The Singapore Medical Association (SMA) has had forty years of existence and in that period, 22 Presidents guided its destiny. Table 1 shows the names and the terms that they served. It would be illuminating to capture the views and perspectives of these Presidents for this Commemorative Issue. Letters were thus sent to living Presidents to ask them to recall the issues and controversies (if any) that happened during their terms of office. They were also asked to comment on what do they see as the role that the SMA could play in the future. Five past Presidents gave written submissions and six were interviewed.

THE EARLY YEARS (1959 - 1969)

There were ten Presidents in the first decade of thc SMA’s existence. Dr Robert Loh was interviewed and Dr Arthur Lim gave a written submission. The SMA started with a very small office which gradually expanded. As a professional organisation, the SMA had to relate to various organisations. The early years were also a period of the "firsts". The First National Medical Convention, the First Issue of the Newsletter and the First Issue of the Singapore Medical Journal (SMJ) are examples.

Independent Body

Dr Robert Loh: "I was President of the 5th Council and held office from 1964 to 1965. The SMA was founded in 1959 as an independent medical body from the BMA Malayan Branch. The latter continued as the Alumni Association.

"In 1964, Singapore was still part of Malaysia. Discussion was underway for the SMA to be part of the Malaysian Medical Association. The Constitution had to be amended to reflect that. A meeting was held in Johore Bahru to discuss the details and this was attended by some 70 members.

"The inaugural meeting of the Malaysian Medical Association was scheduled to be held on 27 August 1965. This did not materialise because Singapore left Malaysia on 9 August 1965 and became an independent sovereign nation. The professional relationship between the Singaporean doctors and the Malaysian doctors nevertheless remained warm to this day."

Relationship With Ministry of Health

Dr Robert Loh: "The cholera epidemic in Singapore created some differences with the Ministry of Health (MOH). The latter wanted to publicise the names and clinics of doctors who participated in the anti-cholera campaign. The SMA felt advertising was against the ethics of the profession and declined the offer for its members to be publicised. This angered the MOH at that time."

The SMA Secretariat

Dr Arthur Lim SM: "SMA was very active when I was President and as President for three terms there was a lot of activities during my tenure. Dr Thambipillai (who was elected President for the term 1967 - 8) was dying from leukemia and as President-Elect I was doing his work.

"When I took over, there was only a part-time clerk (Mr Chee) working 2 hours for two afternoons with a small desk in a small room. There were hardly any activities. He was there just to help the Honorary Secretary and President type some letters and there were some sort of filing system.

"The first decision was to strengthen the infrastructure (of the SMA Secretariat) with a proper office. This would need an increase in subscription fee which was not an easy task. Many eminent members and leaders of the day helped in the debate and they included Dr Gwee Ah Leng, Dr Yahya Cohen, Dr Un Hon Hing and particularly Dr Chee Phui Hung. They were convinced that it was important to restructure the SMA.

"The Alumni Centre was renovated and this increased our office space by almost 10 times and for the first time we had our own SMA Conference room and secretariat of three. Subscription was also increased and membership during this period was doubled and reached a thousand."

The First National Medical Convention

Dr Arthur Lim SM: "The First National Medical Convention was held in 1967 at the Singapore Trade Union Congress Hall. It was very successful. The Minister for Health, Mr Yong Nyuk Lin, was the guest of honour. The two major themes highlighted were Occupational Health, which had become more and more important with the increased tempo of industrialisation, and Cancer, which has become one of the two major threats to life in Singapore."

Dispensing

Dr Arthur Lim SM: "Dispensing became a major issue as there was a move by the pharmacists to take over dispensing from doctors. As I know little about dispensing, Dr John Chong was elected to represent SMA but Dr Gwee Ah Leng insisted that I should be the representative as he thought that this would be political and we would be up against 10 Ministry of Health officers, dispensers and pharmacists. It was interesting because I had to read over 10 books and met numerous doctors about dispensing as I did not do dispensing and knew little about this. We were fortunate that due to the help from all doctors t we won the dispensing issue. This was one of the major issues facing doctors."

Abortion

Dr Arthur Lim SM: "We were criticised by Health Minister Chua Sian Chin for not coming out with a ‘Learned Support’. There was considerable argument and debate because we felt that abortion was a serious criminal offence. If a patient dies because of abortion it was considered murder and doctors for centuries have been taught that abortion was wrong. In fact it was good that doctors resisted that because people who had been brought up in a way of thinking should not completely change their mind too rapidly because of social needs. I think at the moment most doctors are convinced that abortion has value, although there are still Catholics and some doctors for special reasons are not in favour of abortion."

