PM Lee Hsien Loong at the Singapore Medical Association's 50th Anniversary Dinner

Dr Chong Yeh Woei, SMA President

Distinguished guests, Ladies and Gentlemen

I am glad to be with you tonight at the Singapore Medical Association (SMA) 50^th Anniversary dinner.

In the last 50 years, Singapore’s healthcare standards have been totally transformed. Life expectancy has risen to one of the highest in the world and infant mortality is one of the lowest in the world. Ordinary citizens enjoy high quality medical care, comparable to any OECD country. This reflects the economic and social progress of our country, and the resources that we have invested into our healthcare system. But a lot of credit must also go to our medical professionals. Your professionalism, dedication and patient labours have benefited generations of Singa poreans, all of whom will need medical care at some stage of their lives. I thank all our doctors for your countless contributions, and look forward to your full support to keep up standards and further improve medical care in Singa pore.

We have faced some difficult public health problems in the past five decades. Although Singapore maintains good hygiene and healthcare standards, we are vulnerable to trans-national diseases, because we are so highly connected to the rest of the world. Six years ago, we were struck by SARS. Fortunately, the medical profession rose to the challenge, and led Singaporeans to contain and eventually defeat the disease. Some Singaporeans tragically perished, including several courageous health workers. But we learnt important lessons, especially from our mistakes, and hence were more ready to tackle the recent outbreak of Influenza A(H1N1). 

Our response this time has been more focused, rapid and coordinated. We reacted aggressively at first, when we knew very little about the new disease, and had to prepare for the worst. As the outbreak progressed, and we learnt more about the new virus, we gradually downgraded our responses. This was the appropriate strategy – better for us to be safe than sorry.

Now the immediate danger has subsided, but the battle is far from over. We have to remain vigilant as the virus continues to spread to more countries. We must watch closely how this pandemic unfolds, and continually update and improve our contingency plans. We will have to address shortcomings, sharpen our procedures and restock our medical stores. Pandemics are a dangerous threat that we must take seriously. Influenza and other viruses will continue to mutate and evolve, and if not Influenza A(H1N1), then some other new viruses will eventually emerge and reach our shores. We must be fully prepared when that happens.

But tonight, let us enjoy a moment’s break to commemorate this milestone in the SMA’s history, and recognise those who have contributed to the medical profession.I am honoured and happy to become an Honorary Member of the SMA. I am not a doctor, but I know many doctors. My first wife was a doctor, and so are my sister, cousin and two uncles. I know doctors as colleagues in Cabinet and Parliament, and have also worked with many doctors on our healthcare system. I have been treated by a succession of doctors at various times, and but for their good judgement and conscientious care, I might not be here tonight. 

But the closest I have come to practising doctoring is perhaps when I conduct Meet-The-People sessions for my residents in Teck Ghee. (Indeed, in Britain such Meet-The-People sessions by Members of Parliament are called clinics.) The residents come to see me, their MP. They come one case after another, each problem important to him or her, each one seeking advice, assistance, and a solution, preferably immediately. I am conscious of their high hopes, and of the limits of what I can do. I have learnt the importance of good bedside manners, and found that even when I cannot solve my residents’ problems, lending a patient listening ear will often help them unburden themselves and feel better. For MPs, like doctors, must not only try to cure – and in fact not all cases can be cured – but must always care. There is great wisdom in the ancient medical aphorism – “To cure sometimes, to relieve often and to comfort always”. So each time I finish a Meet-the-People session, I leave with a greater admiration for doctors, especially GPs or polyclinic doctors who see patients in this way every working day.

Hence when the Minister for Health asked me what I proposed to talk about tonight, I told him my theme was that doctors have a very difficult job, so please do your best. Let me explain the reasons why.

First, doctors have to be perpetually learning and relearning. You have to keep abreast of the flood of medical knowledge that is expanding day-by-day, at least in your area of specialty. New research contradicts earlier studies, new treatment protocols supersede old ones, and new drugs deliver superior results, but with different complications and trade-offs. As a layman, I find it hard enough to keep up with constantly-changing fitness advice – is taking Vitamin C good for my body, should I go low-carbo or high-carbo, will eating eggs raise my cholesterol levels, etc.. Doctors have an even harder time keeping up with rapid medical advancements, but it is crucial that you do so, because as a patient I depend on you to provide me the best advice, and I will assume that you are current and correct.

