Medicine is not just a career, but a calling... by Dr. Lee Wei Ling

Medicine is not just a career, but a calling.

by Dr. Lee Wei Ling (Lee Kuan Yew's daughter)

 

I have always felt keenly the suffering of animals. Since I was a child, I had wanted to be a vet. My parents persuaded me to abandon that idea by using the example of a vet whose university education was funded by the Public Service Commission. When he returned to Singapore , he was posted to serve his bond at the abattoirs. That was enough to persuade me to select my second career choice – a doctor. I have never regretted that decision.

 

There are still many diseases for which medical science has no cure, and this is especially true of neurological diseases because nerve cells in the brain and spinal cord do not usually regenerate. Hence, a significant percentage of patients seeing neurologists, of which I am one, cannot be cured. But as in all areas of medicine, we still try our best for the patient, ‘to cure, sometimes; to relieve, often; to comfort, always’.

 

An example is a 70-year-old woman who sees me for her epilepsy. Her husband has taken a China mistress whom he has brought back to his marital home. He wants my patient to sell her 50 per cent ownership of their HDB flat and move out. Her children side with the husband because he is the one with the money and assets to will to them.

 

When this patient comes, I always greet her with a big smile and compliment her on her cheongsam. She will tell me she sewed it herself, and I will praise her for her skill. Then I ask her whether she has had any seizures since the last time she saw me. She sees me at yearly intervals, and usually, she will have had none.

 

Next, I ask her how she is coping at home. She would say she just ignores her husband and his mistress. I would give her a thumbs-up in reply, then ask her whether she still goes to watch Chinese operas. She would say yes.

 

By then, I would have prepared her prescription. I hand it to her, pat her on her back and she would walk out with a smile on her face, back straight and a spring in her step.

 

It takes me only five minutes to do the above. I can control but not cure her epilepsy. But I have cheered her up for the day.

 

One very special patient, Jac, has idiopathic severe generalised torsion dystonia. By the age of 11, she was as twisted as a pretzel and barely able to speak intelligibly. She did well in the Primary School Leaving Examination, but was a few points short of the score needed for an external student to be accepted by Methodist Girls’ School (MGS).

 

I had done fund-raising for MGS prior to this and knew the principal. I phoned her and explained Jac’s disease as well as her determination and diligence.

 

I told the principal that the nurturing environment of MGS would be good for Jac, and that it would be a good lesson for the other students in MGS to learn to interact with a peer with disability.

 

At the end of Secondary 2, Jac mailed me a book and a typed letter. The book was a collection of Chinese essays by students in MGS.

 

There were two essays by Jac. In addition, she had topped the entire Secondary 1 and, subsequently, Secondary 2 in Chinese. She was second in the entire Secondary 2 for Chemistry. She was happy at MGS, and her peers accepted her and helped wheel her around in her wheelchair.

 

Medication merely gave Jac some degree of pain relief from her dystonia. Being admitted to MGS gave her the opportunity to enjoy school and thrive in it.

 

I was walking on clouds for the next few hours after I received the book and letter. Jac showed that an indomitable human spirit can triumph over a severe physical disability. As a doctor, I am not just handling a medical problem but the entire patient, including her education and social life.

 

I have been practising medicine for 30 years now. Over this period, medical science has advanced tremendously, but the values held by the medical community seem to have changed for the worse.

 

Yearning and working for money is more widely and openly practised; and sometimes this is perceived as acceptable behaviour, though our moral instinct tells us otherwise.

 

Most normal humans have a moral instinct that can clearly distinguish between right and wrong. But we are more likely to excuse our own wrongdoing if there are others who are doing the same and getting away with it.

 

These doctors who profit unfairly from their patients know they are doing wrong. But if A, B and C are doing wrong – and X, Y and Z too – then I need not be ashamed of doing the same. Medical students who see this behaviour being tacitly condoned will tend to lower their own moral standards. Instead of putting patients’ welfare first, they will enrich themselves first.

 

The most important trait a doctor needs is empathy. If we can feel our patient’s pain and suffering, we would certainly do our best by our patients and their welfare would override everything else.

 

Medicine is not just a prestigious, profitable career – it is a calling. Being a doctor will guarantee almost anyone a decent standard of living. How much money we need for a decent standard of living varies from individual to individual.

 

My needs are simple and I live a spartan life. I choose to practise in the public sector because I want to serve all patients without needing to consider whether they can pay my fees.

 

I try not to judge others who demand an expensive lifestyle and treat patients mainly as a source of income. But when the greed is too overwhelming, I cannot help but point out that such behaviour is unethical.

 

The biggest challenge facing medicine in Singapore today is the struggle between two incentives that drive doctors in opposite directions: the humanitarian, ethical, compassionate drive to do the best by all patients versus the cold, calculating attitude that seeks to profit from as many patients as possible. Hopefully, the first will triumph.

 

Doctors do have families to support. Needing and wanting money is not wrong. But doctors must never allow greed to determine their actions.

 

I think if a fair system of pricing medical fees – such that doctors can earn what they deserve but not profit too much from patients – can be implemented, this problem will be much reduced. The Guideline of Fees, which previously was in effect, was dropped last year. I am trying to revive it as soon as possible.

 

The writer is director of the National Neuroscience Institute.

I was born and bred in Singapore .

This is my home, to which I am tied by family and friends.

Yet many Singaporeans find me eccentric, though most are too polite to verbalise it.

I only realised how eccentric I am when one friend pointed out  to me why I could not use my own yardstick to judge others..
 

I dislike intensely the elitist attitude of some in our upper socio-economic class.

 I have been accused of reverse snobbery because I tend to avoid the wealthy who flaunt  their wealth ostentatiously or do not help the less fortunate members of our society.

 

I treat all people I meet  as equals, be it a truck driver friend or a patient and  friend who belongs to the richest family in Singapore .

I appraise people not by their usefulness to me but by their character. I favour those with integrity, compassion and courage..

 I feel too many among us place inordinate emphasis on academic performance, job status, appearance and presentation.

 

 I am a doctor and director of the smallest  public sector hospital in Singapore , the National Neuroscience Institute (NNI).

 I have 300 staff, of whom 100 are doctors. I emphasise to my doctors that they must do  their best for every patient regardless of paying status.

 I also appraise my doctors on how well they care for our patients, not by how much money they bring in for NNI.