The Military

Dr Arthur Lim SM: "When the British forces withdrew in 1965, Dr Goh Keng Swee with his officers wanted volunteers. As President I had numerous meetings and called the doctors up on the basis that the Singapore Armed Forces required doctors. If we did not volunteer, laws will be passed to conscript us. So rather than be forced into the military, 14 doctors volunteered and the first batch was commissioned in 1970."

General Practice and Specialties

Dr Arthur Lim SM: "During this time there was great interest in the development of specialties including general practice. SMA was the vehicle where approximately 20 specialty societies linked up with us. As an interim arrangement, in the beginning they were with us as it would save costs because we had a secretariat, but as soon as they can go on their own they were encouraged to move on. This was so also with the College of General Practitioners, Singapore."

Medic Awas

Dr Arthur Lim SM: "Medic Awas, a medical alert started by SMA as a contribution to society, was formed to alert people who were allergic to penicillin or other drugs. Dr Oon Chong Lin was in-charge."

Unemployment

Dr Arthur Lim SM: "There was also unemployment of doctors and for the first time in history there was a cut in the number of doctors employed in the civil service. As a result, 20 doctors could not find employment and SMA was involved in getting employment either within Singapore or outside Singapore for these doctors. We held a number of meetings regarding this."

Ethics

Dr Arthur Lim SM: "A Committee consisting of Drs Gwee Ah Leng, Tan Joo Liang and myself was formed to revise the SMA Ethical Code. We held a number of forums on Ethics. The Ethical Code was re-written mainly by Dr Gwee and Dr Tan."


THE SECOND TEN YEARS (1970 - 1979)

The SMA had seven Presidents in the second ten years. Besides Dr Arthur Lim, Dr Koh Eng Kheng gave a written submission. Drs Choo Jim Eng and Mah Guan Kong were interviewed. The SMA China Trip remained a memorable event for those who went. Singapore in the 1970s dealt with drug abuse and drug labelling. Discussion on the Private Hospitals and Medical Clinics Bill was initiated towards the end of the decade.

SMA Visited China

Dr Koh EK: "One of the first things I did on assuming office was to ask what I could do for our members. It was suggested that many of our members wanted cheap air tickets to visit abroad. At that one Caledonian airways offered up to 50% off their regular fares if professional bodies travelled in a group. We decided to take advantage of this offer.

"I set around to enquire which was their first destination choice and was quite surprised to hear that this was the People’s Republic of China. The oncoming visit of President Nixon to China plus all the media attention on this and Chinese acupuncture made our doctors curious to know what went on behind the bamboo curtain in Chinese medicine.

"Accordingly I wrote to the Chinese Medical Association informing them of our wish to see medicine as practiced in the PRC. I was even more surprised to receive a letter in English welcoming us to the country. I had not realised then that as Singapore did not have formal relations with China we had first to seek permission from the Singapore Government. It was not a simple pack up your bags and go affair. We received permission from the Government provided it was to be a purely professional visit to see the medical situation in that country.

"As the visit was necessarily a low key affair with no media publicity we decided to pick members of the team by ballot from the many applicants we had. This exercise so infuriated some of our members that we were accused of not being transparent in our balloting procedures.

"The SMA medical team consisting of twenty doctors arrived in Beijing on a cold April night in 1972. The Chinese reception of our team was an unforgettable experience. The Chinese doctors and government officials lined up in the cold alongside a long red carpet. This was to be no ordinary welcome. They had rolled out the same red carpet that had been used to welcome President Nixon to China just two months earlier.

"Not being used to being a VIP and fussed over I must have looked more like Charlie Chaplin come to town with my hat, handbag and umbrella. The inappropriateness of my attire struck me and I quickly turned round to my colleague behind me and plonked my personal bric-a-brac into his arms. This freed my own to shake the outstretched hands of those who were waiting in line to welcome us. My personal batman happened to be none other than a senior physician from SGH and I daresay he was not pleased nor amused to be my man Friday.

"This warm welcome was accorded to us throughout the trip. On one occasion they even closed an MRT station and provided us a train ride from one end of Beijing to another. We even merited several paragraphs in the People’s Daily, a notable event considering the fact at that time as a one sheet newspaper.

