Experiences in caring for the dying: a doctor's narratives.

The study of narratives is increasingly noted for its value in the professional and personal development of doctors. We present the narratives of one of the author's experiences in the care of dying patients over a span of three decades. From the narratives, we identified three paradigms with which doctors respond to and care for dying patients and their families: 'No death', where there is a general denial of death and dying; 'Death', where the care provider's focus is directed to the facilitation of a 'good' death; and 'Life', where the doctor responds to the patients' death and dying as integrated and inseparable aspects of the patient's and family's life. The origins and implications of the paradigms are discussed. In addition to good communication, these narratives underscore the importance of personal reflection and insight when providing end-of-life care.

Factors influencing cardiac auscultation proficiency in physician trainees.

INTRODUCTION: We assessed the accuracy of physician trainees in identifying different cardiac sounds and examined the factors influencing their cardiac auscultation proficiency. METHODS: A total of 106 physicians in the Family Medicine Training Programme were asked to identify 10 cardiac sounds played sequentially on the Littmann electronic stethoscope, which functioned as a surrogate patient. Their auscultation accuracy was scored numerically out of a maximum of 10. Demographical data of the physicians was collected prospectively. RESULTS: The mean (+/-SD) auscultation proficiency score of the study population was 4.0 +/- 1.7. Physicians who graduated in 1994 or earlier fared significantly poorer than those who obtained their Bachelor of Medicine and Bachelor of Surgery degrees between 1995 and 2000 (p-value equals 0.02). Auscultation proficiency was not related to current practice, previous years of primary care, cardiology, internal medicine or paediatric medicine postings, or cumulative years of postings. Normal heart sounds were most accurately identified. Prosthetic cardiac sounds were better identified than other extra-cardiac sounds while systolic murmurs were more accurately identified than diastolic murmurs. Tachycardia had the lowest identification rate. CONCLUSION: Our data suggest that cardiac auscultation skill declined with time, being significantly impaired eight years after graduation. We suggest that there is a need for retraining in the form of continuing medical education to address not only new knowledge and skills, but also basic skill competency.

2001 survey on primary medical care in Singapore.

INTRODUCTION: The 2001 survey on primary medical care was undertaken to compare updated primary healthcare practices such as workload and working hours in the public and private sectors; determine private and public sector market shares in primary medical care provision; and gather the biographical profile and morbidity profile of patients seeking primary medical care from both sectors in Singapore. This is the third survey in its series, the earlier two having been carried out in 1988 and 1993, respectively. METHODS: The survey questionnaire was sent out to all the 1480 family doctors in private primary health outpatient practice, the 89 community-based paediatricians in the private sector who were registered with the Singapore Medical Council and also to all 152 family doctors working in the public sector primary medical care clinics. The latter comprised the polyclinics under the two health clusters in Singapore, namely the Singapore Health Services and National Healthcare Group, and to a very much smaller extent, the School Health Service's (SHS) outpatient clinics. The survey was conducted on 21 August 2001, and repeated on 25 September 2001 to enable those who had not responded to the original survey date to participate. Subjects consisted of all outpatients who sought treatment at the private family practice clinics (including the clinics of the community-based paediatricians), and the public sector primary medical care clinics, on the survey day. RESULTS: The response rate from the family doctors in private practice was 36 percent. Owing to the structured administrative organisation of the polyclinics and SHS outpatient clinics, all returns were completed and submitted to the respective headquarters. Response from the community-based paediatricians was poor, so their findings were omitted in the survey analysis. The survey showed that the average daily patient-load of a family doctor in private practice was 33 patients per day, which was lower than the 40 patients a day recorded in 1993. The average working hours of each of these private practitioners was 7.6 hours per day. Family doctors in public sector primary medical care clinics were responsible for 16.6 percent of the patient-load for primary medical care in Singapore while the remaining 83.4 percent was provided by family doctors in private practice. Singaporeans made approximately 4.4 visits to a family doctor in 2001, which was lower than the 5.0 visits ascertained in 1993. Chronic medical conditions seen by family doctors as a whole, increased from 29.2 percent in 1993 to 34.3 percent in 2001. Upper respiratory tract infections and hypertension were the two leading disease conditions seen at both private and public sector primary medical care clinics in 2001. The load of hypertension managed at primary medical care clinics had notably increased. CONCLUSION: The public sector share of outpatient load at 17 percent in 2001 is well within the 25 percent level set in the Government's 1993 White Paper on Affordable Healthcare. The private sector remains the main provider of primary medical care in Singapore, serving 83 percent of the population. The average workload for each family doctor in private practice had dropped from 40 to 33 patients a day between 1993 and 2001. There had been a notable growth in family doctors working in the private sector over this period. Both sectors saw an increase in the chronic disease load that they managed.

