A friend of mine who has remained a cloistered academic most of his working life buys into the narrative that economic growth is imperative regardless of what is needed to sustain it. He was trying to mock those who highlight the devastation that follows unchecked growth.
Like all kinds of growth, economic growth can be healthy and it can also be toxic – like cancers. As Singapore heads towards a recession (after many years of impressive GDP), many asset-rich folks will worry and hope that those at the helm can do something about it. A few mavericks who have their feet on the ground may see this downturn as something positive. Yes, it’s time to hit the reset button.
But in the meantime, quite a number of my friends who have been trained as engineers or who are in IT are now doing a whole variety of unrelated jobs from driving Grab to directing funerals. Growth has brought about a massive influx of cheap foreign professionals to replace our expensive technicians and engineers. Yes, the industries have been growing, but at whose expense? The effect of foreign talent on the medical or dental profession may be a little less pronounced (we’re not driving Grab yet), but new onerous regulations are also forcing some clinicians to “moonlight”. One of the most popular jobs out there is selling MLM products. You’ll be surprised by the number of doctors and dentists quietly doing it.
While most MLM products are harmless or even pretty good (albeit overpriced), there are products and treatments which are not only ineffective but even harmful. I’ve written about clinicians who have gone over “the other side” to condemn and turn against everything they have been trained to do (and make a fortune out of it). COC or no COC, it’s the money that talks. Let me bring up an interesting item which has been abused and exploited for monetary gains for decades. Repeated actions from the US courts and the FDA have failed to kill it. What is this tenacious substance?
Google search for the word Laetrile yields descriptions like “clinically ineffective,” “dangerously toxic” and “quackery”. What is Laetrile? Well, simply put, it’s a synthetic form of the compound amygdalin found naturally in apricot seeds, bitter almonds, peaches and plums.
And that’s the shocking thing (not truth) about Laetrile. I thought it’s dead and buried after countless lawsuits and aggressive actions from the FDA, until it reared its ugly head in the form of a relatively new book by Ralph Moss PhD I found at the library. It’s entitled Doctored Results and it supposedly reveals how mainstream medicine suppresses valuable research data on the efficacy of Laetrile against cancer. Like other conspiracy theorists, Moss believes that mainstream medicine is colluding with big pharma and government to protect the chemotherapeutic industry by hiding the “truth” about Laeterile. Note that Doctored Results was published in 2014. Note also that Dr Moss’ PhD is in the Classics (like Greek literature).
Before we go further, there’s an important piece of history that we need to look at to appreciate how absurd that such a dangerous substance can still be believed.
In 1977, a little boy by the name of Joey Hofbauer was diagnosed with Hodgkin’s disease. He was warded in hospital, scheduled for radiation and chemotherapy. The oncologist who presided over the case was Dr Arthur Cohn. Cohn was optimistic, giving Joey a 95% chance of survival.
Before any treatment was done, the Hofbauers got frightened due to the invasive and destructive nature of radiation and chemotherapy. They checked him out of the hospital and flew Joey to Jamaica where Laetrile was touted as the latest cure for cancer. Their family doctor threatened to report them to the Children’s Protection Agency. When they returned, the police had to be called in to get Joey back into hospital. His father was so convinced that the hospital was killing him and Laetrile could save him that he secretly smuggled the substance into Joey’s ward and gave him a few doses.
The matter was heard in court. The judge allowed the Hofbauers to try Laetrile for 6 months under Dr Michael Schachter from New York. Michael Schachter’s “treatment” was a witch doctor’s recipe which included not just Laetrile but also raw liver juice, megadoses of vitamin A, pancreatic enzymes and coffee enemas. The patient was also given an injection of bacteria obtained from his own urine. Six months later, the patient’s swollen lymph nodes grew from one to 17! He also showed signs of liver damage due to megadoses of vitamin A and suffered from abdominal cramps and nausea. Laetrile gives off cyanide in the gut and apricot seeds have long been recognised in TCM as toxic.
Miraculously, Dr Schachter was able to convince the judge that his treatment was working. Meanwhile, court cases in several states challenged the FDA’s authority to restrict access to what they claimed are potentially lifesaving drugs. More than twenty states passed laws making the use of Laetrile legal. Joey’s Laetrile treatment was allowed to go on. When actor Steve McQueen checked into a clinic in Mexico run by one Dr William D. Kelly to have alternative treatment for his stomach cancer and the actor went on TV to promote Laetrile, judges were even more convinced that this could be the Holy Grail for cancer. That pretty much sealed Joey Hofbauer’s fate.
Thanks to all the hype and celebrity endorsement, Laetrile developed a significant following due to its wide promotion as a “pain-free”, “non-invasive” treatment of cancer. More audaciously, the previously obscure substance was even deemed an alternative to surgery and chemotherapy which were already known have significant and unpleasant side effects.
Two years later in 1980, Steve McQueen died a very painful death, followed by poor Joey Hofbauer. Dr Michael Schachter was never held accountable even though Joey’s body was riddled with metastatic tumours, contrary to Schachter’s claim that he was improving. For the record, Schachter was a psychiatrist who had neither training nor expertise in treating cancer. His methods were “discovered”. Even more unbelievably, he is still in practice.
Steve McQueen had also died under Dr William D. Kelly. Just a little more surprisingly, Kelly was actually a dentist or orthodontist to be exact. From straightening people’s teeth, Dr Kelly went on to diagnose cancer from blood samples and treat them with supplements. After he was struck off, he moved to Mexico to continue practising his “alternative cancer cures”. Because there is nothing to stop these doctors from practising alternative medicine, they could pretty much go wherever they wanted. Incidentally, Dr Kelly also suffered from cancer and died in 2005, not long after he wrote a book on his victory over cancer.
In spite of the number of deaths and failures, Laetrile continues to be popular. The US Food and Drug Administration went out on a limb to seek jail sentences for vendors marketing Laetrile for cancer treatment, calling it a “highly toxic product that has not shown any effect on treating cancer.” However, the FDA and AMA (American Medical Association) crackdown which begun as early as the 1970s, only managed to push prices up on the black market. Some vendors tried to pass Laetrile off as “vitamin B7”. Many desperate cancer patients bought the conspiracy narrative and had ironically enabled scammers and unscrupulous profiteers to foster multimillion-dollar smuggling empires; not to mention Mexico’s lucrative medical tourism for treatments and procedures banned in the US.