"What I did not realise then was that this was the first occasion that the Chinese government had recognised the existence of Singapore as a sovereign independent state. Before this they had always regarded us as an appendage of Malaysia with all the historical baggage. Although other groups from Singapore had previously visited China before, they had always been regarded as Overseas-Chinese trade missions and were accommodated in local hotels. We were the first to gain international status in their eyes and stayed in luxurious international hotels.

"After our enjoyable and successful trip marked by a great deal of mao-tai being tossed down by ourselves and our hosts, we came home suitably impressed by the hospitality of our Chinese colleagues. Their success with acupuncture anaesthesia also opened a window into their world. And so when it was time some months later to return the lavish hospitality to members of a Chinese badminton team visiting Singapore we were non-plussed as to how to get about this. Our problem was solved when the Singapore government kindly invited us to use the Istana. We were awed. Since the Singapore government at that time had no bilateral ties with the PRC it was appropriate for the SMA to play hosts. We did our best, both willingly and happily. It was an evening enjoyed by everyone who were present. In turn some of our Government ministers were invited to visit China. The rest of course is history. The ties between the two countries have been friendly and strong from that time since. It was a little niche in history, one I am glad to have done my little bit for my country and the SMA was richer for the experience."

Relationship With The Government

Dr Choo JE: "It was the experience then that the Guest-of-Honour at SMA functions would give the profession a pasting. During my time as President it was easier. I was on friendly terms with the DMS and DDMS. I know the Minister Dr Toh Chin Chye from Raffles College days. Relationship became so good that we were able to come together on a lot of issues."

Drug Addiction

Dr Mah GK: "Drug addiction hit Singapore in the 1970s. In the initial stages, the SMA was actively involved in cooperation with the Central Narcotic Bureau in the founding of 140the Singapore Anti-Narcotics Association (SANA). A large number of doctors spent their time to give talks to the public on the dangers of drug addiction and the need to control that. By the time I was President, we had done our work to warn Singaporeans of the dangers. The drug addiction programme moved into the rehabilitative phase which comes under the direct purview of SANA."

Labelling of Medicines

Dr Mah GK: "Another forgotten issue is the labelling of medicines. This was discussed in the 1970s. At first many doctors had reservations and the profession was evenly split. Nevertheless, we cooperated with the Ministry because we felt there were positive points. The labelling of medicines made it easy for the next doctor attending to the patient to know what medications the patient had been taking."

Changes in the SMA Constitution

Dr Choo JE: "During my term as President in 1974 - 5, there were changes made to the SMA Constitution. Until then, there was a President Elect, who assumed position as President in the following year. The President-Elect’s position became the Vice President. Each President could serve consecutively for three one-year terms. After a lapse of one year, he could put himself up for election again.

"All ordinary members were elected at the AGM and they held office for two years. Three members of the Council would retire each year and three new Council members would be elected to fill their vacant posts for a term of two years."

Dr Low LP: "My term as President came much later (1981 - 2) but to add to the changes in the SMA Constitution, what Dr Choo said was a milestone. The next milestone was some time later when Dr Khoo Chong Yew was President. Both and he and I looked into the process of election. Until then, the Council members were elected at the AGM. We introduced the concept of nominating members to the incoming Council and having the election at the AGM if there were more candidates than vacancies. The Council was also enlarged by having a Second Vice-President and Asst Hon Secretary.

The Private Hospital and Medical Clinics Bill

Dr Mah GK: "An Extraordinary General Meeting was held to discuss the Private Hospitals and Medical Clinics Bill. Following the meeting, a delegation met the then Minister for Health, Dr Toh Chin Chye to present the views of the House. Agreement was reached on several issues which were subsequently mentioned by the Minister in the second reading of the Bill in Parliament. I am pleased to note that in the final Act which was passed, the provisions we suggested which governed confidentiality of doctors and their patients, the need to give reasons for evocation or suspension of licence and the right of appeal to the Singapore Medical Council in the case of the registered medical practitioner were included."

THE THIRD TEN YEARS (1980 - 1990)

There were four Past Presidents in the third decade: Drs NK Yong, Low Lip Ping, Khoo Chong Yew and Wilmot Rasanayagam. Dr Khoo and Dr Rasanayagam sent written submissions. The rest were interviewed. Singapore in the early 1980s was about to embark on the privatisation of health care. The Blue Paper on the National Health Plan was released in 1983. Not unexpectedly, quite a bit of the energy of the Presidents of the day was focussed on Guideline on Fees, Privatisation and Advertising. An appraisal of the problems of the GPs was also made.