Fever attribution in the SARS outbreak.

Fever as a somatised symptom is not commonly described. We report a patient who complained of recurrent unexplained "fevers" during the severe acute respiratory syndrome (SARS) outbreak in Singapore. The presentation, while likely to be peculiar to the outbreak, posed challenges and difficulties to the primary care doctors. Investigations did little to allay her anxiety. Instead, appreciating the psychosocial backdrop and how the SARS outbreak affects patient and doctor may be useful.

A review of 5 years' experience in the use of botulinium toxin A in the treatment of sixth cranial nerve palsy at the Singapore National Eye Centre.

INTRODUCTION: This retrospective study reports our experience on the use of botulinum toxin A (BTXA) in the treatment of sixth cranial nerve palsy at the Singapore National Eye Centre. BTXA is derived from clostridium botulinum; it causes temporary paralysis of the extraocular muscle (medial rectus) into which it is injected, thus preventing its contracture and allows the antagonist lateral rectus muscle to take up the slack and reduce or correct the ocular misalignment. METHODS: Nineteen patients had BTXA injection for estropia due to sixth cranial nerve palsy during the period September 1992 to August 1997. The sixth cranial nerve palsy was related to nasopharyngeal carcinoma in 76.7% of cases. Follow-up after the last injection ranged from zero (defaulted) to 21 months (mean 8, median 6 months). RESULTS: A total of 25 injections were given to 19 patients. Seven patients (36.8%) had final ocular alignment within 10 prism dioptres of orthotropia of which six achieved fusion at primary gaze position. There was no correlation between the number of injections per patient and the size of strabismus or grade of lateral rectus muscle function. The incidence of ptosis was 48%, subconjunctival haemorrhage 16% and hypertropia 16%. DISCUSSION: Our results suggest that those patients with smaller strabismus and a shorter time interval between onset of strabismus and botulinum injection tend to achieve better outcome in terms of fusion or ocular alignment within 10 prism dioptres of orthotropia. The treatment of strabismus with BTXA is an acceptable approach in selected patients. The procedure is simple, safe, cheap, effective, and avoids the risks of general anaesthesia. It can substitute for or eliminate the need for strabismus surgery in some cases of sixth nerve palsy.

Delayed diagnosis of tuberculosis presenting as small joint arthritis--a case report.

Small joint arthritis is an uncommon manifestation of tuberculosis. We report a case of tuberculosis presenting as arthritis of the midtarsal joints with concomitant spinal involvement. This case illustrates the difficulties in diagnosing tuberculous arthritis as it has an insidious onset, paucity of constitutional symptoms, unremarkable early physical findings and frequent absence of associated pulmonary involvement. A high index of suspicion in high-risk individuals with chronic monoarthritis, is required to avoid delayed diagnosis.

Experience with portfolio-based learning in family medicine for master of medicine degree.

BACKGROUND: The Private Practitioners Stream (PPS) of the Family Medicine Traineeship Programme for the Master of Medicine (Family Medicine) (MMed (FM)) was started in 1995. The portfolio-based learning approach was used as the staple learning method in the tutorial system. Due to the autonomy given to Family Medicine trainees in choosing the topics for the portfolio-based presentations, the completeness of coverage of the Family Medicine training syllabus is a research question. AIM: To study if portfolio-based presentations in a tutorial system covered the broad based Family Medicine training syllabus. METHOD: Data in the one-page portfolio-based records developed were used to categorise the presentations according to the topics in the Family Medicine Modular Course. RESULTS: In the three-year period since the introduction of the PPS, 83 tutorials were conducted in which 87 portfolio-based presentations were made. Thirteen (15%) were in the Whole Person Medicine category, 70 (80%) in the Disease Management category and 4 (5%) in the Practice Management category. CONCLUSION: The portfolio-based learning is recognised as useful in continuing medical education because of the autonomy it gives to the adult learner. In our three years' experience, the one-page portfolio-based record developed was effective as the staple learning tool to cover the broad range of topics required in the defined syllabus of training and to meet the focus of the MMed(FM) examination.