Yes, it’s hard to believe, but Laetrile is still alive and well. Just look at Ralph Moss’ 2014 book. It has an average review of 5 stars on Amazon and the book is available in our libraries. However, there is obvious copping out in the introductory disclaimer. The author bears no responsibility and cancer patients are advised to consult a board-certified cancer specialist. Moss must be hoping that readers will miss this part of the book – which is enough for it to lose all credibility.
Moss’ book The Cancer Industry (published 1996) has been negatively reviewed by Quackwatch, which noted that “the book is dangerous because it may induce desperate cancer patients to abandon sound, scientifically based medical care for a bizarre, ineffective “alternatives”.
Interestingly, many recent advocates of Laetrile have changed the rationale for its use. It was originally an alternative treatment of cancer. Later, some alternative medicine practitioners claim that it’s only a vitamin (which it isn’t). And most recently, most of these practitioners have taken a step back and use the substance only as part of a “holistic” nutritional regimen and pain management in cancer. In other words, they are no longer fighting to replace conventional medicine but trying to play a supportive role.
I’m not sure what Quakwatch will say about Moss’ 2014 book Doctored Results, but going back to doctors and dentists who are struggling to make ends meet, some of my jaded colleagues out there may get some funny ideas of cooking up conspiracy theories and starting a crusade against the “conspiracy”. While this may be a little far-fetched in Singapore, insane competition, financial stress and the availability of claimable treatments are the ingredients for undesirable outcomes – not the lack of competence.
According to Singapore Dental Association (SDA) members who had attended recent meetings, COC is not compulsory and there will be no restrictions. All this sounds like backtracking and too good to be true. It’s also pretty much hearsay, with no firm assurance from officialdom. As such, it shouldn’t stop me from thinking about Plan B.
Consider writing. This is my favourite, my life. But gone are days when I could earn almost $2000 a month from book sales and from freelancing for magazines. Back then, I had to run around interviewing celebrities and news-makers. It required a lot more energy than dentistry, but it was also a lot more rewarding when I saw my work in print, my name next to a celebrity’s and a cheque in the mail. During those days, my side income paid for my frequent side trips to Thailand. Nowadays, writing pays pittance and income from it pays only for candy and ice cream – both of which I don’t particularly like.
But as always, I try to keep my persona as a writer separate from my persona as a dentist. Why? This is something that many of my fans and followers cannot understand. Allow me to go back to one of the happiest moments in my life – when my works were first published in the Straits Times and Singa magazine in 1989/1990. When they asked me for my occupation, I filled “unemployed” without a second thought.
You see, back then, the Dental Board had strict rules against dentists advertising. Though publishing poems and short stories could hardly be considered “advertising”, I still entertained the possibility that someone might not like it. After being a regular contributor to the Life section of the Straits Times, the folks there didn’t believe that I was unemployed. My decision to reveal my profession was purely based on the answer to the question: “Are you ashamed of your profession?”. The answer was a definite no. I finally revealed my profession and instantly became someone newsworthy. Why?
The late Dr Goh Poh Seng (GP) is the grandfather of Singapore literature. The late Dr Gopal Baratam (neurosurgeon) was also a prominent writer. But in an arena dominated by lawyers, teachers and journalists, the “errant” dentist became an instant talking point. An interview was requested. From unemployed to writer/dentist. Should I do it? Would a backlash come faster than you can say amalgam? My decision was made based on the answer to the question: “Will your profession feel proud of you?”. I accepted the interview and perhaps because I was too much of a chatterbox, the result was a full page feature in the Straits Times. That mystery person behind the poems and short stories, a novel, the magazine articles, that “unemployed” dude was finally revealed. Sure, I received some fan mail, calls from editors who offered me jobs, but certainly not more patients as most of them don’t even read English. A couple of weeks later, I received a letter from SDA. It was not a congratulatory letter. It was a stern letter asking me to “explain” the article after a member of the fraternity thought that I was advertising my dental services.
I was flummoxed. Could these guys even read? That article had absolutely nothing to do with dentistry even though it carried a photo of me sitting next to a dental chair. What was there to explain? Being young and overly honest, I spoke my mind and pissed the SDA council off. I received a call and the council member said that he simply wanted me to assure them that it was the journalist’s own idea to feature me and not me who shamelessly asked to be interviewed! Yao mo gao chor ah? The complainant might have been anonymous, but this episode really said a lot about him/her. The answer to the question “are you ashamed of the profession?” was no longer obvious. I have not been an SDA member since then.
This website (name of my former clinic) and my former Facebook page on aesthetics used to be very prominent. At the height of its popularity, it drew some 30,000 hits every month, thanks to the beautiful faces, smiles and my dabble in portrait photography. I also wrote many entertaining articles on dentistry; very different from the boring stuff that you read on official sites. I caught some practices copying and printing my articles for patient education. I decided to be generous and not claim copyright. This went on for almost 7 years until some dentist complained that the contents on my website and social media were “unbecoming of the dental profession in Singapore”.
The tribe has spoken. Pretty faces, creative poses and playful captions are not allowed in dentistry. I had to take them all down and direct my creative energies elsewhere. And presumably the same standards also apply in medicine. While chatting with a model in a park, I discovered that she is a medical colleague. Let’s call her Dr L. To me, she’s not some exhibitionist all out to corrupt young minds or seduce someone’s bored husband. She’s simply passionate about modelling. While doing shoots with her, I warned her about the dangers of revealing her profession to the public. It’s worse for models than for photographers as there is always the assumption of immorality in our pseudo-conservative society.
Dr L went on to take part in a beauty pageant. I watched her competing on YouTube and she had wisely lied about her employment. She got into the finals but didn’t win. I wondered how many who knew she is a doctor recognised her. I guess it’s OK when your haters are unlikely to watch. It might be just as well that she didn’t win. There is no way she could have continued to lie about her profession when journalists start following her.
Anyway, Dr L is now married and she still models once in a while with the full knowledge and approval of her husband who is also a doctor. The moralists should just shut the … (words unbecoming of the dental profession), but this is Singapore and you don’t always decide what is good for yourself. Burmese doctor Dr Nang Mwe San is not so lucky. I can’t read Burmese, so I can’t tell whether she had identified herself as a doctor in her “edgy” photos. If not, then, she must have been sabotaged by members of her fraternity who recognised her and ogled privately while publicly denouncing her.