Relationship with Ministry of Health

Dr NK Yong: "In the 1980s when I took over, the SMA was looked upon by the MOH with some suspicion. Some officials had the view that private doctors were out for a quick buck. I therefore found the relationship with MOH sometimes frustrating. Nevertheless, there was steady improvement of the SMA-MOH relationship over the years."

Dr Low LP: "The relationship between government and profession should not be seen as with the doctors only but in the context of the attitude of government’s philosophy and this extended to every aspect of life. The first generation government leaders decided what was good for the country and not just the medical profession. The second generation of government leaders had a general change of attitude to be more participative both in ideas and execution of policies."

Rise of the Private Sector

Dr Low LP: "Until the 1970s, most of the doctors in private practice were primary care physicians. It was around the mid-1970s that the Government realised the private sector was growing to be important and more attention needed to be paid to this sector."

Private Hospitals

Low LP: "Up to the early 1980s, the private hospital’s role was to serve the multinational corporations. The notion of a for-profit hospital only came later. These latter hospitals wanted to promote their services and opened up issues of advertising."

Public Health Education

Dr Low LP: "Another area is the role of the medical association in public education. Until the 1980s the SMA Medical Conventions were confined to the medical profession. One of the first meetings for the audience outside the profession was in the Hyatt Hotel. It was the best convention I had ever attended. There was standing room only. There is a duty of the SMA to educate the public."

APMPS

Dr Choo JE: "The idea of Association of Private Medical Practitioners, Singapore (APMPS) as an independent body as the successor of the Society of Private Practice (SPP) was mooted during my term of office. The SPP was an affiliate society of the SMA. My impression was that it was a question of finances. The SPP wanted to have control of the money it raised."

Dr Low LP: "The story was more than that. In one of the editorials of the newsletter of SPP, the SMA Council did not quite agree with the Editorial Board of the SPP and took it to task. The private practitioners wanted then to be autonomous to be able to decide what they wanted to say. The APMPS was formed in 1981 and existed till 1994."

Dr Cheong PY: "It was during Dr Tan Kok Soo’s time as President that it was mooted for APMPS to merge into the SMA since many of its office bearers were in the SMA Council. The merge was completed in 1994/5 and APMPS was wound down as an organisation. It had achieved its purpose of giving a voice to the private sector."

Issues in the Mid 1980s

Dr Khoo CY: "I was President for two terms of office from 1985 - 1987. There were many issues that were dealt with, namely,

* Establishment of the Guideline on Fees for doctors in private practice. It was adopted at an EOGM on 12 October 1986.

Extension of Medisave scheme to private hospitals.

* Privatisation of NUH and SGH.

* The term "Re-structuring" was then coined.

* Catastrophic Illness Insurance Scheme.

* Provision of guidelines for advertisements by hospitals of health care services. An appraisal of general practitioners’ problems.

A 37-page Report on "Primary Health Care in Singapore" was completed by the SMA Ad-hoc Committee on General Practice, under the chairmanship of Dr Patrick Kee.

* Implementation of the law for labelling drugs.

* Opting-out for organ donation.

* National Drug Registration.

* Guidelines for Continuing Medical Education and "Recertification".

* Setting up of Hospital Standards.

* Discussion of the role of traditional medicine in Singapore.

* Warning of excess supply of doctors.

* Complaints of high HDB rental for clinic space.

* The effects of clustering of GP clinics.

* The issues related to examination of female patients.

* Answering emergency calls.

* Drive to encourage volunteering for SMA activities and 70 members volunteered Increase in activity on Public Health Education.

* The issue of photographs of doctors in the press, and

* The issue of discounts given by laboratories to doctors.

Closer Rapport

Dr Khoo CY: "During my two terms of office, I made a special effort for closer rapport with members through three channels:

* "The President’s memo", a fortnightly letter to members with a detachable slip for their comments. "This was an effective way of sampling member’s view on any topic and replies reached me within 2 - 3 days."

* "Highlights of Council Meeting" published in the SMA Newsletter.

* "The President’s Column", published in the SMA Newsletter.

"I also departed from the usual practice by having a President’s Message at the beginning of the Annual Report. There were frequent communications between SMA and MOH on many matters during my term of office and subsequently. It is important to maintain this close relationship.

"A closer rapport with the Singapore Medical Council was also important. During my term of office, I represented SMA on SMC’s Co-ordinating Committee for Specialists’ Registration, and the Committee for CME, which set out the guidelines for requirements for CME.

"A closer rapport with the community was achieved through:

* Public health education. For the first time, the National Convention was opened to public participation in 1985.

