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) 50th 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 Singapore.

We have faced some difficult healthcare 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, just in case. As the outbreak progressed, and we learnt more about the new virus, we gradually downgraded our responses. Now we are back to alert yellow. I think 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 continue to update and improve our contingency plans. We will have to address shortcomings, sharpen our procedures and restock our medical supplies – N95 masks, gowns, the whole lot. Pandemics are in general 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. So, happy birthday to SMA, and to all of you.

I am honoured and very happy to become an Honorary Member of the SMA. Despite what President said just now, 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 down in Teck Ghee. Indeed, in Britain such Meet-The-People sessions by Members of Parliament are called clinics. The residents come to see me, as 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 seek 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.

Firstly, 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 you, should I go low-carbo or high-carbo, will eating eggs damage my cholesterol levels. But these are the simple questions. Doctors have an even harder time keeping up with rapid medical advancements, but it is crucial that you do so, because when I am confused, I will ask you, and you cannot afford to be confused. And I will assume that you will provide me the best advice, and you are current and correct.

Secondly, doctors must always do what is best for your patient. The patient has the final say, but he relies heavily on you for advice. When I am in hospital and they send me a consent form, I just sign. After all you are my doctor, and you know much more about my condition and about medicine than I do. So patients always say “doctor’s orders”, and never “doctor’s advice”. If you tell a patient he needs an expensive drug or a risky procedure, and that this 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” – I was talking to your president just now, and he was telling me about it – 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. He has to depend on a doctor being capable, being honest, having his interest at heart. So your advice must always be honest, well-founded, and based on what the patient needs.

Of course, 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 take responsibility 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 at the same time, is through personal lifestyle changes. It is easier said than done, you can give advice, you can even prescribe medicine, but whether the patient takes your advice, swallows the medicine according to instructions, is not totally within your control. At Meet-The-People sessions MPs have to take the same approach. We help residents not just by petitioning government departments and mobilising resources for them, but also by advising residents to help themselves – please spend within their means, please find a job, please get along with in-laws under the same roof, and so, not having to apply for a separate HDB rental flat, 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 like me then, because often he could cure them completely, and they would go home well. There is a tremendous sense of satisfaction. 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, opposite attributes, to put yourself in your patient’s position, but to think rationally, coolly, without getting emotionally involved, and recommend what he would want for himself, if only he knew what you knew of medicine and his condition.

Thirdly, 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 ultimately undermine the reputation of the whole profession. And 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 good 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 charge a fee when they operate. In some medical disciplines, the financial rewards are substantial, especially disciplines involving intervention procedures. And increasingly, more disciplines nowadays involve intervention.

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 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. And in times of stress, like when there was SARS, and now with the flu, they stay on duty at personal danger, treating their patients. 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.

Fourthly, 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, for him to think at the same time in terms of what works for the whole medical system. These are two different casts of mind and two different disciplines of thinking. One focuses on the particular, what is in front of him, the immediate decision which needs to be taken. The other on the whole system, the tradeoffs, the broader considerations – what would work to have the biggest number of people to get the best medical care over a period of time. But doctors need this, because the soundness of the medical system makes a big difference to the overall healthcare outcomes of the country, and doctors have to appreciate how it works, what the constraints are, what the tradeoffs are, and how their own decisions affect the overall outcomes in the long term, and how their own contributions fit 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, and so on. In Singapore, our doctors need to understand how our system works – the 3Ms financing framework, the restructured hospitals, subsidies and means testing, step-down care, etc. Not every doctor needs to be an expert in our healthcare system, but all doctors need to appreciate enough to operate within it, so as to keep healthcare costs under control and to benefit the biggest number of patients.

Finally, 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, and 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. And fortunately, quite a number of good doctors write well, so when you combine a good writer with a good doctor, it is a joy to read. 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, and in distress, and 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, maybe wearing N95 masks, and much more, 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, coming face-to-face and at close quarters, an upsetting and emotionally draining experience. After the first dissection class, they could be spotted, in Singapore anyway, 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, or shortened the cadaveric dissection part of the course. Indeed, some anatomy departments have totally disappeared. Instead, they use computer simulation. You can wield a virtual scalpel, apply it to a virtual cadaver, peeling away layer by layer, piece by piece. In fact, you can have a virtual live person, and if you cut the wrong place, it will scream. Even the nerves and vessels can be properly colour-coded. You don’t have to rummage for it, you won’t cut it by mistake. 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 article 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 the author pointed out, she is a lady doctor, a resident in psychiatric, “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, who is here tonight, told me that our practice too had changed a little bit, and that bodies are now dissected for the students to show them, 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. So our future doctors must still learn about the human and emotional aspects of doctoring, but they will have to do so in other ways, as they progress through medical school and beyond in their careers.

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. The calligraphy which you generously presented to me applies equally to all of you. Then we can keep on raising our standards of medical care, and improving the lives of all Singaporeans. Thank you very much.