BANGKOK: A Myanmar model and doctor said she would appeal against a medical council decision to revoke her licence for posting photos of herself on Facebook in revealing outfits and bikinis.
On her Facebook page, the 28-year-old often posts photos of herself wearing tight dresses, lingerie, swimwear and even traditional Burmese clothing in sexy poses.
Dr NangMwe San has been a general physician for four years, but stopped practicing two years ago to pursue a modelling career. The move to revoke her licence bans her from medical practice.
According to the letter posted on her Facebook page, the council said Mwe San had continued to post photos of herself in outfits that did “not fit with Burmese tradition”.
No, I’m not writing whimsical dental articles or taking pictures related to dentistry anymore. Dr Nang Mwe San has the international community behind her, a few disgusted Singaporean women notwithstanding. Artistic expression requires space. An officer from the Dental Council once told me to keep dentistry “clean” (and boring). For once, all my English lessons failed me as the opposite of “clean” is “dirty” and it all made no sense. Anyway, message received, point taken. I will just have to channel my creative energies elsewhere. I will need to separate the two and remain a low profile, boring dentist – until COC kicks in. What then?
As an adventurer and survivor, the most painless way to resolve this problem (while still practising) is to simply relocate and bring all my surgical kits over. I can live on Nepalese dhal baat like few Singaporeans can. I have lived cheaply in many parts of Thailand and Indonesia like few Singaporeans can. I can cook complete meals for the family like few Singaporeans can. I can even make my own wine unlike most Singaporeans.
Given my background, Thailand seems the natural choice, but given the current political situation and the rather unhealthy social order as a result of it, Thailand may have to wait. Furthermore, Thailand is also saturated with dentists (in towns and cities where people can afford them), but still not as bad as in Singapore. If I ever relocate to Thailand, I would be running a spa/clinic based on TCM principles. Yes, the website will be full of pretty faces and athletic bodies. Disgusted folks can ask for it to be blocked in Singapore.
A little more seriously, I’m considering Bali or some other part of Indonesia as the only possible location if I choose to remain a dentist. If that doesn’t work out, I can consider turning another thing which I enjoy doing into a business. Cooking.
So if for some reason I can’t practise in Bali, what do I do? How about cooking? The food business? It’s not a shot in the dark. I have a Singaporean friend whose son moved to Bali and set up a restaurant there. Can I move Dr Chan’s Kitchen from the virtual world into the real world? This is worth considering even though I know how tough the food business is. I’ve been cooking, preparing all kinds of meals for the family for decades. I’ve even appeared on a cooking show on TV (luckily nobody complained; my haters probably wouldn’t watch something so unglam). Cooking for customers is very different and I dread the stress, the learning curve and the bottom line considerations when sourcing ingredients. I probably need an environment that is kinder to the newbie; perhaps in Thailand (when things get better), Indonesia or Malaysia. Setting up in Singapore is not even worth considering as I foresee more onerous regulations hitting this business as well.
Some folks who read my previous post remarked that I am too negative and pessimistic. Of course I welcome a backtrack from the original concept of the COC, but even then, a major shakeup of the industry is imminent. The bubble must and will burst. Meanwhile, I’ll continue writing. The ultimate happy ending is to have several books that sell millions of copies. I shall write and dream on.
A short while ago, I posted something on Facebook that sparked the curiosity of many of my closer friends.
Yes, I’ve been in the profession for 30 years and boredom set in since the very start! Believe it or not, I was already talking about retirement (from the profession) and migrating (voting with my feet) 15 years ago. While I’ve gone back to pursue my passion in the arts, dentistry is still bringing home the bacon. If I ever have to quit any time soon, it would most likely be because it fails to bring home the bacon.
The cataclysmic changes I was talking about was reported by the Online Citizen a month later. It has to do with a new policy which restricts the practice of dental GPs. They would not be allowed to carry out complex dental procedures without first acquiring a Certificate of Competency (COC)
I’ll come back to COC later. First, some background and history of dentistry in Singapore that I have managed to live through.
In my book Dental Phobia, I painted the alamak patient as one who would refer to the neighbourhood dentist as Pull Teeth One. Indeed, to most heartlanders born in the 1950s or earlier, dentistry is little more than filling teeth, pulling out teeth and making plastic teeth. In spite of the lack of glamour and prestige, many retired dentists who once had lines as long as Toto queues managed to make their fortunes just providing these relatively simple services. If they had wanted their children to follow in their footsteps, the younger generation will need to swim against some very hostile currents engulfing the profession today. Suffice to say that unless they somehow have the same Toto-like queues that their predecessors once had (extremely unlikely in today’s competitive environment), they may not even survive, let alone thrive and make their fortunes.
When I first graduated in 1988, dentistry was decidedly a sunset profession. Crowns and bridges were considered extremely high end procedures and root canals occurred as frequently as condemned criminals getting a presidential pardon. My starting pay was not as “upper middle class” as I had wanted it to be, but the cost of living was low then and I managed to get by.
Into the 1990s, many patients started asking for tooth-cloured fillings – which were invented in 1962. These materials evolved rapidly and by the 1990s, had become a lot more reliable since my student days. But Singapore tends to be a little behind time due to the low priority placed on good dentition. Full ceramic Dicor crowns (which were more aesthetic than porcelain fused to metal crowns) were already around since the 1950s and Empress crowns were already available since 1980. They did not become popular in Singapore until the turn of the century circa 2000.
But as millennials grew into image-conscious, blogging teens, orthodontics turned into a virtual necessity for kids with malocclusion. More and more dentists started doing it. Even as the tussle between Taiwanese serials and Korean dramas was still ongoing and K-pop was still in its infancy, costly European implants with limited user support became drowned under the tide of cheap and good Korean products with excellent after sales service provided by smiling, bowing Korean staff.