Second, doctors must always do what is best for your patient. The patient has the final say, but he relies heavily on you for advice. After all you are his doctor, and you know much more about his condition and about medicine than he does. So patients always say “doctor’s orders”, and never “doctor’s advice”. If you tell a patient an expensive drug or a risky procedure is vital to make him better, he will take your advice very seriously, even if he decides to seek a second opinion. Economists call this “information asymmetry”, which means that your patient is not in a position to judge for himself the soundness of your recommendations, and protect himself against a bad doctor. So your advice must always be honest, well-founded, and based on what is in the patient’s best interest. 

Doing what is best for the patient often means advising him how not to be a repeat customer. Doctors should use your position of authority to counsel and badger patients to tackle the problems underlying their medical conditions – please stop smoking, exercise more, and lose weight. On their part, patients have to takeresponsibility for their own good health, and not leave everything to doctors. Indeed, the most effective way to make our population healthier, reduce morbidity and mortality, and save on healthcare costs, is through personal lifestyle changes. At Meet-The-People sessions MPs have to take the same approach. We help residents not only by mobilising government departments and resources, but also by advising residents to help themselves – spending within their means, finding a job, getting along with in-laws under the same roof, etc. In life, misfortunes and illnesses are not always within our control, but solving our own problems always begins with our personal efforts.

For doctors advising patients in their best interests, the most difficult issues are not about money, but about life and death. As a teenager, I had an appendicectomy. My doctor told me that he was happiest treating young patients, because often he could cure them completely, and they would go home well. But unfortunately that is not the whole human condition. Increasingly doctors have to manage patients who are elderly and declining, advise patients who are terminally ill, give palliative care, and deal with end of life issues. Doctors have to help patients and their families to come to terms with bad news, to think through and make emotionally wrenching choices, to decide whether to treat a patient aggressively or conservatively, whether to struggle on or to let go. Doctors have to exercise judgment and in some situations say “no”, because doing more can be counter-productive and cause more suffering and harm to patients. These are really more matters for the divine than the physician, yet doctors have to deal with them. It calls for not only knowledge and intelligence, but also both empathy and detachment, to put yourself in your patient’s position, and recommend what he would want for himself, if only he knew what you knew of medicine and his condition. 

Third, doctors are expected to uphold the highest ethical standards. Without this, patients cannot trust you to advise or treat them in their best interest, and you will be undermining the reputation of the whole profession. Indeed medicine is not just a profession, but a vocation. To be a good doctor you must not only know medicine well, and be able to diagnose and treat conditions. You must also have integrity, recommending treatments or drugs only when they are necessary, and not because you will gain financially from it. Take a broad view of your role, especially if you are a leader in the profession. Do not focus only on servicing your own patients, but also mentor younger doctors who are still learning their craft, and teach them the skills, values and ethos to become good doctors in time. 

Doctors are human beings, and human beings respond to incentives. The medical world is full of financial incentives – drug companies sponsor doctors to attend medical conferences, GPs add a mark-up when they dispense medicines, and surgeons earn a fee when they operate. In some medical disciplines, the financial rewards are substantial, especially disciplines involving intervention procedures. 

In themselves, financial incentives are not necessarily bad. Doctors too have to earn a living, and a medical system cannot run by assuming that every doctor is an Albert Schweitzer. If a doctor does well financially, it may well be because he is a good doctor who attracts more patients. If so, it is well and good. But from time to time, we get complaints against doctors who perform unnecessary operations, prescribe controlled drugs indiscriminately or charge excessive fees when they think their patients can afford to pay and they can get away with it. Such cases do happen, but I believe that in Singa pore such black sheep are in a small minority. The majority of Singa pore doctors are upright, honest, and motivated by a desire to help their fellow human beings. Many volunteer for charity work, and take part in disaster relief and humanitarian missions. We must make sure it stays that way. That is why the medical profession must act firmly against errant doctors when cases come to light. 