 

My doctors know I have friends who are likely to come in as subsidised patients. I warn them that if I find them not treating any subsidised patient well, their appraisal - and hence bonus and annual salary increments - would be negatively affected. My doctors know I will do as I say..

 

 I remind them that the purpose of our existence and the  measure of our success is how well we care for all our patients - and that this is the morally correct way to  behave and should be the reason why we are doctors.

In NNI, almost all patients are given the best possible treatment  regardless of their paying status.

 My preference for egalitarianism extends to how I interact with my staff. I am  director because the organisation needs a reporting structure...  But my staff are encouraged to speak out when they disagree with me.

This tends to be a rarity in several institutions in Singapore .

The fear that one's career  path may be negatively affected is what prevents many peoplefrom speaking out.

 

 This reflects poorly on leadership. In many organisations, superiors do not like to be contradicted by those who work under them. Intellectual arrogance is a deplorable attitude. 

'Listen to others, even the dull and ignorant; they too have their story,' the Desiderata tells us.

It is advice we should all heed - especially leaders, especially doctors.

 I speak out when I see something wrong that no one appears to be trying to correct.
 

 Not infrequently, I try to right the wrong. In doing so, I have stepped on the sensitive toes of quite a few members of  the establishment. As a result, I have been labelled 'anti-establishment'.

 

Less kind comments include:

 I am indifferent to these untrue criticisms; I report to my conscience; and I would not be able to face myself if I knew that there was a wrong that I could have righted but failed to do so. I have no protective godfather.

 

My father, Minister Mentor Lee Kuan Yew, would not interfere with any disciplinary measures that might be meted out to me.

 

 And I  am not anti-establishment. I am proud of what Singapore has achieved.

 But I am not a mouthpiece of the government.

 I am capable of independent thought and I can view problems or issues from a perspective that others may have overlooked.

A few months ago, I gave a talk on medical ethics to students  of our Graduate Medical School.

 They sent me a thank-you card with a message written by each student.

One wrote: 'You are a maverick, yet you are certainly not anti-establishment. You obey the moral law.'

 

 Another wrote: 'Thank you for sharing your perspective with us and being the voice that not many dare to take.'

It would be better for Singapore 's medical fraternity if the young can feel this way about all of us in positions of authority.

 After the SARs epidemic in 2003, the Government  began to transform Singapore into a vibrant city with arts and cultural festivals, and soon, integrated resorts and night F1.

But can we claim to be a civilised first world country if we do not treat all members of our society with  equal care and dignity?

There are other first world countries where the disparity between the different socio- economic classes is much more extreme and social snobbery is even worse than in Singapore .

But that is no excuse for Singaporeans not to try harder to treat each other with  dignity and care.

After all, both the Bible and Confucius tell us not to treat others in a way that we ourselves wouldnot want to be treated.

I wish Singapore could be an exception in this as it has been in many other areas where we have surprised others with our success.

MMA News September 2010: What if… Medical Professionals ask the truly important questions? The Dilemma of Leadership…

What if… Medical Professionals ask the truly important questions? The Dilemma of Leadership…

Dr David KL Quek

This month I would like to reminisce on the changing dynamics of medical leadership. In a recent July JAMA commentary, Rand Health director Dr Robert H Brook, discusses some intriguing aspects of “Medical Leadership in an increasingly complex world”.[1]

Medical leadership, he argues must move beyond the usual norm of professional practice issues, which are narrowly defined within the realms of our own immediate interests. While he acknowledges that medical professionals are found in most leadership strata of the political arena, few if any ever reach the pinnacle of being elected national President—in effect to become the quintessential executive policy maker and shaper.

In Malaysia, we did have that envious exception of having had a doctor take on the helm of political leadership of the country. It is debatable if being a doctor influenced the way Dr Mahathir had run the country for 22 years. It is equally contentious if he had left behind a benign or a malevolent legacy!

Many of us still bristle at the thought that Dr M was once heard to have said that we should “flood the country with enough doctors” so that they wouldn’t demand too much in terms of wages and perks! Curiously, in this coming decade, his prescient prediction could become a reality, when MOH plans are afoot to increase the number of doctors in this country to more than 80,000 by 2020, so as to achieve the target of 1:400 doctor-population! As a professional body, the MMA believes that this is too many, too fast, and too soon; perhaps over a 20-year period might be more manageable, but ten?!

Thus, doctors would no longer be a ‘small’ professional group, but one, which could become arguably bloated, redundant, and possibly unemployed or scrambling after some tit-bits or scraps of hand-me-down service!

Our true worries follow 2015, or even 2020. What then with the continuing production of 5,000 new medical graduates or more per year? How long can this go on? Would our standards of medical graduates be acceptable or would the profession self-destruct into a quagmire of second-rated diploma-milled ‘doctor’ that few would accept as trustworthy or good enough professionally or in skills?

Interestingly, we wonder why the lawyers in the country have so carefully shunned such a messy thought experiment, when they jealously guard their turf by scrupulously controlling the production and passing rates of their counterparts!

Perhaps it is not too exaggerated to say, that more often than not, our quiet professionalism (or apathy!) seems to have been parlayed by policy makers into a politically devious cycle of below-the-belt punches instigating public demanded virtue and selfless altruism, while losing sight of what’s realistic or fair-minded.

Sadly too, the few physicians who had embroiled themselves into our Malaysian politics appear to have become more politically expedient rather than to have exerted the more kindly expectations of the soothing caring professional! Perhaps, we expect our ‘comrades-in-arms’ to be more robust in engaging ‘our’ cause with more reason and tempered fairness, as we do our own medical professionals in the bureaucratic policy-making departments of the Health Ministry.

Yes, physicians can and do wield extraordinary influence, or so we believe. But often, not in the most agreeable way that society or the profession accepts as benevolent or agreeable. Worse still, even among doctors there are always those with divergent ideas or expectations: the confused schizoid demands of placard-caring unionist vs. more professional activist stances, vs. advocating even cautious indifference by not rocking the unstable boat amidst the tempestuous calm of government-professional equability.