* Community Service by doctors. Members were encouraged to participate.

"During my term of office, my Council had a meeting with the Government’s Feedback Unit on Health Care Issues, and asked for a schedule of regular meetings."

THE FOURTH TEN YEARS (1990 - 1999)

The Presidents in this decade were Drs Wilmot R Rasanayagam, Giam Choo Keong, Tan Kok Soo and the incumbent President is Dr Cheong Pak Yean. Drs Rasanayagam and Giam gave a written submission. The rest were interviewed.

The experience of privatisation since the 1980s showed that the "free market forces" paradigm needed to be moderated if it were not to lead to runaway health care costs. Patients may confuse needs with wants. The need for affordable health care and how to achieve that was noted by the Government and the Government paper on "Affordable Health Care" reflected that sentiment. The low consultation fees of the general practitioner continued to be a problem.

GP Fees

Dr W R Rasanayagam: "When I was President in 1989 I spoke about GP Fees. The General Practitioners were charging very low fees with the aim of seeing many patients and of seeing them fast."

"For many, in depth consultation was not possible and the haste allowed little time for health education or advice on prevention. To raise the level of medical care and commitment to the patient, it is necessary to charge an adequate consultation fee. Only then can the present system lead to the development of personalised medical care for all patients. My attempts to suggest this were criticised and resisted in the newspapers."

Issues In The Early 1990s

Dr Giam CK: "In the two years that I was SMA President from 1991 to 1993, my Council had to deal with various issues and controversies. There were five that I regard as more significant:

* Relationship with the press, SMA members, Government and general public;

* Retaining existing SMA Members and attracting new members;

* SMA Guideline of Fees and Display of Charges;

* The 1991 MOH Review Committee on National Health Policies; and

* the NTUC Pre-paid Healthcare Plan and Health Maintenance Organisations (HMOs).

"My first year as President (1991 - 2) was pre-occupied with improving the SMA’s relationship with its members, the general public, news media and government bodies such as the Ministry of Health (MOH) and Singapore Medical Council (SMC). This was partly due to controversies on doctor’s fees generated during my predecessor (Dr Rasanayagam)’s term of office."

The Press

Dr Giam CK: "In Jun and Jul 1991, the English language press in Singapore openly castigated the medical profession and the SMA. This arose from the response that the SMA made within 48 hours of a 27 Jun 1991 Straits Times (ST) report on a doctor (not an SMA member) who had allegedly refused to attend to a serious road traffic casualty victim near his clinic in Katong. The ST and Sunday Times (Sun T) then wrote editorials and published several letters and comments from the general public condemning this doctor for his behaviour and criticising the SMA for not identifying the doctor and taking disciplinary action against him."

"The ST and Sun T did not agree to the SMA’s request to publish, without editing, its reasons for not identifying or condemning this doctor (as the case was then being investigated by the SMC) and to explain why the SMA does not have disciplinary powers as the SMC has."

"Thru the SMA Newsletter, I circulated a 5-page detailed President’s Column titled ‘Innocent until proven guilty and not guilty until proven innocent’ to not only SMA members but also to all members of SMC, Cabinet ministers, Members of Parliament, Directors of Singapore Press Holdings and Chief editors of all local news media, editors and journalists who reported on this case."

"Subsequently, I received replies or responses from Senior Minister, Minister for Health, Minister for Information and the Arts, and other MPs. Some indicated neutral or no views but none indicated they disagreed with the views I expressed in my President’s Column.

"The only disagreement came from an Associate Editor of the Straits Times who defended his paper’s stand in a 3-plus page letter. This was reproduced unedited in the SMA Newsletter. Perhaps it was coincidental that subsequent to these SMA actions, the newspaper discontinued its criticism of the SMA and the medical profession!."

Retaining and Attracting Members

Dr Giam CK: "To attract new members, the following initiatives were launched or revived... A Forum Page in the SMA Newsletter, the President’s Column, free associate membership to medical students in their final year and complimentary issues of the SMA Newsletter, Introduction of the SMA Membership Identification Card, SMA-UOB Gold Credit Card and the SMA Discount Scheme to enhance membership value."

SMA Guideline on Fees and Display of Charges

Dr Giam CK: "For several months, the SMA and the APMPS worked on a standard tent-card to display the basic consultation charges based on the SMA Guideline of Fees for Doctors in Private Practice. This tent-card, to be displayed only in the doctors’s clinic to inform the doctor’s own patients, was issued on 7 Oct 91. On 22 Oct 91, the MOH announced that all doctors were required to display their charges and agreed that this tent-card could be used for such purposes.