Molecular studies of loss of heterozygosity in retinoblastoma.

Retinoblastoma (Rb) is a paediatric intraocular tumour in which predisposition can be inherited. Cases of Rb tumours can be divided into three types: familial cases, sporadic bilateral cases and sporadic unilateral cases. Familial and sporadic bilateral cases are usually categorised as hereditary while sporadic unilateral cases as non-hereditary. In both familial and non-familial forms of Rb, loss of heterozygosity of the Rb locus has been reported although its frequency in tumours has not so far been accurately determined. The cloning of the gene responsible for retinoblastoma (Rb1) has facilitated DNA studies and genetic counselling of patients. We have examined forty-five cases of retinoblastoma at five intragenic sites of the Rb1 locus, namely intron 1/BamH1, intron 17/Xba1, intron 24/TthIII1, intron 25/Dra1 and Rb1.20 VNTR. Thirty-six out of the forty-five cases (80%) were informative for these markers. Comparison of results between genomic DNA from peripheral blood and from tumours revealed that loss of heterozygosity of alleles could be detected in 50% of cases studied in which tumour samples were available. Investigation of parental origin of retained alleles showed that in all these cases, the paternal alleles were preferentially retained. The analysis of the genetic origin of mutations predisposing to retinoblastoma can facilitate new approaches for identifying recessive mutant genes that lead to cancer as well as to provide a conceptual basis for accurate prenatal predictions of cancer predisposition.

Incidence of retinopathy of prematurity in Singapore.

The study was done to investigate the incidence and severity of retinopathy of prematurity (ROP) in Singapore over a one-year period. Its relation to factors like birth weight, gestational age are also explored so as to identify high risk groups and provide guidelines for the implementation of a screening programme in Singapore. At the various government restructured hospitals from Dec 1993 to Nov 1994, 34.4% (72 out of 209) of babies, with birth weights less than 1250 g or gestational ages less than 32 weeks, developed ROP. The incidence of ROP correlated significantly with low birth weight, early gestational age, multiple births; the severity correlated with low birth weight and multiple births. There was a notably higher proportion of Malays in the study population (premature babies) than all the live births of the same period. From the results, an optimal screening programme should include babies weighing less than 1250 g or of gestation earlier than 32 weeks. A first examination at 33 weeks of post-menstrual age is suggested.

Tendon xanthoma in familial hypercholesterolemia--a clinical and ultrasonographic study.

Familial hypercholesterolemia is a common autosomal dominant condition characterised by increased low density lipoprotein cholesterol, tendon xanthomas and premature atherosclerosis. Ultrasonography is the diagnostic tool of choice for the detection of tendon xanthomas in the Achilles tendon, demonstrated by the presence of hypoechoeic nodules or an increase in the antero-posterior diameter. It can also be used in screening and clinical follow-up of patients with familial hypercholesterolemia.

Growth of the internal and external eye in term and preterm infants.

BACKGROUND: Better knowledge of the growth patterns of the external and internal eyes of neonates would permit more accurate diagnosis of disorders that affect ocular size such as infantile glaucoma and microphthalmos. Such disorders preferentially may affect certain parts of the internal eye but not other parts. No previous study statistically has evaluated internal ocular growth in preterm newborns. METHODS: A-scan ultrasonography was applied directly to the corneas of 101 healthy preterm and term newborns to determine axial length, anterior chamber depth, lens thickness, and vitreous chamber depth. The growth of these structures was evaluated by correlation and regression analyses. RESULTS: At term, the mean measurements were axial length, 16.2 mm; anterior chamber depth, 2.0 mm; lens thickness, 3.8 mm; and vitreous chamber depth, 10.5 mm. Postconceptional age correlated to axial length (P < 0.001), anterior chamber depth (P = 0.032), and vitreous chamber depth (P < 0.001), but not to lens thickness (P = 0.48). By regression analysis, the eyes of males grew faster than those of females (P < 0.001) mainly due to the vitreous chamber. CONCLUSION: In the last trimester and first 2 postnatal months, lens thickness remains constant, while the anterior chamber and, especially, the vitreous chamber deepen.