There appear to be the fragmented and incoherent approaches, which would please some but anger others. But diversity of ideas and demands are perhaps the epitome of ‘intelligent’ single-minded professionals or even the public! Undoubtedly the public is progressively becoming more sensible and knowledgeable. The rakyat is no longer easily satisfied by mere rhetoric or paternalistic dictates. But sadly, as an increasingly emasculated profession, doctors’ voices of concern have become steadily muted…

Therein lies the paradox for the medical profession. Doctors even in Malaysia have been engaged to run huge health ministries and the public sector healthcare service, which literally shape and dictate how healthcare delivery and practices are regulated and implemented. How these public sector physicians envision the entire healthcare sector is important and would in many instances shape the direction and the structure of the health service for the nation.

We can only hope that they can remember their singular profession as they are charged to impact those of the others around them, notwithstanding the touted concept of ‘national’ agenda or ‘national’ interests, or the bigger picture…

Lest it is forgotten, private sector doctors also look after three-fifths of the population as outpatients, annually engaging some 65 million doctor-patient encounters! The MMA does not believe that such innumerable encounters are so deficient as to compromise our rakyat’s health in the long term. As the laws of economics would dictate, people will find their own comfort levels of acceptance for services or goods. We believe doctors are doing a sufficiently cost-effective and acceptable service for most if not all of our patients, for such a system to have endured so long and so well, as proved by our improving health indices!

Our countless patient-doctor connections can serve as powerful opportunities and tools for engagement and sharing of most intimate ideas and thoughts. Doctors therefore, should learn how to harness this possible influence to help shape how health policies are decided and enacted, by advising governments, appropriately. But then again, it is arguable if this influence would be wrought with intelligent feedback, evenhanded bipartisan consensus, or simply timid capitulation, or brushed aside as inconsequential by the powers that be.

Health professionals have always been seen to serve as the medical profession’s ‘moral compass’ when they are appointed surgeon general (in the US) or Chief Medical Officer (CMO in the UK) or as in the case with Malaysia, when appointed the Director-General of Health and other senior civil servants.

But we do recognise that the CMO or our equivalent DG has important responsibilities too. In the UK, the CMO provides advice to the Secretary of State for Health and other Health Ministers, other Government departments’ Ministers and on occasions to the Prime Minister directly.[2] 

• The role goes beyond its simple advisory remit. Responsibilities include:
• Preparing policies and plans and implementing programmes to protect the health of the public
• Promoting and taking action to improve the health of the population and reduce health inequalities
• Leading initiatives within the NHS to enhance the quality, safety and standards in clinical services

We believe these roles apply equally to our public health authorities.

However, in the same document, the CMO of the NHS explains his leadership role as follows:

“I do not have a role in the employment or management of NHS doctors. However, my responsibilities include providing national leadership to the medical profession, helping to explain the health policies of the day and listening to the concerns of the profession and their ideas. In this way I can provide, where necessary, a bridge between the medical profession and the government.”

We certainly hope that here too in Malaysia, our senior health officials would also offer a reasonable listening ear to our professional concerns, and serve as a much-needed bridge for the medical profession and the government… Shared leadership implies sharing of concerns and ideas, especially crucial feedback, contrasting viewpoints and counter-arguments to shape and finely-hone policies which hopefully can be implemented with greater precision and less recriminations from public or professional dissatisfaction or disagreement.

In this regard we sincerely thank the Ministry and the Minister for having recently acquiesced to a much needed and definitive dialogue with the MMA, in Putrajaya on 2 September, 2010. Whether anything concrete would come out of this dialogue remains to be seen. But, we must meet more often to share concerns and work closer together toward a common goal for the nation’s healthcare service.

Another tier of regulatory oversight is when doctors are appointed or elected into the Medical Council, where some professional input are expected to be made, on behalf of the profession and the public good. The more academic minded also help train and teach new medical graduates and other healthcare professionals.

But are these all the professional limits of our influence or leadership to make meaningful impact on healthcare as a critical social service?

Conversely, on the other more commercial ‘scientific’ health sector, physician influence and activities serve a different perspective altogether. Scientist-physicians research, invent and innovate therapies or new pharmaceutical modalities, which advance medical care, prolong survival or improve quality of life, but perhaps also increase costs and expense. In the wake of such advancements, they help create public demand for newfangled sometimes cutting-edge therapies or diagnostic procedures, which unfortunately drive healthcare costs upwards in a dizzying spiral of never-ending escalations.

Would 3 months extension of life expectancy for a hitherto terminal cancer be worth say, USD 100,000 as would be needed for a novel therapy? Is aggressive end-of-life futile care a necessary evil to extract perhaps a few extra hours or a few days of prolonged ‘life’?

Can or should experimental therapies such as stem cell or unproven pharmaco-genomic treatments, etc. be offered to every one, any one, or only as research protocols? How does one measure the worth of any life, any life extension no matter how short or long, or the quality? Are doctors as such, fuelling ‘cost and demand’ escalation for healthcare of the future?

Would creating ever more sub-specialised expertise and modalities of treatment mean that there would be that ever-increasing physician demand for greater incentive toward higher professional fees or salaries? Some highly trained and skilled doctors are asking that they be reimbursed more for their expertise, which raises the debate as to how we should gauge professional worth or relative values of one’s talent, skills or training. Is technical skill worth more than say, therapeutic counseling advice? How do we appraise or affix monetary values for skills, for arduous training, etc.? Or, are human values and differing professional skills ‘equal’ in the impartial eyes of society or even the profession?

Should rising reimbursements always be the rightful accompaniment of medical progress and advances? Is the relentless drive toward greater and greater advances in medical care an acceptable paradigm of our health care model?

Is identifying and naming more ‘medical’ conditions, such as impotence as erectile dysfunction, personal self-image disorder as aesthetics, wear-and-tear ageing disorders, etc. collectively and increasingly termed as ‘medicalisation’ of health, always be for the greater good of the public, our hitherto uninformed well but perhaps ‘flawed’ patients?

Is this ‘medical’ model of illness-driven, individual patient care and treatment, sufficient or right for this modern age? Or would the ‘public health’ model be the preferred approach—one that is driven by trying to eliminate root causes to ill health i.e. by preventive measures against communicable diseases, smoking, alcoholism, obesity, drug addiction, etc.

Or would a third model encompassing even wider social strategies such as poverty reduction, wealth redistribution, empowering children, women and the needy, be the better way forward, to enhance health and healthier choices in the community?

Should indeed the medical professional reconsider his or her concept of medical care and the healthcare system by considering all aspects of social determinants that impact health in the community? Or should we stick to our narrow fields of practice, finely tuning our skills in a one-on-one basis, oblivious to the wider scope out there? How do we improve health for the community? Or is this too huge a problem for a puny professional to handle?