"After five years of extensive study and feedback from doctors from the SMA, APMPS and other specialist organisations, the Second Edition of the SMA Guideline on Fees was released in Nov 92. It listed 1,839 items of medical consultations, procedures and operations."

The 1991 MOH Review Committee on National Health Policies

Dr Giam CK: "The SMA submitted a 34-page submission to the Review Committee on National Health Policies. This was based on the work of Adhoc committees on Healthcare Financing, Undergraduate and Postgraduate Training, Medical Specialisation and Subspecialisation, Family Medicine and Role of the Private and Public Sectors. Many of the SMA’s recommendations were subsequently included in the 72-page Report of the MOH Review Committee."

NTUC Pre-Paid Healthcare Plan and Health Maintenance Organisations (HMOs)

Dr Giam CK: "An Adhoc Working Committee on Managed Healthcare (MHC) was established in Nov 92 to focus on issues of rising healthcare costs in Singapore, MHC in general and the proposed NTUC plan in particular. During my meetings with NTUC and MOH representatives, I advised caution and reservation about Singapore adopting the HMO system in the USA as there was sufficient feedback by then from US doctors and patients that their system often did not benefit them although it benefited HMOs and employers. Details of the NTUC plan were still not available when my term as President ended. As such, the then SMA Council just reiterated its stand that ‘It supports any scheme which reduces healthcare costs provided there is no compromise to the professional integrity of doctors to provide good basic standards of medical care to all patients regardless of socio-economic background and that it does not put the doctor in conflict with the SMA Ethical Code."’

The Next Three Years

Dr Tan KS: "I was President for three terms from 1993 - 1996. The following were milestones during my terms of office:

* Spearheaded a series of lectures on setting up of private practice.

* Initiated a committee to look into issues relating to Fitness to Drive.

* Participated in the Committee set up to look into the issue of Traditional Chinese Medicine. The Committee decided that Traditional Chinese Medicine is a from of Alternative Medicine and not complimentary to Western Medicine as practised in Singapore.

* Liberalisation of advertising guidelines for medical doctors in Singapore.

* Formation of the SMA Membership Committee which led to the publication of the SMA Membership Directory.

* Formation of the MO Committee to give a forum for younger doctors in SMA.

* The SMA Council, Ethics Committee and Ethical Issues & Policies Review Committee submitted a SMA consensus paper on the proposed of "Living Will", legislation to the National Medical Ethics Committee of the MOH on 22 Sep 94.

* APMPS was dissolved and joint APMPS-SMA activities took shape."

Caning of Michael Fay

Dr Tan KS: "The caning of Michael Fay attracted some attention. An ethical issue was raised concerning whether or not it is right for doctors to participate in such cases like caning, hanging and even lethal injection (though not likely in Singapore). SMA was bombarded with letters from foreign medical associations, especially the American Medical Association, which was none too pleased with SMA’s stand that it is alright for doctors to participate in the pre and post-caning examination of accused.

"In my letter to the American Medical Association I said: ‘The Singapore Medical Association takes the ethical code of the medical profession very seriously. We have no difficulties adhering to the provisions in Singapore laws concerning crime and punishment. These laws, which include caning and death penalty for certain criminal offences, reflect Singapore’s own set of social standard and order. It is because of our tough laws that we are able to keep Singapore orderly and relatively crime free. As doctors, we are indeed glad that Singapore’s approach to crime and punishment helps to preserve life and quality of life for the majority of law-abiding citizens and residents, unlike the situation in many cities in the US, where people, including children, are injured, maimed or killed by criminals at an alarming rate. We believe that prevention is better than cure and that the interests and concern of the victim are more important than those of the criminals."’

The Immediate Past Three Years

Dr Cheong PY: "Apart from the usual operational matters that occupied our time, the following were the significant issues that were dealt with by my Council.

* The membership of SMA has increased over the last 3 years from 2,880 (62% of all doctors) in 1996 to 3,387 (66%) in 1999. The accumulated funds have also grown from about $1.09 million to $1.60 million.

* The Ministry of Health in 1997 agreed that SMA acts as a channel of feedback on medical advertisement, provide a consultancy service in accordance with the Guideline on medical advertisement and publish a directory of all licensed healthcare establishment for the public. The President represented the profession in the Inter-ministerial committee for Healthcare for the Elderly and the Medicine Advisory Committee.