Fourth, doctors need to have a good systems view of the whole healthcare system. It is inherently difficult for a doctor, trained to do what is best for individual patients, also to think in terms of what works for the whole medical system. These are two different casts of mind and disciplines of thinking. But the soundness of the medical system makes a big difference to the overall healthcare outcomes of the country. Doctors need to understand this, to appreciate what the constraints are, and how their own contribution fits into the whole. Only then will the whole system work well.

The US is an example of a country with many excellent doctors, but a healthcare system that has major shortcomings. Despite spending enormous sums each year, the US healthcare system is plagued by bad practices like over-servicing and defensive medicine, and poor outcomes in terms of coverage, life expectancy, etc. In Singapore, our doctors need to understand how our system works – the 3Ms financing framework, the restructured hospitals, subsidies and means testing, etc. Not every doctor needs to be an expert in our healthcare system, but doctors need to appreciate enough to operate within it, so as to keep healthcare costs under control and to benefit the greatest number of patients.

Fifth, and most importantly, doctors must value the human relationship between doctor and patient. The mission of a doctor is not simply to heal illnesses but also to treat patients. This requires respect and empathy for your patients and their families. You must not only treat the physical ailments, but also lend a sympathetic ear to your patients and respond to their need for reassurance and emotional support. 

This profoundly human relationship is why I enjoy hearing doctors talk about their experiences, and reading their accounts of memorable cases they had treated. These stories do not always end with the patient getting well and living happily ever after, because in reality medical science has its limits, and so do doctors. But the stories are often heart-warming, telling how people can harness the accumulated scientific and medical knowledge of humanity to help others in need, how the doctors see not just a disease, but the lives and families of their patients, and how patients find human dignity, hope, and joy even when faced with dire illness or death.

Medical schools have the enormous task of preparing future doctors for this challenging profession. Equipping students with the requisite medical knowledge is itself an arduous undertaking, but it is not enough. Students must also learn to operate under stressful medical settings, and most of all, imbibe a deep sense of humanity and compassion.

In the old days, cadaveric dissection was an important rite of passage for medical students. Many students found handling and dissecting a dead body for the first time an upsetting and emotionally draining experience. After the first dissection class, they could be spotted in King Edward Hall, looking slightly shell-shocked, off their food, and needing some time to recover. But this experience also forced them to confront the reality of mortality and helped them to comprehend their future duty as doctors who would hold life and death in their hands.

Nowadays, with many new things to teach, many medical schools have dropped cadaveric dissection. Instead, they use computer simulation. Students can wield a virtual scalpel to a virtual cadaver, peeling away layer by layer, piece by piece. Even the nerves and vessels can be properly colour-coded. Or students can access the “Visible Human Project” on the internet, and view cross-sections of the entire human body, in high resolution and full colour, slice by slice, millimetre by millimetre. There is no blood, no smell, and no messiness, but also no emotional engagement. 

Old-timers worry that we have lost something important along the way. I recently read an article¹ by a US doctor, lamenting this loss of a valuable tool for future doctors to learn about humanity and the emotional strains of doctoring. As she pointed out, “we learn to heal the living by first dismantling the dead.”

I shared the article with the Ministry of Health and asked what our medical school was now doing. The Director of Medical Services told me that our practice too had changed, and that bodies are now dissected for the students, and a single body is used to teach eight students at one time. I accepted this explanation. As we update our medical school curriculum to include all the new knowledge and skills that students must absorb, something has to give. Our future doctors must still learn about the human and emotional aspects of doctoring, and will have to do so in other ways, as they progress through medical school and beyond.

I am confident that our medical profession will continue to nurture morally upright doctors, who are committed to their patients and selfless in serving the public interest. Do your best, professionally, ethically, and as a compassionate human being, in your chosen vocation. Then we can keep on raising our standards of medical care, and improving the lives of all Singaporeans.

[1] “Dead Body of Knowledge” by Christine Montross, NYT March 26, 2009.