On top of that, Medisave could be used to make partial payment for some surgical procedures. Tooth replacement with implants, root canal surgery, wisdom tooth surgery became a bit more affordable for all. Extractions were feared, not for the pain, but the loss. Endodontics (root canal) became commonplace – with that came crowns, metal-free restorations, cosmetic gum surgery, flexible dentures. More and more people wanted to save their teeth. More and more asked for implants to replace their missing teeth. More and more did ceramic crowns and veneers for their front teeth. More and more whitened and straightened their teeth, or even go through extreme makeovers for that winning smile. The scope of practice for the dental GP swelled and so did our population. Dentistry in Singapore was no longer behind time.
The Sun Rises
New technology and innovations always excite Singaporeans and rising from the ashes, dentistry became a sunrise profession. All of a sudden, dentists started attending continuing education courses, not just to earn continuing education points (they need 70 points in a 2-year period) by sleeping through irrelevant lectures but actually acquiring new skills and adopting new technologies. I have personally witnessed many young and even not so young dentists getting energised into bringing their practices to the next level. Many who are not specialists have trained themselves to provide complex, high value cases for considerably lower fees. Consequently, demand for sophisticated dentistry went up. In my opinion, that was the golden decade (2000-2010) for the profession in Singapore. Never mind the alamak patients. The internet provided an almost endless stream of curious and interested inquirers. Dentistry regained its status as a promising career and a glamorous one at that. Straight A students started pounding the doors to be enrolled in the Faculty. The barrier to entry was raised accordingly. GPs who had upgraded themselves became decidedly upper middle class.
But it ought to be noted that the concept of the super GP is not new. Quite a number of dental GPs currently in their 70s were already doing braces, wisdom tooth surgeries, precision dentures and even implants during their heydays. It was during this golden decade, with the increase in opportunities to learn, share and advertise skills that super GPs flourished.
With so much potential within the profession, it’s difficult for venture capitalists not to take notice. As money started pouring in and a few blue eyed boys were identified as potential CEOs, some dental clinics started to transform, branching out into every nook and cranny of our tiny little island. An Indian professor once gave a talk at one of our continuing education lectures. He said that the ratio of dentist to population was still not ideal. He felt that we didn’t have enough dentists and ought to produce more until we attained a healthy ratio like that in Australia.
Our professor seemed to have forgotten that our geography here is very different from that in Australia. If you don’t want to see Dentist A in Australia, Dentists B could be 2-hours’ drive away. In Singapore, there are scores of dental clinics between 2 MRT stations. How difficult is it to obtain treatment if one really needs it? Then, he also talked about our aging population and why we need more dentists. I wish he had attended a conference on geriatric dentistry here. The room was barely 25% full whereas at a conference on aesthetic dentistry, there’s only standing room available. It’s obviously not simple arithmetic at work here.
After one company went public, a dozen or so wannabes started rooting for a ride on the IPO bandwagon. On a street with only two blocks of flats with two rows of shops on the ground floor, there were 3 dental clinics and only 2 medical clinics. Things have gone totally irrational. A patient recently remarked to me that he sees more dental clinics than coffee shops and that’s not an exaggeration. At one of the clinics where I work, there are two other dental clinics within 20m and another 4 within 300m, another 2 within 500m.
The CEOs of these rapidly multiplying practices were not only desperate for dentists to man their new branches but they lose sleep while closely monitoring “sales figures”. The problem of manpower is not too difficult to overcome. Foreign dentists or dentists who graduated from certain foreign universities are allowed to work in Singapore. Meanwhile the Faculty of Dentistry at NUS has almost doubled its intake of dental students since my time. Only about 30+ of us graduated back then. Today, almost 80 are expected to graduate every year!
The arithmetic is simple. If you set up 100 clinics, you “need” 100 dentists. The manpower issue is by no means an insurmountable issue. As in any other industry, you could either employ foreign graduates or wait for NUS to churn them out or do both. The problem of sales target is a lot trickier and it’s not difficult to figure out why. Are there enough patients and indications to feed these high maintenance clinics equipped with high tech equipment on hefty leases? Can the trees keep branching out without looking back on whether there’s enough earth to support it? What happens when there are too many dentists and too few patients? Will dental treatment become cheaper as dentists undercut one another? Will dentistry still be practised as ethically as before?
In 2013, the Chinese authorities decided to introduce a cooling measure for their overheating property market. Couples who sold a second property had to pay hefty taxes for the sale. What did the Chinese couples in Shanghai do? The selling couples teamed up with the buying couples and both couples got divorced. The ex-husband in the selling couple would keep the property. Money from the buying couple was given to the ex-wife in the selling couple so it didn’t look like a sales transaction. The ex-wife from the buying couple then married the ex-husband from the selling couple! They then got divorced with the ex-wife from the original buying couple keeping the property. When everything was back in place and the property transferred, the two couples got together again. No taxes paid. Shanghai saw 30 divorces a day when this game was ongoing.
While Singaporeans are way less crafty and unscrupulous, dentists are pretty smart people – until they get caught. Be prepared for lots of juicy scandals. The golden decade is pretty much over.
Dentistry depends a lot on skill and skills take time to develop. Nobody is skillful when he first graduates. I would have gone crazy if my boss set a quota for me when I first started private practice. In a way, many young graduates today are not so lucky. And the character of the whole industry has also been totally transformed. This is the age of dental empires. Your friendly neighbourhood dentist is fast going extinct. With cookie cutters on steroids, new clinics are sprouting up everywhere with emphasis placed almost entirely on branding and not the practitioner. They don’t even put the practitioner(s)’ names out there anymore. As a result, practitioners no longer have any sense of belonging to the practices. The practices milk them and they in turn milk patients and get out, either to another practice or another country. The only real winner here is the dental empire. I will come to the aftermath of this carnage in a moment.
I’ve heard about the COC way back in early April and I’d wanted to refrain from commenting until the thing goes public. And would you believe it, some commercial entity has already prepared itself for it long before the rest of us have any inkling of this shocking development. TOC reported that “The Singapore dental fraternity is up in arms over the possibility of a conflict of interest in relation to the introduction of certificate of competencies (COC) and restriction framework for dentists who are general practitioners.”
The latest development involves a complaint being made to the CPIB and I shall not comment on whether the complainants have a case until investigations have concluded. Suffice to say that there are too many coincidences. It’s sad that some of my colleagues had to resort to reporting criminal activity to get this problem solved, but then again, is there any other way?