The President of the Royal College of Physicians of London, Dr Richard Thompson in the September 2010 Bulletin, wrote recently that medical leadership must indeed be made a part of our profession: “We must be the catalyst once more in improving care and spreading more kindness… so as to offer the same standard of care we would expect for ourselves and our families. There are too many stories of thoughtless and unkind care from friends and relatives in the media. Physicians can and should be leaders in every part of their trusts.”

In a RCP 2008 document Understanding Doctors: Harnessing Professionalism[3] the question of fragmented and incoherent medical leadership was discussed:

“If the leadership of the profession is fragmented, then the profession may have a problem in terms of wasted opportunities to impart its collective wisdom. Equally, society as a whole has a corresponding problem if a lack of transparency about professional leadership, or a lack of agreement within the profession, makes it difficult for politicians, policy-makers, patients and the public to engage in dialogue with the medical profession as a whole.

“As we shall see, doctors are keen to make their voices heard on a wide range of issues. There is clearly scope to develop the leadership of the profession so that they are better able to do so.”

Sadly, when a straw poll carried out by the King’s Fund on 406 doctors and 376 non-doctors, leadership of the profession was found to be severely wanting: “86 per cent considered the leadership of the medical profession in the past 10 years to be ‘poor’ or worse than poor.”

In arguing that medical leadership means harnessing greater and wider professionalism, more of us doctor-leaders must become more proactive. Below I paraphrase the conclusions of this insightful document.[4]

First, the medical profession must collectively seek to understand the dynamics of future healthcare demands, medical education, students and graduates. We must explicitly place modern medical professional core values at the heart of our collective behaviour in order to buttress the inculcation of these values in our younger colleagues. We must also work with others to develop clearer roles for the doctor working in an increasingly multidisciplinary clinical environment. 

Second, the profession at all levels must work towards developing new relationships with government, patients and the local community. We must take responsibility for establishing a more constructive and influential relationship with the authorities and the government. We must continually learn how best to meet patients’ preference for a less paternalistic and more facilitative relationship with their doctors. And we must find ways to engage with the community served by the health care system where doctors work. We must help build more realistic and informed understanding of services and resources, and work towards constructive engagement to improve future restructured systems. 

Third, the profession, particularly leaders of national institutions, must take a hard look at how our profession might adopt greater flexibility in work patterns across all medical roles and responsibilities. We must ensure more effective and widespread implementation and adoption of continuing professional development and possibly revalidation of our skills and practice. Ultimately, as medical leaders, we must make our collective voice stronger in public debates about issues of health and health care.

From a more personal and individual perspective, the doctor is always to be reminded that his duties and responsibilities remain as robust and as expected. Medical leadership must therefore, take on this solitary aspect too, particularly with regards the last statement of duties, i.e. ensuring that we are personally accountable for our professional practice and that we must always be prepared to justify our decisions and actions vis-à-vis our patients and the public at large.

The General Medical Council’s Good Medical Practice[5] sets out the duties of a doctor as follows:

Patients must be able to trust doctors with their lives and health. To justify that trust you must show respect for human life and you must:

• Make the care of your patient your first concern
• Protect and promote the health of patients and the public
• Provide a good standard of practice and care
• Keep your professional knowledge and skills up to date
• Recognise and work within the limits of your competence
• Work with colleagues in the ways that best serve patients' interests
• Treat patients as individuals and respect their dignity
• Treat patients politely and considerately
• Respect patients' right to confidentiality
• Work in partnership with patients
• Listen to patients and respond to their concerns and preferences
• Give patients the information they want or need in a way they can understand
• Respect patients' right to reach decisions with you about their treatment and care
• Support patients in caring for themselves to improve and maintain their health 
• Be honest and open and act with integrity
• Act without delay if you have good reason to believe that you or a colleague may be putting patients at risk
• Never discriminate unfairly against patients or colleagues
• Never abuse your patients' trust in you or the public's trust in the profession.

You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions.

Medical leadership indeed is much needed in today’s healthcare scenario, more so in systems undergoing change and restructuring. As concerned medical professionals, we must all rise up to the challenge and engage as robustly and as intelligently as we can. Anything short would be a travesty of our moral position as an enlightened professional.

What if every one of us dare to take on this challenge, and urge the authorities to work with us, listen to us more as we do so too, and arrive at measures collectively, which present the best possible win-win approaches for all, especially for our patients and our rakyat, to improve and restructure the health system so as to achieve the best that can be for all Malaysians; what if?

---

[1] Robert H Brook. Medical leadership in an increasingly complex world. JAMA 2010; 304(4):465-6.

[2] Department of Health. ‘The role of the Chief Medical Officer (CMO)’. Department of Health website, last modified 10 Jun 2010. Available at: www.dh.gov.uk/en/Aboutus/MinistersandDepartmentLeaders/ChiefMedicalOfficer/AboutTheChiefMedicalOfficerCMO/ DH_4103960 (accessed on 10 September 2010).

[3] Ros Levenson, Steve Dewar, Susan Shepherd. Royal College of Physicians, London. Understanding Doctors: Harnessing Professionalism. Chapter on “Leading the profession”. King’s Fund, London 2008, pg 38-45.

[4] Ibid. Chapter on “Conclusion”. King’s Fund, London 2008, pg 50-52.

[5] General Medical Council (2006). Good Medical Practice. Duties of a doctor. http://www.gmc-uk.org/guidance/good_medical_practice/duties_of_a_doctor.asp (Accessed 10 September 2010)

The Physician’s Noblesse Oblige—Reviewing our Social Contract!

The Physician’s Noblesse Oblige—Reviewing our Social Contract!
Dr David KL Quek

AGM Aftermath

After the tumultuous if successful close of the last Melaka AGM, I must confess to being a little jaded, disappointed, despondent—perhaps even burnt-out. Events have overtaken our Association, which would in no small measure change completely how the MMA is run or will be run. There are real dangers of usurpation of a few over the many. But I sincerely hope that good will and common sense will create a new era for the future of our medical profession.