Calculating the GP consultation fee in Singapore: towards a rational costing approach.

PURPOSES: The General Practitioner (GP) consultation fee in Singapore, unlike that of his specialist colleague, has been left very much undefined over the years. There is a need for an objective way of calculating the GP consultation fee. METHOD: A proposed method of calculating the GP consultation fee based on the model of estimating the total cost of producing the service plus the doctor's remuneration is described. Known prevailing costs were used in the computation. This model allows us to work out the cost to the patient by dividing the total cost of producing the service by the number of patients (referred to as patient encounter load) seen by each duration of consultation--4, 6, 10, 15 and 30 minutes. Different monthly remuneration levels for the doctor were used to compute the different consultation fees that would result for each of the duration of consultations. RESULTS: Using this method of calculation, for a doctor with a desired monthly remuneration of $7000, and seeing a patient every 6 minutes over a 150-hour month, the consultation fee is $13.00. This drops to $11.00 if the doctor receives a remuneration of $4000 per month. Using the same parameters, a 15 minute consultation will cost the patient $30.00 and $25.00 respectively. CONCLUSION: This method can be used to derive a consultation fee for services requiring different durations and varying remuneration brackets for the doctor.

Sclerosing haemangioma of lung--case report with histologic, immunohistochemical and ultrastructural correlation.

We report a case of a large sclerosing haemangioma of the lung that was found incidentally on roentgenography of an asymptomatic woman presenting for routine health screening. Computed tomographic scan showed a well-defined "coin" lesion with peripheral foci of calcification. The lesion had a variegated histological appearance comprising four major patterns--solid, papillary, haemorrhagic and sclerotic. There appeared to be two populations of cells--distinct round cells with abundant clear cytoplasm constituting the solid component and uniform cuboidal cells with small, dark nuclei lining irregular spaces. Positive immunohistochemical staining for cytokeratin and epithelial membrane antigen, and the ultrastructural demonstration of epithelial characteristics and electron-dense bodies showed that the proliferating cells had features in keeping with type 2 pneumocytes. This is a benign condition and the prognosis is excellent.

A computerised out-patient medical records programme based on the Summary Time-Oriented Record (STOR) System.

Advances in microcomputer hardware and software technology have made computerised outpatient medical records practical. We have developed a programme based on the Summary Time-Oriented Record (STOR) system which complements existing paper-based record keeping. The elements of the Problem Oriented Medical Record (POMR) System are displayed in two windows within one screen, namely, the SOAP (Subjective information, Objective information, Assessments and Plans) elements in the Reason For Encounter (RFE) window and the problem list with outcomes in the Problem List (PL) window. Context sensitive child windows display details of plans of management in the RFE window and clinical notes in the PL window. The benefits of such innovations to clinical decision making and practice based research and its medico-legal implications are discussed.

Oculocutaneous albinism: variable expressivity of nystagmus in a sibship.

Traditionally, the diagnosis of ocular or oculocutaneous albinism (OCA) is based on a constellation of features including the presence of nystagmus associated with iris transillumination defects, hypopigmentation of the fundus, and hypoplasia of the fovea and optic nerve head. Nystagmus is the most frequent ocular sign for the ascertainment of albinism particularly in individuals who have lightly-pigmented parents. We report two siblings, a male and female, with minimal, if any, pigmentation of skin and hair, iris transillumination defects, blond fundi, and hypoplasia of the foveae and optic nerve heads who were discordant for nystagmus; the diagnosis of OCA was based on the clinical findings. These siblings presumably have the same genetic hypopigmentation defect and demonstrate that nystagmus is not a consistent finding in OCA and may not be an absolute criterion for diagnosis.

Penetrating keratoplasty and cataract surgery: the advantages of an extracapsular technique combined with posterior chamber intraocular implantation.

The results of 28 consecutive triple procedures and 33 cases of combined penetrating keratoplasty and extracapsular extraction are presented. All the eyes with the triple procedure maintained a clear graft; 77 per cent achieved an acuity of 6/12 or better. The average time before a refractive correction could be dispensed was 8.2 months, while after a combined procedure the interval was 17.4 months, although in both groups the average time until the best visual acuity was reached was similar.