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"Over the Years- The Marathon Race"

"A marathon race is exhausting and sooner or later fatigue will set in. Some doctors are fitter than others but training and keeping in condition have to be an on-going process if we are to continue in the race."

Not very long ago we were told that it would be an unending marathon race for all Singaporeans. My immediate reaction to the pronouncement was that it must be a joke, for we all know what happened to the messenger Pheidippides when he arrived at Athens, but then the minister who said it is better known for designing and plotting our destiny rather then for his wisecracks, and like it or not we have to take his words seriously.

I have been on the road, so to speak, for quite a while, not as long as the 40 years that SMA has been around but certainly I have run a long way and am feeling somewhat tired. I didn’t have a good night sleep for days after his proclamation. I had a recurring nightmare in which I saw myself wobbling along Shenton Way, dragging one weary foot ahead of the other, feeling feverish, giddy and nauseous, unable to focus on what’s ahead and hallucinating, in a state of cerebral dysfunction and thermo-regulatory collapse. I would then wake up in a cold sweat.

Running a marathon is impossible for me. I wouldn’t be able to manage even a quarter marathon, far less an unending one. I couldn’t help feeling sorry for many of my colleagues too. Although most of them have vital capacities much larger than mine nevertheless they are not marathon runners. The only doctor I know of who could possibly run a decent marathon is one named Roger Bannister and he isn’t even a Singaporean.

Of course the minister did not mean that we run the marathon literally. His message is that we must keep going forward otherwise competitors will overtake us. Heaven forbids a drop in ranking in the many fields we are leading the rest. We may not be able to live it down, having told all those who bothered to listen, how good we were.

Now it would be presumptuous for me to comment on the relevance of the marathon with regard to other professionals and their ability to run, although some generalisation can be made. For example a priest would probably run a very steady and focused race and he will go on and on because his avowed objective is to travel from here to eternity. On the other hand a politician will certainly run an uncertain race. His route is full of potholes, with many a twist and turn on the way and opponents waiting to pasang kaki him.

Perhaps being a doctor would entitle me to offer some comments on the marathon race as far as the medical one is concerned. I realise fully that entitlement to opinions be them good ones or bad ones cannot be taken for granted. Gut feelings, impressions and anecdotal accounts cannot always be backed up with statistics or sworn statements, but in their absence, if we were to refrain totally from expressing our feelings and thoughts, society I think will be poorer. Having said this, I’ll give my personal two cents worth of opinion regarding our medical marathon.

Important changes have taken place along the route for the medical profession especially during the last two decades. First and foremost is the blurring of the boundary between the private and public sectors. Government hospitals have been "restructured". The term initially used was "privatised". The reason for the restructuring is supposedly to make the hospitals more efficient.

Efficiency means different things to different people. To patients it means a high standard of affordable health care; to the health providers, a conducive working environment: and to the government, providing a reasonable service without straining the budget. It is only when all the three parties involved are satisfied then can it be said that the system is truly efficient.

Where do we stand now? The restructured hospitals look impressive, both in terms of their physical amenities and the services they offer. The downside is that the accusation of being too commercialised is not infrequently heard. Doctors, many of whom are senior ones, have been leaving the service and the government has had to reassure the public again and again that the bottom line is still service above all else for every citizen.

Another milestone is the creation of Medisave in 1984, a pre-paid scheme for medical fees. Although there is much to commend about the scheme, it faces the same old problem of Money No Enough.

Compulsory contribution to Medisave is now 6% for those below age 35, 7% for those age 35 to 45 and 8% for those above age 45. This may still not be enough because of the continuing escalating cost, due firstly to an increase in demand of usage because of the aging population, secondly to the increasing use of expensive technology and medicine and thirdly contribution to the fund ceases when a person stops working. That Medisave is already insufficient for some is evident by the fact that very often family members have to pool their funds to pay the medical bill.

There are two other problems with Medisave. Some patients have the wrong perception of the fund. Just because they don’t actually pay hard cash at the time of usage, they don’t feel very anxious over the expenditure. Secondly, Medisave has created a source of readily available fund and this had led to the development, consciously or unconsciously, of a "have gun will travel" mentality among many patients and health providers. If there is no Medisave fund it is very likely that we will see a significant drop in the usage of health facilities. A stricter control of the usage of Medisave fund is desirable.

In our marathon race most of our energy is spent on raising funds to meet the ever-increasing cost. Very little is done to contain it. Maybe we are afraid that by doing so we may stifle progress and tarnish our image of being a sophisticated and high-tech society. For example, reviving the clinical physicians as compared to nurturing techno-physicians and having open utilitarian wards instead of hotel-like hospital rooms with all the creature comforts may take away the class and glamour. One is not against comfort and one must be receptive to new ideas and innovations but one has to be circumspect.

After almost 15 years perhaps it is timely for the SMA to make a study on the impact of Medisave on the practice of medicine in Singapore.