Sadly, many of our members out there still remain as busily practice-orientated. Despite appeals to participate more, many have not bothered to personalize their involvement with the MMA, while still expecting the few interested to work tirelessly for them. Most are oblivious to taking part, unwilling to sacrifice a little time and effort, believing that there are others who would surely do their bidding for them. Well, now their apathy and passivity may be their undoing, when they would have even lesser control over the affairs of the MMA, of the medical profession, of healthcare even.

Nevertheless, I have had some weeks of reflection, which have blunted the acid-sharpness of the despair and pain that I had allowed myself to wallow into. Time heals, and this almost always returns me toward what truly matters—to the ideal of medical practice, which is what this profession is all about.

I realize that sometimes we all get too embroiled with so many trivial if narrow issues that we lose out on the sense of our vocation. But truly in a philosophic sense, these are passing events, which might simply create a few small etches or ripples in the fabric of history of our times… C’est la vie…

I wish to revisit in this issue, a review of our professional "noblesse oblige”, our social responsibility as physicians.

Noblesse Oblige

The Miriam-Webster’s Dictionary defines “Noblesse Oblige” as “the obligation of honorable, generous, and responsible behavior associated with high rank or birth”. For the physician such unspoken if tacitly-understood principles of benevolence of helping those less fortunate, are not highborn, inborn or hereditary, but are nonetheless expected by many as obligatory ideals.

In many ways our entry into the medical profession is certainly one measure which elevates us into a new strata of society, one that we’ve been constantly reminded, carries so much trust and responsibilities.

Since time immemorial, the physician has been expected to behave within a circumscribed system of practices, which helped define the healing profession as compassionately embedded with ethics and socially acceptable correctness.

However, for most of us, the practice of medicine is far easier, more mundane and is usually of second nature to us. Our healing art so steeped with such ponderous ideals is more subliminal than of conscious awareness. Although inconsistently taught, almost all medical graduates have been instilled in a culture of caring altruism and empathy toward our patients.

The Hippocratic principles have been seen as the underpinning ethos of how the physician should live out his profession, with dos and don’ts, of what is correct or otherwise frowned upon behaviour, which carries the commission-omission penalty of public reprimand, or censure, or worse...

What is perhaps often understated and less known is that the physician even in the era of the ancient Greeks, were paid for their services. This fee-for-service mechanism had almost always been the mode of exchange of goods and services—sometimes through barter, but more often with agreed upon money, cash or valuables. However, failure to cure or resultant untoward outcomes were also responded to harshly. Physicians were punished, run-out of towns and villages, banished or even killed for their mistakes and less than capable actions!

Thus, the physician has not always been seen to be that quintessential healer par excellence, one that we have grown accustomed to nowadays. (Yes, there are many who remain skeptical as to whether the doctor heals more than harms!) Clearly though, history has never unequivocally accepted the physician as a natural or consistent boon to mankind—we have always had our fair share of detractors.

Medicine’s Detractors & Distractions

Macedonian world conqueror, Alexander the Great, was reputed to have said that “I am dying with the help of too many physicians.”

Thomas Young, in 1815, had whimsically said that “Medical men, my mood mistaking, Most mawkish, monstrous messes making, Molest me much; more manfully, My mind might meet my malady: Medicine’s mere mockery murders me.”

Irish playwright, George Bernard Shaw sneered that, “Medical science is as yet very imperfectly differentiated from common cure-mongering witchcraft.”

Well-known 20th century philosopher, Ivan Illich in Limits to medicine. Medical nemesis: the expropriation of health, 1975, had argued cynically that "In a morbid society the belief prevails that defined and diagnosed ill-health is infinitely preferable to any other form of negative label or to no label at all… More and more people subconsciously know that they are sick and tired of their jobs and of their leisure passivities, but they want to hear the lie that physical illness relieves them of social and political responsibilities. They want their doctor to act as lawyer and priest… Social life becomes a giving and receiving of therapy: medical, psychiatric, pedagogic, or geriatric. Claiming access to treatment becomes a political duty, and medical certification a powerful device for social control.”

Medical historian, Roy Porter also cautions against the growing medicalisation of life: "...an expanding medical establishment, faced with a healthier population of its own creation, is driven to medicating normal life events (such as the menopause), to converting risks into diseases, and to treating trivial complaints with fancy procedures. Doctors and 'consumers' alike are becoming locked within a fantasy that unites the creation of anxiety with gung-ho 'can-do, must- do' technological perfectibilism: everyone has something wrong with them, everyone can be cured."

In fact many people and historical leaders had in the past almost always lamented the fact that the doctor was associated with more suffering and questionable consequences than success or cure. French Emperor, Napoleon had said that “Medicine is a collection of uncertain prescriptions, the results of which, taken collectively, are more fatal than useful to mankind. I do not want two diseases—one nature-made, one doctor-made.”

That chancy “luck” or for want of a better prediction for many a serious ailment had often been entrusted to the final arbiter of “fate”—that last gasp opinion or prognostication of the physician. Until the recent past (late 19th century), most doctors could possibly diagnose but not really treat, but only predict when death was imminent, and hence, they were often not terribly successful at healing or saving lives!

Thus, the serendipity of healing was more or less as predictable as a throw of the dice, not the so-called healing touch of the physician who prescribed unverified bleeding (venesection), simplistic use of induced vomiting emetics, “poisonous” herbs and chemicals, and prayers—that magical salve that conquered or consumed all!

Debacles vs. Public health success

Most if not all ill patients prior to the nineteenth-twentieth century, got better due to one’s natural recovery process, in spite of the occasional interference by the physician. The unwashed hands of the obstetrician killed more women through puerperal sepsis than was recognised for decades, until antisepsis (pioneered by Hungarian Ignaz Semmelweis) and asepsis (Lister) techniques gained ground, ever so reluctantly due to huge egos of famous physicians!

Nevertheless, the past 100 years or so has showcased the relentless march of success of the illness-wellness health model. There can be no denying that the 20th century had produced a paradigm of health care practices which had not only enhanced scientific knowledge and understanding, but more importantly, produced a consistent if changing array of curative therapies, previously quite unheard of.

Through public health measures, better public and personal cleanliness and sanitation, common communicable diseases have been drastically reduced, except in the poorest pockets of the developing world. Cures either via medicines or surgeries have transformed the landscape of disease and ill health until there is so much hope and hype that modern medicine could perhaps soon heal all and sundry! Longer life expectancies and good quality of life are now the norm rather than just for the privileged few.