Now, what is the COC and why do the authorities think that it should be implemented? The COC is a scheme that follows a recent proposal by the Ministry of Health (MOH) and the Singapore Dental Council (SDC) — which is the profession’s self-regulatory body — that could require dentists in general practice to undergo more training for procedures such as wisdom teeth surgery and implants before they are certified “competent”.
For the record, there is already a COC in force for facial aesthetics (Botox and filler injections). Of course, we’ve never learned that in dental school, so it’s only fair that we must attend a course (with a written test at the end) and pass it before we can perform the procedure. However, I remember I only had to take a one-day course to obtain my COC for that. Even though the 1-day course is officially recognised, I felt it was really inadequate. I learned much more from a voluntary programme with a lot of hands-on practice on volunteers in Taiwan.
The obvious irrationality here is, you can be a total newbie in the field of facial aesthetics and you just need one day’s course to get a COC. You can have decades of experiences removing wisdom teeth and sinking implants. You still need a COC to certify your competence.
Explaining the purpose of the COC, the Ministry of Health (MOH) and the Singapore Dental Council (SDC) said in a joint statement that the moves are meant to allow “dentists to be further trained in these specific dental procedures and to be able to practice safely and competently without having to undergo specialist training. Both the MOH and SDC added that the decision on certification is backed by international benchmarks, patient concerns and complaints.
Let’s say you want to “further train” a dentist to do a complex root canal. Will this “further training” exceed the length of training that the dentist had in dental school? If not, then is this just a formality? If not, does it then mean that the curriculum for the procedure of root canal in NUS is somehow inadequate? Does it mean that foreign degrees that are recognised by the ministry are inadequate and they are just beginning to realise that?
There are some very senior super GPs out there who have done literally thousands of wisdom tooth surgeries and implants. That is competency. Do they need to attend courses to be certified for basic competency in procedures which they have been doing expertly for decades?
Coincidentally (or so it seemed), local dental group Q&M dental group stated in an interview with ST on 2 May that it was setting up a private dental college in Singapore by the middle of this year. The college wouldn’t provide degrees but would provide “courses” for graduate students. How superior are these “courses” (days?weeks?months?) compared to those which our GPs have been attending? What value do they add to their decades of experience?
The company running the college, Q & M College of Dentistry Pte Ltd, has already been incorporated in December last year (long before we knew anything about the COC). Coincidentally again, the Aoxin Q&M dental group limited, a subsidiary company which is also registered in Singapore lists Professor Chew Chong Lin as an independent director. My colleagues who made the complaint to CPIB has an issue with this arrangement as Professor Chew Chong Lin is also the President of the Singapore Dental Council since 2009. SDC is the self-regulatory body for the dental professions constituted under the Dental Registration Act (Chapter 76).
This is an important milestone. For the longest time, the regulatory body for dentists has been throwing rules, guidelines and regulations at us. The so called “self-regulation” is quite a misnomer. In spite of the elected members of the council, the cue always appears to come from the Ministry and not from the general body of dentists. Besides that, the council in both SDA and SDC are dominated by Q&M dentists. For the first time in our history, dentists who have been under the thumb of the council are calling out on a possible major transgression.
Other colleagues talked about a “slippery slope”. What are we slipping into? Certification for dental assistants before they are allowed to assist? Which company is going to manage this certification process? Your guess is probably the same as mine. It of course does not mean that inhouse, informally trained assistants are less competent. It’s going to be a question of who is approved and what is recognised.
When news of the COC first emerged, the response from the public was quite predictable. Folks who had bad experiences with treatment outcomes flooded Facebook with comments supporting it. If these comments were to be taken seriously, then there should be no argument as to whether there ought to be a COC. The impulsive commenters may not be aware that with the COC in place, they may have to go to a specialist to get their wisdom tooth removed or their implant placed. They may not think twice about supporting it until they need to pay for it. By then, it’s already too late.
So do the specialists have any cause for celebration? Maybe, maybe not. The biggest losers are the super GPs whose numbers have grown steadily throughout the golden decade. If there are hundreds of disciplines and procedures they need to obtain COCs for, it could take years before they are certified “competent” in all these procedures.
What about the public? Why do people complain? Many dentists who have been practising successfully for 40 years had all the complaints they ever received made within the last 10 years. Why no complaints before that? Because they suddenly became lousy dentists in the last 10 years? Or is it because patients have become more knowledgeable and demanding? Has it also become a lot easier to complain? Just a click of the mouse. Assuming that these complaints are justified and treatment outcomes could have been better, why did such problems arise? Why are so many inexperienced dentists attempting risky procedures which are beyond them? Why are they cutting costs with incompatible third party implant components? Could it be because they have committed themselves to a massive implant package and suppliers are chasing them for payment? Could it be because the staff are not paid, the leasing company is hounding them and the landlord sends another reminder? Could it be because they have a “sales target” and the CEO of their dental empire is breathing down their necks?
If I were a patient and I need to have my wisdom teeth removed, would I go to a dentist with a good track record or would I go to a newbie with a COC. It’s a no-brainer for me, but the scheme should make sense as long as there are enough unthinking people around.
Treating these problems with COC is like treating cancer with antibiotics. The root of the problem is that we have too many dentists and dental clinics. Way too many. Only some of us are doing well. The rest are struggling and forced to do things they shouldn’t do. The numbers are unreal and should not have been allowed to build up in the first place. And the biggest irony is that in spite of the numbers, the public is not going to be served any faster or better because so many super GPs are going to get their hands tied. And that’s after beefing up the supply of dentists to a “healthier” level. It’s a joke, except that it’s not funny. The bubble is set to burst and the empires are striking out at the small fries who have been minding their own business. Make no mistake, we are at (or perhaps even gone past) the peak of a dental bull run and the only way to go is down. It ain’t going to be a pretty picture down there.
Nobody can be sure what the outcome is. One part of me wants things to go back to the status quo, let me practise the way I’m used to for another 10 years or so before I quit for good. Another part of me is hoping that a tsunami would sweep through the dental landscape, flattening out all the cookie cutter practices and restore the old school of solo and small group practices (not more than 6 branches) where patients identify with their friendly neighbourhood dentists and not some brand.
Unfortunately, neither of these outcomes are likely, given the interests of corporations and the numbers they show. Couple that with a ministry that knows better than the rest of us and you have a perfect recipe for a humble pie that we will all be forced to eat. To endure the humiliation/inconvenience and settle for much less than what I deserve? Or to quit and move on to something else?
