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HOW NOT TO "END UP" AS A GP of the most appropriate means to raise the status of GPs and optimally engineer our primary healthcare system hinges on GPs promoting themselves.

Not long ago, the NUS Medical Society organised a career forum for medical students. Doctors from private and restructured hospitals as well as staff from the Medicine Faculty spoke on the different academic qualifications and personal attributes required for advancement in the various fields of medicine. In addition, a spokesman from the Ministry of Health was invited to give an outline of the human resource projections for medical professionals for the coming years.

For me, the most interesting point of the evening came towards the end. Associate Professor Goh Lee Gan had just spoken on the career opportunities in family practice and it was time for the question-and-answer session. Since the medical students in NUS are mostly Singaporeans, the syndrome of situational lingual paralysis expectedly prevailed. For a few silent seconds all in the lecture theatre looked around to see who would throw the floodgates open. One of the speakers was obviously used to this sort of situation and decided to take matters into his own hands: "Since there are no questions, let me ask you a question." he said. "How many of you have decided to go into family practice?" After a short moment, some hands were seen going up. I counted less than 10. There were more than 150 in the lecture hall.

Our tutors periodically remind us that sixty percent of each class will "end up" as general practitioners. From the audience’s response at that meeting, it seemed like everyone thinks someone else will "end up" being constituted within that figure. One might ask, just how indicative of the general medical school cohort was the crowd at that event? Well, they were mostly M1 and M2s, the ones with the least clinical exposure. The optimist might say that the appeal of general practice grows with ward experience. But then again, how can that be, when more than ninety per cent of clinical teaching is conducted at tertiary medical centers? Thus, there seems only one reasonable conclusion: not many willingly choose to go into family practice.

Some regard this as a foregone conclusion, a no-brainer. But why should it be? What’s so wrong about being a GP? And what’s so right about being a specialist? Do most medical students want to be specialists because it is what they want, or because it is what they are expected to want? Are these questions worth considering? I believe so, for they not only tell of the culture of medical practice in Singapore, but also indicate to a large extent, the societal view of medical professionals here.

The two options are probably flip sides of the same coin. After all doctors do not practise in a vacuum; they must remain responsive to the needs and expectations of society. However it seems that many have forgotten their personal role in this equation _ the fact that they too can influence the views of society on the profession.

I have often wondered why so many people ask me "so what are you going to specialise in?" when they find out that I am a medical student. In my younger and needless to say, brasher days, I would answer "something that I can make a mistake in and the patient does not die immediately". Nowadays I know I can raise more eyebrows by saying "I intend to be a GP." Friends with no doubt good, though misguided intentions have argued: "Since you have slogged so hard already, why not continue to slog a little more and get the big bucks?"

Where do these friends of mine get the notion that it is "a waste" for a person with good grades in medical school to waste his mind on something as elementary as general practice. No doubt from their parents (I often hear the same rhetoric from older persons) and perhaps even from the GPs they encounter.

It is too tempting to think that such notions arise de novo, that they are the products of living in a materialistic society, where the need to obtain the 5Cs (I use this for lack of a better term) and keep up with the Tans and Lims compels one to choose the career path with the greatest prospects of monetary rewards. Yes, certainly this must be a major factor, but is it not more helpful to consider the role of the victim in this state of affairs? We can do little about societal values (the pull factor), but we can certainly do our best to ensure the "push factor" is kept to a minimum.

I often hear from friends who have received an overseas education how good their GPs in the UK and US are. How their bedside manners surpass those of the local doctors, how they do not treat their patient like storehouses of ignorance and would often go the extra mile to explain their conditions to them etc. The vast majority of these friends have never consulted a single specialist while they were abroad. However, interestingly upon their return, this same group of people would consult a dermatologist for their skin problems, an ophthalmologist for myopia, a respiratory physician for asthma and so on. Certainly, the main reason for this is that it is not the done thing to make a direct appointment to see a specialist in these foreign countries, whereas such a practice is more prevalent here. But again, why is this so?

If our primary healthcare system is to function optimally, the GPs here must manage the majority of common conditions. The simplest way to accomplish this is through legislation. But this would go against the grain of the MOH’s philosophy of providing a range of healthcare services. For obvious reasons, many specialists would certainly resist this high-handed approach as well. Thus, one of the most appropriate means to raise the status of GPs and optimally engineer our primary healthcare system hinges on GPs promoting themselves. By this, I do not mean putting ads in Yellow Pages or providing freebies to regular patients.

GPs must not "end up" as triage clerks for specialist outpatient clinics. Neither must they be lettermen (pun intended) specialising in drafting letters of referral to specialists. When this happens, poor patients are to the ones to suffer and the poorer patients suffer even more. When a GP refers a patient with a condition which he or she should be able to manage but lacks the necessary know-how or confidence to do so to the restructured hospitals, the poorer patients will probably "end up" seeing the most junior doctor in the specialist clinic.

No doubt these junior doctors would be well trained. Still, is it always for the best interest of the patient that an experienced GP "passes the buck" to his significantly less experienced junior colleague? The vast majority of the public thinks that just because they are seeing a doctor in a large modern hospital, they are better served. This is a fallacy and should be corrected. The GPs themselves can help correct this fallacy by providing excellent healthcare services.

Opportunities are aplenty in general practice. It all depends on the interests and more importantly, the values of the doctor. Do you as a GP want to play pass the parcel with your patients or do you want to play as active a role in the lives of many of your patients as possible? The choice is yours. You have a part to play in changing the attitude of "end up being a GP" to "deciding to be a GP". K