Yet, as we enter and dabble into newer realms of scientific knowledge, into the very heart of individual-based personalised gene-based therapies, and finer and finer skilled surgical expertise, aided by technology and even robotics, the margins of possibilities rather than promises continue to blur.

Touted evidence-based practices compete with newfangled if unproven hi-tech hype, which pushes the envelope of stupendous progress and advancement, but at huge uncontainable costs! The success principle also translates into wishful expectations that everyone should be entitled to the very “best” of healthcare and medical expertise that modern medicine can offer.

Dr Herbert H Nehrlich, an English private practitioner wrote to say that (BMJ 2004;328:770 (27 March), doi:10.1136/bmj.328.7442.770-a): “Our real enemies are the powers that aim to make us dependent: the merchants who try to sell health care as a proactive entity rather than a reactive one. They offer free examinations, and they manipulate long established laboratory measurements, all in the name of more profit. They go hunting for potential new patients and persuade them that they need treatment or ‘preventive’ measures. They deliver ‘health care’ to the eager, brainwashed consumer like the milkman delivers milk. But they often come empty handed. They do not owe you anything, but they promise much.”

Under this scenario, the greater the perceived success of the healthcare model, the greater have been the expectations; and the greater the demand for access and equity by one and all. Malaysians now expect that everyone should have equal and immediate access to an undisclosed if unlimited tranche of healthcare services.

Malaysia’s rising expectations

In Malaysia, we do have an enviable position of having done remarkably well in terms of primary healthcare infrastructure. For decades now following independence, we have had a fantastic run of well-planned and executed healthcare policies which saw the widespread development of rural and semi-urban community clinics (Klinik Kesihatan), almost all of which are within 5 kilometers of public reach.

A reasonable basket of services are provided including the essential maternal and child care services which incorporate mandatory maternal checkups and childhood vaccinations, as well as certain simple primary healthcare treatments, accessible to everyone at most affordable costs, i.e. almost free, and provided for via tax allocations.

For the urban sector however, tertiary public hospitals at state capitals have also been modernized at huge costs to keep up to date with modern advances in secondary and tertiary care. They are complementary to looking after more complex admissions and surgeries.

However, the development of the healthcare sector in the urban setting has been rather laissez faire.

Beginning in the 1980s, there was a tacit nudge to allow the somewhat haphazard sprouting of private clinics and private hospitals to offload the seriously overcrowded government clinics and hospitals. Without doubt, these private clinics have to some extent enabled most city-dwellers to have ready and reasonably affordable access to healthcare.

The National Health & Morbidity Survey 2006, showed that some 62% of patients actually look to the GP for first access to healthcare. These GP clinics of course offer real choices for those urbanites who are unwilling to queue with the overcrowded public sector outpatient services. Such has been the unheralded contribution of the GPs for so many years.

Unfortunately, many of these doctors who have been placidly if single-mindedly plying their trade and unspectacular services for years on end, also lack a collective voice, so much so that their rights and livelihood have been shortchanged, when seemingly more and more regulatory exercises appear to have been foisted upon them. Of late the role of the private GPs and hospitals have been questioned and debated, especially when costs of care appear to have escalated beyond many people’s expectations.

Escalating Healthcare costs

Alas, as we enter into the new century amidst financial uncertainty, healthcare costs the world over have reached critical proportions, which threaten to undermine the very fabric of social services expected by every population at large. No matter the mechanisms of healthcare payment or system of cost-sharing, expenses continue to escalate to the point of painful limits of public affordability, and even personal-familial bankruptcies and indebtedness.

In the USA, this has reached 16-17% of the GDP, a staggering 2.3 trillion dollars! Most other first world countries spend some 10% of their GDPs on healthcare, while rationing and forced containing the rising costs and services. The concept of universal access to healthcare services is fast becoming fully tested as demands continue to outstrip the supply side limitations—instant unlimited service for every demand for healthcare for all, appears untenable and unsustainable.

Wait times, queueing and rationing, with denial of newest if promising but untested experimental therapies will progressively become the modus operandi for all nations. There is no free lunch even if one opts for the best most comprehensive insurance or co-payment mechanism, some form of social insurance or special taxes, etc.

In Malaysia, our healthcare budget just tops 4.7% of our GDP, with 2.2% coming from the public purse—a total estimated healthcare expenditure of around 35 billion Ringgit. There has been a cutback of some 4.8% in the last budget, which implies that the private sector was supposed to take up the slack, through greater investments as well as private initiatives. Yet from our national healthcare accounts, we have been warned that our private out-of-pocket (OOP) spending (~57%) on healthcare is too high, and might not be sustainable in the long term.

Thus, we are thus at a crossroads. We have a modern well-equipped and potentially quite proficient secondary to tertiary healthcare system, which can provide up-to-date care for most if not all ailments including catastrophic illness, such as state-of-the-art surgeries and anti-cancer therapies.

Yet, we have a less than systematic system of payment mechanism, which creates technical gridlock and delay in access for some of these demanded treatments. We have no declared universal access to healthcare for all our citizens, although for most basic medical care, this is offered at token subsidised rates—RM1 to RM5 for outpatient primary or specialist care respectively and hugely subsidised in-hospital care upwards of 98%! Still, demands for rapid access to tertiary treatment have snowballed, until we can no longer sustain the cost without essentially cost-constrained rationing.

Healthcare Review/Reform, soon?

We recognise that the government is very sensitive to the public perception of what should be offered as a benefit of citizenship, i.e. greatly subsidised healthcare. We also know that the public has been very vocal and averse to any talk of revision of this “social contract”. But this subsidy quantum has to be redefined sooner than later. We simply cannot afford this, notwithstanding the fact that everyone clamours for greater accountability or stringently containing wastages and leakages, whether political or bureaucratic.

Thus, we understand the need to reform our healthcare system. We would have to find a more sustainable model where more of our citizens can be served well, without the cost escalation bankrupting our public purse.

We need to devise a better more comprehensive system of copayment through a form of either specially allocated healthcare tax, or a community-rated national health insurance, which embodies every citizen and his/her dependents.

We need to integrate or closely align our now dichotomized public-private sectors, so that there will be better utilization of limited resources and less duplication or wastage. We need to persuade our people that this is truly the only way forward. Everyone has to wake up to the fact that he or she has to take responsibility for his/her own health. The government can no longer be left to shoulder this alone.