For a country that fiercely defends its independence when criticised about press freedom and human rights, we are virtually led by the nose when it comes to following cool innovations from Western countries. Just like in Singapore, the folks who implement these policies over in the US have little idea of the challenges on the ground.
The usual narrative is that this is something that will help us keep up, failing which we would fall behind the rest of the world. Sometimes, it’s better to fall behind than to march along with the other children as they follow the pied piper of Hamelin.
Toni Bark is a forceful promoter of ice-cold dips in lakes and other dubious “alternative cures” like homeopathy. On her website, she claims to practise “Disease Reversal, Holistic, and Functional Medicine”. A bestselling author, popular speaker and a powerful crusader on social media, she has also made a vocation out of speaking against vaccines and how they harm our children. You would think that she must be some self-taught guru with no substance beyond her gift of the gab. Except that Dr Toni Bark is a qualified paediatrician.
Yes, she sees (or appears to see) little or no threat from measles and other illnesses that had killed many children in the past. At the same time, she makes many parents think that there are safe “natural cures” for these conditions. Instead of managing common paediatric conditions in a clinical practice, she focuses on “illnesses” caused by vaccines and insists that vaccines are the cause for autism in the face of overwhelming evidence to the contrary. As a layman, she could have been dismissed as some snake oil salesman, by Dr Bark testifies in courts as an expert witness!
There is always a supply of conspiracy theorists ready to lap up whatever sensational cover ups that the activists have exposed. Dr Spark claims that 70% of the reports on the safety of vaccines in mainstream media are paid for by the big pharmaceutical companies (Big Pharma). Followers and believers of the anti-vaccination movement come in all shapes and sizes. From Jews to Muslims, school dropouts to university professors, homeless folks to those who live in mansions – there is no typical profile for the average “anti-vaxxer”, as they are commonly referred to. Throw in a few celebrity “influencers” and you’ll have an unstoppable anti-vaxxer movement.
However, if you were to study these anti-vaxxer websites, a predictable pattern is observed. There is usually very little scientific data or statistics – just moving, even tear-jerking stories. While most rational people will not accept these stories as representative of the mean, some people just fall for it. Knowingly or otherwise, the cult leaders capitalise on the people’s mistrust in the government (and who can blame them after the fake news about WMD in Iraq that cost Americans thousands of lives and $2.4 trillion) and manipulate that mistrust so that they can even make the most far-fetched conspiracy theory believable. Sadly, the writing is on the wall. Truth is losing ground. The more the authorities try to beat them down with statistics, the more the cult would try to rebel against the system and recruit new members.
All cults come with leaders and for someone as intelligent and well-trained as Dr Toni Bark, it’s hard to see her as a follower even though the anti-vaxxer movement may not have started with her. Whatever her motives, it is likely that she became much better known after she spoke out so vehemently against vaccines, especially when she travels the country to give fiery speeches and riveting talks against the establishment in contrast with the usual stuff that most unassuming paediatricians talk about. She wouldn’t have generated any buzz. She wouldn’t have become famous if she had worked as a regular doctor. By going against all that and practising quakery, her patient load increased rather than decreased.
“The anti-vaccine lobby has grown from a fringe movement in the late ’90s, early 2000s to this massive media empire that has now hundreds of websites, amplified on social media. They have political action committees now, it’s become politicized,” said Peter Jay Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine and the director of the Texas Children’s Center for Vaccine Development. “This was never a problem up until a few years ago, but now it’s become this huge issue.”
Yes, it’s now so huge that it has become political. It is believed that Donald Trump scored quite a number of points by pointing out that vaccines could be a cause for autism. Like Dr Bark, Senator Rand Paul is also a doctor and an ophthalmologist to boot. He too seemed to have gained quite a few supporters by suggesting that vaccination should not be compulsory. A 2015 Pew Research Poll concluded that 68 percent of U.S. adults say childhood vaccinations should be required, but 30 percent say parents should be able to decide.
The movement is bearing a toxic fruit. In 2018, 349 individual cases of measles were confirmed in 26 states and the District of Columbia. This is second to 667 cases reported in 2014. Measles was supposed to have been eliminated in the US in 2000 but most recently from January 1 to April 4, 2019, 465 individual cases of measles have been confirmed in 19 states! Will it hit a new high?
Meanwhile, the anti-vaxxers continue their crusade to leave more children unprotected. Are they simply ignorant, misled, or do they have a more devious motive – like some vegan guru who doesn’t practise what she preaches?
We all know that politicians are in a breed of their own and their stand can shift with the movement of public sentiment. But It would not just be an irony but an utter insult to the medical profession if doctors who are not doing well practising medicine somehow manage to earn a fortune by going against it.
True story. Tim was gym owner who was all stressed out even though he was doing a booming business. After numerous ranting sessions with friends and family, he began to rationalise his position. He realised that over 90% of his customers were satisfied with the service and amenities he provided. Less than 10% were habitually complaining, threatening and making all sorts of demands.
Tim had been reading books by business gurus who said that he must hold his customers as a bucket would hold water. Once there’s a leak, his business will bleed. It all sounds very nice and logical, but the reality is something that the guru had not grasped. Tim decided that he would just refund the membership fee to that measly 10% and focus on that 90%.
The guru was wrong. He did earn a little less money, but his business did not bleed. Most importantly, Tim’s sleep and appetite improved. His regained his health and he was even beginning to enjoy his work.
Sometimes, even after 30 years in practice, dentists still get new experiences; cases they have not seen before, patients they have yet to encounter.
How often do patients sympathise with their dentists? Not very often. They don’t feel bad when they keep exhaling through their mouths, fogging dentist’s mirror. They may not even try to keep their mouths open for a long procedure. They think it’s the dentist’s problem when they can’t open their mouths.
On a few rare occasions, they say “sorry”. But when a difficult patient (who claims to have a phobia for dentists) says “poor thing” when she sees the dentist struggling, it brings a strange feeling to the poor dentist. Is she being apologetic? Is she mocking? Something to chew on.
