25 Aug 2011
By: POON CHIAN HUI
AN OBSTETRICS and gynaecological (O&G) doctor may refer a patient to a sub-specialist out of good intentions but this might not be in the patient’s best interest.
“The patients may end up consulting multiple specialists for their problems, leading to lack of continuity of care and rising health-care costs,” said Minister of State for Health Amy Khor yesterday.
Speaking during the opening of the 8th Singapore International Congress of Obstetrics and Gynaecology, she noted that the rising trend of sub-specialisation has led to “fragmentation of care” for women, and many O&G doctors refer patients who might need specific care to colleagues.
Dr Khor said there is a need to “be wary of this phenomenon and work together to ensure that our specialists receive broad-based training”. This is so that they are able to manage the common O&G problems women suffer from, she added.
Singapore has more than 280 specialists in the O&G field which deals with the female reproductive organs. Two-thirds of them are in the private sector.
Doctors said some grey areas exist. For example, it is sometimes unclear when cases should be referred to sub-specialists, said Dr Tony Tan, vice-president of the Obstetrical and Gynaecological Society of Singapore.
There are four key O&G sub-specialities: maternal fetal medicine which deals with matters related to pregnancy; gynaecology-oncology, which refers to gynaecology cancers; minimally invasive surgery; and uro-gynaecology which involves the urinary tract and genitals.
Dr Tan, who is also chairman of the congress’ organising committee, cited the example of using a tape procedure to treat stress urinary incontinence, or difficulty in urinating due to weak pelvic muscles, in women. The procedure is not difficult to perform and could be done by a general specialist, he said. However, this condition falls into the sub-speciality of uro-gynaecology as well.
“One could argue, who should be the one to perform the procedure,” said Dr Tan. The sub-specialist would have completed it more times, but it does not mean that a general specialist could not achieve similar results. “But if everything is done by the sub-specialist, then what’s left for the general specialist to do? It’s a dilemma that, at the moment, does not have an easy answer.”
However, he maintains that sub-specialising is important as it helps bring medical practice “up another notch”.
Besides, said Associate Professor Tan Hak Koon who heads Singapore General Hospital’s O&G department, it is impossible for a doctor to know everything about the field. “Sub-specialising helps to provide the best care to the patient.”
He suggested a simple solution: Identify the most suitable doctor for the patient right from the start. The patient will then be less likely to require a switch of doctors during the course of treatment.
“This problem can be resolved by better coordination between health-care professionals,” he said.
Associate Professor Mahesh Choolani, who is with the O&G department at the National University of Singapore’s Yong Loo Lin School of Medicine, said there is an opportunity to develop a “seamless, integrated care system” between the different specialists. “This is possible – the specialist and sub-specialist need only to work together for the patient.”
He said even though a patient requires another specialist’s expertise midway through his care, he would still keep tabs on her condition every day.
When the patient knows her primary doctor is still involved in her care, she will feel more reassured, he added.
“If both doctors are looking at the problem together, it is less likely for the care to be fragmented,” he added.
The three-day congress, held once every two years, has drawn nearly 800 experts from 36 countries. Held at Raffles City Convention Centre, it is organised by the Obstetrical and Gynaecological Society of Singapore.
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