos down to the precise altitude and latitude, try

creating a travel log in the form of a world map, and drop

pins on all the places you’ve visited! Some cameras have

a built-in global positioning system (GPS) for geotagging

purposes.

For photography courses, workshops and trips, please visit

http://www.canon.com.sg/training. For more production

information on Canon cameras, please visit http://www.

canon.com.sg/personal/productlanding.

Clockwise from top leftLotus lake in Phatthalung, ThailandFisherman at work in PhatthalungFishing net illuminated by the morning sunrise in PhatthalungMorning ice-frozen bridge in northern Xinjiang, China

April 2015 sMA News • 37

AIC SAYS

Please return this slip for for SMA Seminar : The Utility (Benefits and Limits) of Ethical Codes in Teaching and Training of an Ethical Clinician to Denise Tan, Singapore Medical Association, 2 College Road, Level 2, Alumni Medical Centre, Singapore 169850. Tel: 6223 1264, fax: 6224 7827 or email: denisetan@sma.org.sg. A confirmation email will be issued to all applicants.

Name: MCR no.:

Email: Handphone no.:

Profession/Specialty: SMA member: Yes / No

Registration fees (inclusive of GST)

☐ SMA/MLS member: complimentary

☐ Non-member: $120

Mode of payment

☐ Credit card

Visa/MasterCard no.: - - -

Expiry date: / CVV2/CVC2 no.: ☐ Cheque (payable to Singapore Medical Association)

Bank: Cheque no.:

Signature: Date:

By registering for this event, you consent to the collection, usage and disclosure of personal data provided for the purpose of this event, as well as having your photographs and/or videos taken by SMA and its appointed agents for the purpose of publicity and reporting of the event.

SMA Seminar: The Utility (Benefits and Limits) of Ethical Codes in Teaching and Training of an Ethical Clinician

In collaboration with:

Date: 27 May 2015, Wednesday

Time: 6 pm to 7.30 pm

Venue: Health Sciences Authority (HSA) Auditorium

Number of CME Points: Pending approval from the Singapore Medical Council

To register, please complete the form below or visit http://www.sma.org.sg/academy.

sPEAKEr: ProF tAN siANg yoNgEmeritus Professor of Medicine, University of HawaiiProf Tan Siang Yong MD, JD, is emeritus professor of medicine at the University of Hawaii,

and director of the St Francis International Centre for Healthcare Ethics in Honolulu. He is

a distinguished scholar with over 100 published articles in endocrinology, law, ethics and

medical history. Author of the 2006 book Medical Malpractice: Understanding the Law, Managing the Risk, he recently completed Medical Negligence and Professional Misconduct, a Singapore

Halsbury treatise which was released in mid 2012.

Time Topic Speaker

6 pm Registration (Refreshments provided)

6.30 pm Introduction Dr T ThirumoorthyExecutive Director, Centre for Medical Ethics & Professionalism (CMEP), SMA

6.40 pm The Utility (Benefits and Limits) of Ethical Codes in Teaching and Training of an Ethical Clinician

Prof Tan Siang YongEmeritus Professor of Medicine, University of Hawaii

7.10 pm Question & Answers

7.25 pm Closing Remarks Dr T ThirumoorthyExecutive Director, CMEP, SMA

7.30 pm End of Seminar