As physicians, we have to do our part, and engage our patients to recognize this enlightened truth. Of course we will expect better and more prudent use of public funds. We will expect greater productivity and fewer leakages from unnecessary cosmetic or wasteful enterprises. Administrative and bureaucratic expenses must be sharply curtailed and brought down to a minimum.

Whatever the reform, we must set a new paradigm of accountability and economical utilisation of our very finite resources, which are contributed to by everyone—this will engender greater ownership and prudence, ensuring more equitable and fairer treatment for all. We must review our social contract, even as we strive to provide and preserve our social safety net for the most indigent and underserved.

As physicians we can help by ensuring that the authorities and our patients fully understand our benevolence and our sacrifices—we will temper our free-market instinct with altruism provided we are sure that this applies best for the most people in Malaysia. But we must be assured of our just remuneration and our livelihood, we must be given sufficient rewards to justify our calling for excellence and temperance, above the rising tide of mediocrity and despondency…

Physician Malaise, Dwindling Public Trust, Moral Imperative

By Dr David KL Quek

The most recent Readers’ Digest poll on Malaysia found doctors to be third (behind pilots and teachers) in the line of professions whom they can trust (Nichol David, Dr Jemilah Mahmood (MERCY Malaysia), Lee Chong Wei, and Lat were the top 4 eclectic celebrities that Malaysians chose to trust).[1]

This is perhaps not too surprising but maybe a sign of the times. Just a few years ago, doctors were polled as the most trusted profession, so clearly in the interim the public perception has changed somewhat. Have our doctors done anything to deserve this climb down in public trust? If so, how and what has rankled the public?

To be sure if we do scrutinise the above table, there is little to distinguish the top 3 professions. But it is worthwhile scanning down to see that the paramedic, the surgeon, the dentist, the pharmacist and the nurse are now quite high up the hierarchy of public trust from a list of 40 professions. We are now in a highly competitive climate for public trust and regard, and it will get keener with the times!

This became quite clear, when the MMA and many doctors protested the setting up of 1Malaysia clinics to be manned by paramedics in urban centres in January 2010. While the concept of making healthcare access better for urban poor is laudable, our contention that doctors and not just paramedics man these clinics did not receive the expected attention or response that it should.

Medical assistants—now also renamed as “assistant medical officers” and nurses were up in arms that we were belittling their skills and training, when what we intended was to simply state the facts of inequality and disparity in qualifications, schooling, training and possibly standard of care of the 3 professions.

As medical professionals, we maintain that each of the professions has its own niche, task and role. However, without exception, as is stipulated by the Medical Act, all clinics should be fully supervised and manned by doctors.

Nurses and paramedics are clearly indispensable in their respective roles, and we do not dispute that, nor do we wish to denigrate their responsibilities or capabilities. But ultimately, they are there to assist us and carry out certain tasks, but the final responsibilities must rest with doctors, as full supervisors and hopefully not any less!

Sadly, due to political manoeuverings, our authorities have spun a disingenuous tale that we are elitist and uncaring with the full-throttled support and thrust from the mainstream media and a populist public. Perhaps, such run-ins are the stuff that damages our position, unless we choose to quietly abide by the challenges and events, and let them slip by, without comment or debate…

But I think the medical profession cannot afford to keep quiet and let this erosion of our practice issues continue. It is precisely differences of opinions and approaches like these that the MMA must be willing to challenge and question, and expose the fallacy and/or the unacceptability of these moves. Globally, for various reasons, task-shifting is being manipulated mainly on economic grounds, to undermine the scope and practices of the medical profession, and we have to remain vigilant to stall these measures of convenience.

However, perhaps for a growing number of Malaysians there has been a widening schism of trust pertaining to all things authoritative and maybe elitist to some degree. Alas, doctors have sometimes been labelled as such—that we are too patronising, too paternalistic, oftentimes too self-seeking and too all-knowing, that we give too little precious time and trouble to explain more to our patients, the public at large.

The information asymmetry due to the very wide knowledge gap and esoteric nature of medical jargon and terminology only continues to drive a deepening wedge between the medical profession and the public. Our perceived haughty tone also isolate us from the more curious if lesser informed public. Many now hanker for better understanding but because their educational or belief systems are so varied, these create what appears as an unbridgeable divide that makes communication less amiable and severely limits two-way exchanges.

Unfortunately many doctors and medical graduates are never adequately taught to speak and communicate in simple layman’s language. Perhaps this has to be addressed—doctor-speak and ‘medicalese’ vocabulary creates misunderstanding or confusion, which lessens the doctor-patient encounter.

Most doctors tend to find comfort in their own abstruse medical universe. But this clearly must now change. We have to engage the public as never before, we must make ourselves clear and express ourselves better, if we hope to continue to be as meaningful and as trusted by the public. We must give our patients more time and show a greater empathy. We must not be mere business contractors, too busy and too calculating to care.

Paternalistic attitudes of the past when “doctor knows best” are long gone and passé. We must become attuned to the times—we need to re-engage with our more knowledgeable and more inquisitive patient, so that we meet their rising expectations, their trust that we duly deserve.

However, throughout the rest of the world, most people do continue to find doctors most trustworthy. For example, the MORI poll of the United Kingdom has consistently found doctors to be most trusted (with 92% believing that doctors can be trusted to tell the truth), way ahead of politicians (13%), ministers (16%) and journalists (22%).[2]

Expanded Moral Imperative for the Physician

So, in many ways, the Malaysian doctor is now perceived somewhat differently. We are now caught in the crossfire of growing skeptical if flawed sophistic judgement and inquisition by a larger segment of a more discerning public.

Simply put, while we generally still enjoy our much-vaunted position of trust and respect from the general public, we are getting more than the occasional hiccups from bad press and publicity. Perhaps, this trust has dropped a few notches, but there is by and large hope that doctors can rise above the fray of the mundane mediocrity of Malaysian society!

Furthermore, we are exhorted to become more than what we have been accustomed to do thus far—being far too meek, commonly apathetic, conscientiously practice-oriented, and indeed fully focused only on our parochial medical interests, our bread-and-butter humdrum lives and livelihood…

Perhaps, there is greater expectation that as a whole, our usually higher moral standing should buttress a more consistent level of ethics and good societal practices, most of which have taken tumbles from our previously respected lofty heights. Our debilitating institutions and highly questionable state of affairs have cast a shadow of despondency on a large segment of our more enlightened society.