* There is increased dialogue with the Singapore Medical Council. The SMA was consulted in relation to aspects of the new Medical Registration Act and the compulsory voting for SMC council members. Some cases concerning professional conduct of doctors are also referred by SMC to the SMA Ethics Committee.

* The SMA adopted a policy in 1996 that it will leave the appropriate academic bodies to conduct continuing medical education other than those pertaining to ethical and professional matters which SMA would continue to provide.

* The SMA was a founder member of the Inter-professional Presidents’ Group (IPPG) in 1997 comprising Presidents of professional associations of accountants, architects, engineers, lawyers, surveyors and doctors. The IPPG organised the annual Inter-professional games as well as various seminars on professional matters. The SMA withdrew from membership of the Singapore Professional Centre in 1996.

* SMA assumed the position of Secretariat of MASEAN, the Medical Association of South East Asian Nations in 1996 and developed close ties with medical associations in ASEAN countries, especially that in Indonesia, Malaysia and Myanmar.

* SMA gave evidence at the Parliamentary "Select Committee on Verification of Health care Subsidy of Government Polyclinics and Public Hospitals" in Jul 1996.

* The claim of the Pharmaceutical Society of Singapore of ‘pharmacists as minor ailment doctors’ was highlighted by the Press in Dec 1997. SMA publicly refuted the basis of this claim.

* A new committee, the Ethical and Policy Review Committee was set up. The first annual Ethics Convention was organised in 1997 and the first formal ethics course for doctors in 1998. It has recommended the formation of the SMA Centre for Ethics and professionalism to spearhead such activities.

* The procedures for handling complaints against doctors by the SMA Ethics Committee were published in 1996. The Ethics Committee also issued advisory statements on ethical issues such as the practice of traditional medicine by registered medical practitioners (RMP), referral by non-RMP to radiologists and the examination of the breast and chest of female patients.

* The SMA Council adopted a landmark resolution against ‘profit guarantees’ pledged by doctors to commercial concerns in May 1997. The Singapore Medical Council and the Ministry of Health subsequently reaffirmed the ethical principles of this resolution.

* The Singapore Medical Journal (SMJ) which used to be published every two months and the monthly SMA-News were combined into the new monthly SMJ in Jan 1997. The monthly circulation has doubled to 6000 copies and it is now more widely circulated in ASEAN countries. The SMA On-line on the Internet was launched in 1997 with full-length articles of SMJ.

* The Guidelines of Consultation Fees are now extended to include time-based consultations and after usual office hours consultations. A guideline for price of medicine dispensed from the clinic dispensary was also published in Nov 1998."

THE FUTURE ROLE OF THE SMA

Contribution To The Affairs Of The Nation

Dr Robert Loh: "My chairmanship was in an association in its infant years. Singapore had just become independent. Over the years, the Singapore Medical Association has contributed quite a bit. My wish is that it will grow in stature and play a part in the affairs of our nation. The regulation of practice by the SMA as a professional body is important. There is a need for the membership to see self-regulation for their own good as well as for the image of the profession in Singapore."

Dr Choo JE: "A more specific question in the future is how SMA will make itself relevant for members, the public and the Government."

Dr NK Yong: "Perhaps the single most important achievement during my terms of office was to develop the Association to speak up whenever we feel necessary. This was what I set out to do as President. I believe that example has been followed by subsequent presidents. It has been a slow process in trying to make the Association relevant. I felt like a general without troops. The Council and I did not have the backing of the profession on crucial matters.

"The issue of fees was a good example. The need for itemisation of the GP’s fees into professional services and medicines was accepted and passed at the AGM. Yet, when it came to implementation, GPs were reluctant to follow the guidelines of a separate consultation fee. Today, twenty years on, the idea of a consultation fee for the GP is slowly taking root but it still needs to be pursued. Laboratory fees and contract practice are two other areas that need guidelines."

Dr Arthur Lim SM: "I think SMA is going to be very important in the 21st century. This is mainly because the billion dollar health crisis and governments paying attention to the cost of health services."

Professional Stand

Dr NK Yong: "The SMA is a professional body. It needs to play the roles of advocacy, monitoring and collegiate role. It needs to make a professional stand on important matters. The stand on profit guarantees is an example. I congratulate the present Council for the stand they took."