Madam Wang Xiaopu is an investor from China. Convinced that Singapore’s medical aesthetics industry is a gold mine, she signed a contract to buy over 20,000 shares in a company holding a chain of aesthetic clinics for $32.5 million. She was informed by Dr Goh, a major shareholder in the company, that the clinics have a pre-tax profit of $10 million in 2012, and its pre-tax profit was also growing at a rate of more than 30 per cent a year. The chain, which originally had 14 branches, is now facing insolvency, rendering Madam Wang’s shares worthless.
Madam Wang is just one of many faceless (clueless) foreign investors wooed into the seemingly lucrative local healthcare industry. With millions injected into their war chests, the aggressive clinic management teams spawn dozens of branches, quickly saturating the small local market and creating the illusion of insufficient manpower. I’ve already written about the apparent shortage of dentists which is not due to dentists unable to meet the demand of patients but rather them not meeting the demand from the sheer number of “shell” clinics built. And the drying wells are seen everywhere. Small clinics which used to be doing very well have deregistered themselves from GST. Some have seen a 30-50% drop in revenue. On the ground, clinicians bonded to “high performance” practices are struggling to hit targets and this sometimes results in overwork, over-treatment or even cases of fraudulent claims of which we have seen and will see a lot in the coming months and years.
It is unfortunate that most of those in the know hesitate to comment on this issue before the profession/industry reached this state. They are reticent for a variety of reasons. Some keep quiet because they are in the game themselves. Some are afraid of saying the “wrong” thing. Some simply just don’t want to get “marked”. Why speak out when they are still earning a comfortable income? A doctor who commented on my Facebook posting on this subject quickly changed his mind and removed his comments. That’s how fearful Singaporeans are, even when they need to sound the alarm for a house on fire. Instead of voicing out their concerns, some quietly crawl through loopholes to sustain their income. But for how long can all this last without blowing up in our faces?
As Singapore opens its doors to high net worth new citizens, it’s worthwhile to keep an eye on the industries they invest in. What is the demand for high value medical services which are readily available for a lower price tag and with fewer restrictions/regulations in the region? When profits and ROIs fall far short of investor expectations, the scene will turn really ugly.
Recently, the governing body for dentists in Singapore sent out a circular reminding dental practitioners that they are not allowed to carry out any activity relating to the harvesting of dental pulp tissues and DPSCs (dental pulp stem cells).
The reason behind this prohibition is that “dental pulp tissue and dental pulp stem cells currently (bolding mine) lack clinical evidence for therapeutic use and have not been accepted as a form of evidence based therapy for regenerative medicine nor dentistry by the local medical and dental professions.”
Before I go further, I must declare that I have absolutely no interest whatsoever in harvesting dental pulp tissue and neither do I encourage patients to spend money paying for a service which is unlikely to be put to good use in the near future. Sounds a bit like insurance? Well, that’s almost exactly what it is. So if there is currently no evidence that you’re having cancer or kidney failure, why buy a crisis cover? The majority of people who buy insurance will not gain from it, but they buy a policy in case of untoward circumstances because having no evidence of cancer of kidney failure currently does not mean that you won’t get any evidence of cancer or kidney failure in future.
Now let’s take a look at dental stem cells. What are they?
Dental pulp stem cells (DPSCs) are stem cells present in the dental pulp, the soft living tissue within teeth. They are multipotent, so they have the potential to differentiate into a variety of cell types. Other sources of dental stem cells are the dental follicle and the developed periodontal ligament.
Why are stem cells such cool stuff? They are like promising recruits in the army. When a battalion of commandos gets wiped out, you can train them to replace the commandos. When an artillery battery gets wiped out, you can train them to be artillery men. These cells give hope for patients who need organ transplants because theoretically (and sometimes in the laboratory), stem cells can be cultivated to produce various kinds of living tissues. However, not all stem cells have the same potential.
When we talk about stem cell potency, there are several levels to consider. A unipotent stem cell refers to a cell that can differentiate along only one lineage. Of all the stem cells, a unipotent stem cell has the lowest differentiation potential. This means that the cell has the capacity to differentiate into only one type of cell or tissue. Unipotent cells are found in the skin. You can technically grow new skin using these stem cells. However, patients who need skin grafts often need them urgently and there is currently no technique that yields quick and consistent results.
Stem cells can also be pluripotent. As far as embryonic origins go, there are only 3 categories of tissues in our body. Depending on its origin, a pluripotent stem cell can differentiate into one of 3 tissue categories. An ectodermal stem cell can grow into ectodermal tissue (skin, nerves). An endodermal stem cell can grow into endodermal tissue (lung, gut lining) and a mesodermal stem cell can grow into mesodermal tissue (muscle, bone, blood, urogenital).
Dental stem cells are multipotent and there is already quite a bit of literature on it. Multipotency describes progenitor cells which have the gene activation potential to differentiate into discrete cell types. They can theoretically be induced to grow into different types of cells (independent of embryonic origin) as in blood, brain and bone. Multipotent cells have been found in cord blood, adipose (fat) tissue, cardiac (heart) cells, bone marrow, and the mesenchymal stem cells (MSCs) which are found in our wisdom teeth. Seeing the huge potential of an insurance concept, businesses have pounced on the opportunity to sell pricey storage facilities for cord blood and even extracted wisdom teeth as they are the most readily available sources of multipotent stem cells.
Right there at the top of cell potency, totipotency represents the cell with the greatest differentiation potential, being able to differentiate into any type of tissue. Totipotent stem cells are only found in an embryo that is a few hours old – before it grows 3 layers. You can theoretically grow an entire organism or organ with a totipotent stem cell, but obviously, you would need to sacrifice a living organism in the process. Ethical issues get in the way, but it gets more interesting.
Induced pluripotent stem cells, commonly abbreviated as iPS cells or iPSCs, are a type of pluripotent stem cell artificially derived from a non-pluripotent cell, typically an adult somatic cell, by inducing a “forced” expression of certain genes and transcription factors. By 2007 scientists have successfully produced human iPSCs derived from human dermal fibroblasts which are not even stem cells. The feat earned Shinya Yamanaka and John Gurdon the Nobel Prize in Physiology or Medicine 2012. This discovery raised a question. Why do we need to store or harvest stem cells at all if they could be made from an ordinary cell?
But let’s not get carried away and drift into the realm of science fiction. Stem cell technology is still in its infancy and the American FDA does not approve any of the stem cell therapies out there. Some are even considered dangerous. Nevertheless, clinics there are already using stem cells to treat problems ranging from arthritis and torn tendons to paralysis and stroke. These patients are willing to take the risk even though researchers say that there’s (currently) no evidence that the treatments work or are even safe.