Although many of us traditional doctors are wary of treading on the wrong side of political correctness, there are increasingly greater demands on the astute doctor to act according to his or her expected standard of intellectual and professional standing, training and moral compass—to do the right thing or at least to come right out and say so.

The public demands that doctors stand up to be counted, to emerge outside of their previously cloistered if self-contained comfort zones. The long gestation within our pupated hibernation phase should cease; doctors must rekindle their sense of commitment and engagement with society.

Doctors are expected to help influence the finer direction of where we hope our Malaysian society should go, although like any other profession, there would be many amongst us, who would be and have been partisan or even ethnocentrically chauvinistic or religiously fanatical! That is why so many amongst us have participated in politics, some more successfully, others less so, some shaping our entire nation, while others simply creating meagre waves of lesser consequence.

But for most of us, we can be less fraternal and still contribute without partisan leanings, which would therefore be less inclined to colour our judgements and perhaps even our professionalism!

That said, it is perhaps time to become more engaged and involved. It behooves our dignity and arguably may enhance our trustworthiness in the eyes of the general public. Doctors must be doing more and must treat everyone with the respect and dignity no matter who they are.[3]

Improving our Caring Ethos

We need to reaffirm our caring ethos, our trained and ingrained approach as our patients’ greatest advocate, no matter the contradictory signals and opposing forces that insist we are out of kilter. Our unwavering stance on the patients’ ultimate welfare should be our primary goal: “Primum Non Nocere”, and that as medical practitioners we are the best professionals to look after their healthcare concerns.

We also need to help expand the dialogue and public knowledge about healthcare issues and costs, and how some reform may be necessary. We need to expound more simply why everyone must play their part, including becoming more willing to contribute either via taxation or by some community insurance. Lack of in-depth information has hampered discussions on this difficult but necessary subject. The MMA and the medical profession must lead the discussion on the issue of affordable and sustainable healthcare financing.

Truth Telling & Ethical Professional Practice

Incredulous and conflicting forensic pronouncements in the Kugan “death in custody” case, as well as that concerning the more recent Teoh Beng Hock fall from the MACC building, have punctured the believability of health officials involved in the truth-seeking exercises and justice—so crucial for trust in our public institutions. Custodial injuries and deaths number into the hundreds or more, and have remained largely unexplained and unaccounted for, again undermining our state institutions, and potentially breaching international law on human rights and detention rules.

We also hear of possibly coerced and altered medical reports from physicians who have been pressured by higher authorities which endanger the independence and reliability of the truth telling process of what the medical examination and reporting is all about. Our forensic integrity has also been shaken, when external experts are increasingly sought to offer more dispassionate and impartial deliberation of the truth.

In this regard, our local experts and medical professionals must re-examine their own conscience and moral anchor to deliver greater believability and accuracy of their duties and findings. Doctors must not become unduly influenced by any external party or forces; they must endeavour to tell the final unimpeachable truth, without fear or favour.³

State vs. Professional Interests must be clearly defined, with the medical professional always taking the position of determining the medical truth and facts, while protecting the rights and position of the patient, the detainee, the prisoner, even the death row inmate. Detention Health, Torture, Injuries, Death & Medical Professional Duties are all well articulated by world-recognised authorities and bodies such as the World Medical Association’s Declarations of Geneva, Tokyo and the Istanbul Protocol, and the United Nations Commission on Human Rights. We encourage our medical colleagues to be fully aware of these onerous responsibilities and roles.

Healthcare Rights Advocacy

Finally, in this day and age, the medical professional is exhorted to be more involved in human rights advocacy. The World Health Organisation (WHO) has quite categorically stated that health is a human right, i.e. every human being should have the right to access to healthcare.

The difficulty of course, is to define the quantum and the scope of how much and how comprehensive that right to healthcare should extend. Because, unfettered healthcare is becoming an untenably expensive affair, some form of rationing and queuing will have to be the way forward—with the usual altruistic goal of greatest benefits to the greatest number of people.

This means that we have to collectively find some agreeable way to establish what is considered as reasonable and adequate healthcare at the most affordable means, which can benefit the greatest number of people. The poor must not be marginalized or shortchanged in an ideal world. As doctors we must try and find some equitable equilibrium, while continuing to allow choice and freedom to choose within reasonable boundaries.

In this regard I would like to quote Professor Ian Gilmore (President of the Royal College of Physicians of London who said that:

“As doctors, we are often looking at the single patient in front of us, but as ambassadors for improving healthcare we have roles in the NHS, in healthcare and in wider society to become champions of change to protect the planet from climate change. As private individuals, we may well act ecologically, but may not always have carried our private views into the public arena. It is time we stepped up to the plate.”[4]

In Malaysia, we too have to step up to the plate and walk the extra mile to do more, to show our fellow citizens that we can do more. Perhaps we can help bring about greater and more beneficent reform, measures which would perhaps regain the public’s trust in us once again.

The MMA is fully engaged with the MOH, in trying to find a better way for the Malaysian healthcare system. We believe that the public too has a stake and must also be part of the reform process. However, there are many obstacles and divergent viewpoints, which need to be reconciled and overcome. But, we are confident the best is yet to come, if we all put our minds to it. We need knowledgeable physicians to help us move the momentum towards the final goal, which is unlikely to be static but perhaps dynamically evolving...

“Every now and then go away, have a little relaxation, for when you come back to your work your judgment will be surer. Go some distance away because then the work appears smaller and more of it can be taken in at a glance and a lack of harmony and proportion is more readily seen.” ~ Leonardo Da Vinci

References:

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[1] Readers Digest. Trust Survey 2009 – Malaysia (Accessed at http://www.rdasia.com.my/trustsurvey2009my on 10 April 2010)

[2] Ipsos MORI. Trust in Professions 2009 for The Royal College of Physicians. September 2009, London.

[3] David KL Quek. Malaysiakini: Unbiased treatment for all. http://myhealth-matters.blogspot.com/2010/03/malaysiakini-unbiased-treatment-for-all.html (Accessed at 11 April 2010)

[4] Doctors can no longer ignore climate change, says RCP President, Politics.co.uk. (Accessed at http://www.politics.co.uk/press-releases/doctors-can-no-longer-ignore-climate-change-says-rcp-president-$484799.htm on 08 April 2010)