Constitution of the SMA

Dr Giam CK: "Perhaps considerations could be made to amend the Constitution again so that there is a President, a President Elect and Past President. There should be a 2-year term for each of these office holders because my experience is that a 1-year term is too short for any President to be effective or for a President Elect to prepare sufficiently for the presidency. After serving their 2 years as Past President, all past presidents should leave the SMA Council to make way for new and hopefully younger blood. To ensure that the experience and expertise of past presidents continue to be tapped, all past presidents should be invited to be members of an advisory ‘SMA Council of Elders’ whose opinions and advice on all important matters should be sought by the incumbent SMA President and Council. Such opinion and advice should be seriously considered but should not be binding."

Dr Low LP: "When we look at the influence of medical bodies on government and Ministry of Health policies, the Academy of Medicine is more potent. People who form the Council of AM are more senior and MOH will look to them for advice. The Council of the SMA is elected every year. There is a need to look at this aspect of introduction of proportional representation so that more senior representatives on the Council is not left to chance. By chance, it may be possible now to have a council made up of office bearers who graduated in the last two or three years."

Proactive Role

Dr Low LP: "One future role of the SMA is to take on a more proactive role. Presently, it is more reactive. The day-to-day issues occupy its Council’s time. It has not taken a more helicopter view, say over the next 5 - 10 years. What will be the issues that could be anticipated? There is a place for groups of people to form think tanks on Singapore in the next 5 years, for example. Such people can provide directions for the SMA to take in the future. Of course such activities need funds. The SMA could made known its intentions and seek funds from organisations to do such work."

Medical Care Financing

Dr Mah GK: "It is important for the SMA to study the operations of Health Maintenance Organisations (HMOs) in Singapore - what are its weaknesses and strengths. It can then make representations to the government on relevant aspects, particularly medical ones. For example, the decision of a HMO to restrict payment for Hormone Replacement Therapy (HRT) to only patients who have osteoporotic fractures. What about HRT in preventing these fractures?

"There is also a need for SMA to have a considered stand on medical insurance in medical care. It needs to study the terms of coverage and payment and define what constitutes an illness. For example, in some illnesses, it is more practical to admit the patient for a work-up and then discharge the patient to be built up to be fit for operation. Is this one or two illnesses? Shall we be considering a listing on the percentage of wine of HMOs that can be used for alternative purposes? Having studied and considered such issues, it can make its stand. Granted that such issues may be politically sensitive but they need to be sorted out."

Dr W Rasanayagam: "I would like to see enough remuneration for the general practitioner in order that he does not to have to be always in haste. He can then practise a higher level of service by having time for a more in-depth consultation where necessary as well as enough time to provide advice and health education. I would also encourage doctors to develop a family type practice with good follow-up care."

Dr Cheong PY: "Issues related to health care financing need to be studied and appropriate stands made by the SMA. A recent development is case mix funding. This should be seen in the context of health care financing, how and where subsidies go and how doctors are paid to produce the best cost effective care."

Team Work

Dr Cheong PY: "Health care delivery has become more complex. There are different specialists, the GPs and other health care professionals. All things have to be defined. For instance, there was the issue in the last year that pharmacists wanted to practise minor illness dispensing. The SMA after discussion with its Council members defined the role of the pharmacist vis-a-vis the doctor. The SMA needs to make such stands."

Training of the Future Doctor

Dr Mah GK: "It is important that the content of training reflects what the doctor will meet in practice. There is always need for the primary care doctor to be trained well and sharp to be able to pick up not which of the five types of coarctation but to pick the patient who may have coarctation and put the patient to the right path to seek attention from the appropriate specialist."

Dr Low LP: "Medical education is still by and large based on hospital medicine and taught by doctors who practice in a tertiary care setting and who do not know what it is like to be primary care doctors. It must be pointed out that it is not only the content and context that needs to be considered but also the organisation of teaching by teachers. The SMA used to have a representative on the Curriculum Committee of the Faculty of Medicine. It is important that this is continued so that the profession can provide an input and give its views."

Back To Basics

Dr Khoo CY: "It is important to get back to basics - closer rapport and maintenance of ethical standards. It is important to have a closer rapport with members and the world outside. Many of our members aspire to high ethical standards. We should continue to inspire our members with high ethical ideals. Although SMC is the disciplinary body, SMC’s bottom line is ‘infamous conduct’; SMA’s bottom line is high ethical conduct."

CONCLUSION

The conversation with the Past Presidents has provided an insight into the issues that the medical profession has to grapple with. Many of the issues are dynamic and ongoing such as the relationship with members and external bodies, ethical values and professional matters. Some may need periodic review such as Constitutional changes of the Association. 

ACKNOWLEDGEMENTS