What do we do to such experimental therapies? We certainly should not encourage them, but the practically harmless process of harvesting cord blood or dental stem cells should both count only as insurance policies. In the case of cord blood, there is only one chance at birth. For teeth, there are more opportunities, though the process is a little more invasive. What will the outcome be? Will we be able to grow new livers and kidneys from teeth? Will induced pluripotency render cord blood and dental tissue banking obsolete? Or will all this research finally lead us to a dead end?
Hundreds of healthy teeth are extracted in Singapore every day to make way for tooth movements and alignment. What’s wrong with banking these teeth? Those who opt for the service are merely placing their bets on the future. Why should they be dictated by the “lack of clinical evidence for therapeutic use and have not been accepted as a form of evidence based therapy for regenerative medicine nor dentistry by the local medical and dental professions”? Pessimistic and cynical as I am, I believe that the final outcome of a dead end to all this research is most unlikely.
Transport Minister Khaw Boon Wan said in Parliament on Mar 7 2018 that while Singapore’s transport fares are currently “affordable”, the Government also needs to ensure the “sustainability” of the transport network.
“We must be careful that (fares) are not priced too cheaply, as maintaining a “high-quality” transport system requires resources,” he said. “Cheap fares are popular, but they are not sustainable.”
The current formula is “inadequate”, he said, and the Public Transport Council (PTC) is reviewing it to take into account “total costs”.
“I am confident that they can work out a fair and sustainable arrangement. Please support the PTC when they make their recommendations,” Mr Khaw said.
And not too surprisingly, the PTC had this to say:
“A widening gap between cost and fares is not sustainable for any public transport network.”
While PTC said it was too early to commit on whether this new component would mean a fare hike at the next review in the third quarter of this year, it pointed to the need to keep the system sustainable.
An interesting coincidence perhaps, but what does the PTC actually do or claim to do? Let’s take a closer look at info extracted from their website.
As the Public Transport Council (PTC), we regulate public transport fares and ticket payment services. We also advise the Minister for Transport on public transport matters. Established in 1987 under the Public Transport Council Act (Cap 259B), we operate within the ambit of the Public Transport Council Act and in accordance with overarching public transport policies.
We strive to bring about a quality and affordable public transport system for the people of Singapore. We also work closely with the public transport industry players and public agencies like the Land Transport Authority (LTA).
Key Function and Objectives
Our key statutory powers include:
Regulating bus and train fares (taxi fare has been deregulated since 1 September 1998);
Promoting and facilitating the integration of bus and train fares for efficient public passenger transport services and facilities;
Regulating ticket payment services for buses and trains;
Regulating penalty fees to deter fare evasion;
Gathering public feedback on any matter relating to bus, train and taxi services in Singapore, through surveys and other methods; and
Advising the Minister for Transport on public transport matters.
PTC’s Council Members are appointed on the basis of their competency, good public standing and wealth of experience, especially their ability to contribute effectively to PTC’s deliberation on public transport issues. The Council Members are chosen from a wide spectrum of society including:
The composition of the Council is made up of a broad and diverse representation from society, which includes academia, labour union, industry and the people sector. This facilitates a wide representation of views from the public. The Council currently comprises 17 members and many of them are regular users of public transport.
So Council members in the PTC are chosen for their competence, good public standing and “wealth of experience”. If you’re talking about “competence” and “good public standing”, then that should rule out an undistinguished guy like me. But I’m not sure what kind of experience they’re looking for. You see, I have taken the MRT on its test run in 1987 and I’ve been taking it almost on a daily basis ever since, enjoying the speed and comfort, showing it off to friends from overseas till the early 2000s. Then, things changed. The passenger load grew at a frightening rate. There was crowding on the platforms, squeezing in the trains. Our once proud and efficient MRT was no longer as reliable and comfortable as it used to be. Then came the frequent breakdowns, delays, death on the rails, tunnel flooding incident and train collision. Does that count as “experience”? More importantly, do the chosen council members have the experiences of watching our MRT deteriorate to its current state? How justified is an increase in fares?
Then on 18th May 2018, Mr Khaw said something even more outrageous and mind-boggling.
“The Public Transport Council (PTC) had mulled over including rail reliability into the formula for calculating public transport fares, but ultimately decided against it. This was partly because reducing fares in the face of an unreliable rail system would mean withdrawing resources from the operators when they, in fact, need to inject more funds to fix the system. When a system is very unreliable, in fact, that is the time to pump in more resources. And because of that, you punish them through reduced fares; you are withdrawing resources from the operators and you’ll be doing exactly the opposite, the wrong thing.”
Yao mo gao chor ah? Since this is newagedentists.com and I’m promoting my book, Dental Phobia, I should come up with an appropriate analogy.
Once upon a time, there was a dentist by the name of Dr Poh Chwee Kee. He had just taken over a thriving dental practice from a retiring senior. He was glad that there was still a lot of materials left behind, so without bothering to order new materials, he used what was available. Then, his patients started coming back to him, complaining of fillings that fell out. Dr Poh Chwee Kee checked his instruments and his filling materials and discovered that the filling materials handed over to him had all been contaminated. He called the supplier and fresh stocks of filling materials would cost him a bomb.
So Dr Poh Chwee Kee informed the patients affected by the contaminated filling material that he would replace their fillings for a higher fee than they had paid for the old fillings that had failed. He explained that maintaining a “high-quality” dental practice requires resources. His profit had fallen 68%.
“Just pay me more lor. Cheap fees and free re-treatment for failed cases are popular, but they are not sustainable.”
Is it his patients’ fault that this problem had occurred? Why should they be made to pay to fix a problem that ought not be there in the first place? Not surprisingly, Dr Poh lost all his patients in no time. Why? Because it’s the service provider’s responsibility to provide a reasonable standard of service. If he fails to do so, he must rectify the problem at his own expense. How can he ask people to pay him more to fix the problem after he has failed to deliver?
The logic is the same, but the situation is very different. Dr Poh did not have the backing of a council that happens to agree with him most if not all the time. He also did not have a monopoly of dental services in his town. For those who do, karma may strike in an unexpected place.