A spectator watching the present day medical marathon would have noticed that doctors are not the only participants. There are those who carry calculators instead of stethoscopes in the race. The nature of medical practice has undergone a change. It is now regarded as an industry and it appears that doctors on their own may not be able to manage very well and therefore require help from outsiders. Increasingly business people are now part of the scene.

Commercialisation is evident from the plan to develop Singapore into a regional medical centre to cater to the rich in this part of the world, the public listing of medical practices and schemes like managed health care and guaranteed profit etc.

Nowadays a doctor is likely to be part of a business team. He is no longer in absolute charge. This has some side effects. One is the reduction of the role he will play in the running of the practice. In the worst case scenario from a general he becomes a rifleman.

The bottom line of a business is obvious. In order to achieve its end, the means are often less than savoury. Doctors are expected to act honourably but more often than not the big bucks win. Derogatory remarks directed at doctors are increasing. The traditional regard and respect for the profession seem to be waning.

A number of doctors have indeed gone out of bounds but the behaviour of these doctors merely reflect that of many other members of our society. It is unrealistic to expect all doctors to stand back and watch while others are going all out for the kill.

There are other notable happenings and changes affecting medical practice here. Compulsory drug labelling is one. It is logical that patients should know what medicine they are given. Not only it is their right but also it makes the practice of medicine so much easier as far as side-effects, allergies and efficacy of drugs are concerned. Patients can also find out the cost of the medicine if they wish to. Drugs for sale require product licences nowadays and this has given doctors an added confidence when they prescribe them.

Under the Private Hospitals and Medical Clinics Act 1980, (Chapter 248) we have to licensed in order to practice. Taken in the right spirit, it is fine. Sometimes it is good to know that big brother is keeping an eye on you while you are running your marathon because it may prevent you from straying or losing your way.

Of course it is irritating to have somebody looking over your shoulder telling you what you can do and what you cannot do and having to pay attention to such instructions for that matter. The authority will insist the rules and regulations are for the common good, in which case it is hard to understand why sin-sehs, bomohs, druggists and temple medium are not similarly registered.

A marathon race is exhausting and sooner or later fatigue will set in. Some doctors are fitter than others but training and keeping in condition have to be an on-going process if we are to continue in the race. Doctors are fortunate for they are given assistance. There are many CME programmes, most of them free and with refreshments thrown in too. Records are also kept. CME may be made compulsory in the future.

With the population getting better educated there is now a demystification of medicine. The media is playing a major role though sometimes it is overplayed and inaccurate. Hospitals and clinics too are getting into the act; self-promotion and advertisement appears to be the moving force but it is public education nonetheless.

The doctors in the modern race therefore have to deal with a more knowledgeable and unfortunately, also more litigation-minded patients who on the one hand make practice that much more difficult but on the other hand also more challenging.

The frontier of medicine is advancing at a very rapid rate. For example, we can make things grow for the male at both ends, infertile couples have babies and help people overcome their shyness with drugs. We can also perform surgery to repair or remove diseased organs via key-hole openings in the body. Vaccines are available for disease prevention and transplants to replace malfunctioning or lost body parts. Sophisticated body imaging techniques and laboratory tests are available for many disorders. The entire human genome may be completely mapped in five or six years’ time, heralding a new era in medicine. The breakthroughs in biotechnology and genetic engineering will have a tremendous impact on our management of many of our most feared ailments like cancer, heart diseases and many aging and degenerative disorders.

However it is not going to be one smooth ride onwards. There are setbacks now and there will be setbacks in the future. We are faced with "new" bugs like the Aids and Ebola viruses. The TB bacteria, the malaria parasites and the staphylococci have developed drug resistance. There is an increasing morbidity and mortality associated with asthma. Diseases caused by environmental pollution are making millions sick and so is the scourge of drug abuse left. These reverses are indeed humbling experiences for doctors.

The government has put forth the Advance Medical Directive. Doctors can support or object to acting on AMD. In any case it is a stark reminder of our limitations. It is sad to see many patients using up all their hard-earned life savings in a few weeks, in a pathetic, meaningless and futile attempt to prolong life. The Opting Out Scheme is another ethical issue confronting doctors and it would be interesting to know how the scheme is working out.

Over the years that I have spent running the medical marathon I have learnt that a doctor has to fulfill several roles. He has to be a businessman, a counsellor, a student and the occasional philosopher too. The demand to provide "adequately" for the family in the context of living in Singapore is another ardous task for him. Being a doctor, the attainment of a certain standard is deemed necessary. No amount of money seems to be enough and he may feel very insecure.

A medical marathon is therefore a tough and stressful race and we may hurt ourselves if we try too hard to "make it". The saying "Physician, heal thyself" may turn out to be very real indeed. It is prudent to pace ourselves well and not set such impossibly high standards and expectations for both our private and professional lives.

So as we run along why not stop now and then to smell the flowers as golfers are advised to do when they play the game for "What is life if full of care, if we have no time to stand and stare?"