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"TV, mass communication and information technology will inform everyone, everywhere about the wonders of modern medicine....Modern technology has found remedies for previously untreatable conditions."

- Prof Arthur Lim


Professor Arthur Lim delivered the Medical Alumnus Lecture on NUS Alumni Day on 5 September this year. His observation of medicine in the twenty-first century is that medicine will face many controversies and challenges and everything will change everywhere. In short, where will the world of medicine be going? Will the world of medicine be for the better or for the worse? We report on his speech in this issue of the SMA News.


Escalating costs

The question of escalating costs was on the top of his agenda. He said, "In the twenty-first century, the billion-dollar health crisis of escalating health costs can bankrupt governments. Television, mass communication and information technology will inform everyone, everywhere about the wonders of modern medicine. Public demand for quality medical care will "explode". The life span in all nations will increase. Modern technology has found remedies for previously untreatable conditions."


Mistrust of doctors

He also noted that the attitude towards doctors in the spectacular progress of medicine has shifted from admiration in the past to distrust in the present. He observed, "Unfortunately, patient expectations, combined with increased costs, and iatrogenic diseases, created doubts. A few doctors – the black sheep – were dishonest. They created distrust. The global mass media’s publicity of doubts about doctors in almost every country has created immeasurable distrust in doctors worldwide."

He also felt that there is a sagging morale in doctors and gave reasons for the phenomenon. "There are so many responsibilities piled on doctors, in addition to rapid demands of services and education, of administrative roles, and of patients’ rights. Unless stopped, all doctors will be embraced in this sad and slippery decline."

Free market medicine

The question of free market or state control of medicine was raised. Prof Lim said, "It is futile to argue which is better – they are alternatives. Perhaps, a mix of both systems is best."


Non-medical administrators

Prof Lim asked the question whether non-medical administrators are appropriate in the healthcare setting. Will they be negative? Will they make things worse? His recommendation is having "both parties, doctors and the administrators working together, complimenting each other, to ensure that everyone will enjoy the wonders of modern medical care."


Large hospitals

He observed that the large general hospitals are "like medical dinosaurs insidiously declining…We know that for 30 years, large general hospitals have been questioned and a number of world-famous hospitals have been hit by a multitude of problems and many had to restructure, while others had to close. Like large organisations, large general hospitals have inherent problems. They tend to be bureaucratic." The answer may lie in smaller units which can respond more swiftly administratively. Where knowledge is critical, the professionals will demand more control and say over their development. He said that they cannot be treated like "digits running assembly lines".



He observed that "the numerous changes will force reforms in the practice of medicine, creating new controversies in medical ethics. The basis of doctor-patient relationships, so important for good patient care, is the trust the patient has in the doctor and the care that every doctor owes to his patient". In carrying out any new surgical procedure he advised that the well-known principle of "First of all, do no harm" must prevail. The interest of the patient must always be foremost.

He also noted that the question of advertisements is highly controversial. Conflicts between advertisements and professional norms will escalate with the increasing demand by patients for medical knowledge and the medical profession wanting to be known for their excellence.

On the influence of commerce on medicine, he said, "Doctors have to learn how to make hard choices as manufacturers and business enterprises increase their influence on them. When the vibrancy of a nation depends on trade and industry, the wise would want a strong relationship between doctors and commerce. The controversy of commerce in medicine will escalate." His advice is "when in doubt, we must ask ‘Is the decision in the best interest of the patient who, after all, is what the practice of medicine is all about?’"

On the ethics of tomorrow, he also noted that time and place may change practice norms. "When in doubt, let us move slowly – and allow contradictions and controversies to settle with the passage of time. As in philosophy, arguing what is right or wrong and what is good or bad would vary in different communities. It would be influenced by powerful invisible forces. Let us remember that ethics is about the good and the right."


Medical registration

Prof Lim noted that there will be a greater emphasis on knowledge, skills and training in the future. "To satisfy increasing patient demand for quality service, nations will battle for the top medical talents. A strong case exists for us to open our registration to top foreign doctors with special skills. We should welcome talents. There will be a worldwide liberalisation in medical registration in the next 10 years." He did not elaborate on what are the special skills we should be looking for in these doctors and the criteria to adopt for their entry. Also would there be a flood of doctors into Singapore then?


Where are we going?

Prof Lim observed that the 100th anniversary of the Medical College in Singapore will be in the year 2005. The Medical College began in 1905. Its first batch of seven students graduated in the year 1910. Thirteen years later, in the year 1923, the first Medical Alumni activity began. This year, 1998, the medical profession in Singapore celebrates 75 years of alumni activities.

Taking 1923 as the starting point, he observed that in the first 25 years from 1923 – 1947, doctors in Singapore were "colonial digits". The next 25 years from 1948 – 1972, was a period of the "glorious years" for medicine worldwide, including Singapore. This was a period of great scientific advances, such as the discovery of penicillin, followed by streptomycin for tuberculosis and preventive measures for polio. In addition, organ transplantation was developed: eyes, kidneys, and later liver and heart. "Medicine was supported with great enthusiasm, and loved by everyone, and doctors throughout the world were admired. All parents would hope that their children would study medicine."

Local doctors went abroad to train. By the 1960s, hundreds of local doctors returned with postgraduate qualifications. This led to the establishment of post-graduate institutions. They took over the professional and academic functions of the Alumni. "The glorious years were the happiest and most productive years where everyone moved upwards, and we were admired by everyone", observed Prof Lim.

The next 25 years from 1973 – 1998 were "the years of contradiction". Scientific advances and high technology continued, but the high cost of technology began to worry patients, the public and governments. High technology prolonged lives of the very ill patients at great costs. This led to debates on whether things are right. Governments around the world are convinced that medical costs will continue to increase and national budgets can be severely stretched. The non-medical administrators are seen as the solution to the cost-escalation problem. Hence, they have made their appearance. Will the doctors in the next 25 years become "digits" under these administrators?, asked Prof Lim K