Kung-fu Masters and Medical Legends

10 Sep 2008

By Khaw Boon Wan

1 Last month, the US Public Broadcasting Service (PBS) came here to make a documentary on our healthcare system.  PBS is the most prominent provider of TV programming in the US, with over 350 member TV stations.  It is one of America’s most trusted institutions. 

2 I spent an hour with the producer, the journalist and their crew.  They were new to Singapore.  They were fascinated by our high standard of healthcare services, comparable to the US, but delivered at a fraction of their cost.  For example, a total hip-replacement operation in the US costs about US$ 43,000, but a similar operation in Singapore, unsubsidized, averages US$ 12,000.  With subsidy, a Class C patient pays below US$ 2,600, fully funded by MediShield if he has one, or from his Medisave.  If he and his family members have neither, Medifund comes in to pick up the bill.

3 With 50 million Americans getting priced out of costly health insurance, they are interested in how we ensure every Singaporean, even if poor or unemployed, has access to good healthcare.  They interviewed a Medifund-assisted Singaporean patient.  They also interviewed a foreign patient who flew here to get an elective surgery and paid much less, including the trip, than if he were to be treated at home.

4 I explained how we have inherited the British taxation-funded model but carefully grafted onto it useful elements of the US privatized healthcare model, and included an important element of personal responsibility and co-payment.  This way, we incorporate the best features of different systems and avoid their pitfalls.  Our hybrid system is not perfect and we continue to refine it to make it work better for Singaporeans.

5 But there is one important aspect of our healthcare system which we did not have the time to discuss.  I am particularly proud of the high ethical standard of our doctors, which has led to strong public trust and respect for our doctors.  In many other countries, doctors are not as respected and trusted as before.  Medical litigation is common and patients are often left wondering if the doctors are putting their financial interests above their patients’ welfare. 

6 There was a recent media report from the US which stated that dermatologists there offered appointments about three times faster for botox treatment than for evaluation of potential skin cancer.  The article went on to note that they spend more time performing cosmetic procedures at the expense of other more essential dermatological procedures such as mole biopsy.  I hope the media report is exaggerated.  In any case, I hope we do not go down such a path.

7 Technical skills can be acquired; we spent millions of dollars sending our doctors to the best centres in the world to hone their skills.  Designing suitable insurance and health financing schemes can be done through a careful study of other systems elsewhere.

8 But a high ethical standard of medical profession is not so easy to achieve.  It takes years to nurture and inculcate.  Senior doctors demonstrate their values and commitment to their patients through their daily activities; junior doctors observe and internalize these values through a long process of osmosis.  Unfortunately, values cannot be transferred instantly, but their erosion can happen quietly and before we realize it, they are gone.

9 I spent some time learning tabla from an Indian third-generation tabla player in Singapore.  He explained to me how his grandfather and father taught tabla in India.  The masters demand full attention and total devotion from their disciples.  During the foundation years, disciples stay in with the masters, 24 hours a day and 7 days a week.  They follow his instructions fully and without question.  Only after they have completed the foundation course, will the students be allowed to seek out other masters, learn new styles or evolve their own.

10 My teacher told me how his grandfather, who continues to teach in this ancient fashion in India, had disapproved of his style of teaching in modern Singapore, where the students come and go, distracted by various things and events of modern living in between lessons.  I must be his most distracted student.   As a result, my tabla playing is nothing to brag about.

11 Traditional classical music teaching approach is similar to how Buddhism was taught and transmitted in ancient India.  When Buddhism spread to China, the same approach followed there.

Kung-fu Masters

12 Two years ago, I visited the Shao-lin Temple in Henan.  The training of Shao-lin kung-fu and zen meditation has evolved much from the ancient approach.  Modernisation has made it difficult to sustain the old traditions, but they try to retain the essence of the master-disciple relationship and apply it to modern monks.  The ancient masters would likely disapprove, but the practicality of modern life makes such changes inevitable.

13 I am not a doctor but I observe that the best doctor is able to inspire, teach and gather around him many young doctors and inculcates in them his values and ethos, besides his skills.  This is not unlike how a kung-fu master trains and inspires his disciples.  The transfer of technical skill is the easier part.  This can be modernized using IT and other educational tools.  But the values and high ethos have to be passed on through daily interactions, sustained over many years.  There is no short cut.

Medical Legends

14 I attended the recent Annual Dinner of SGH’s Urology Department.  This department was founded by Prof K T Foo.  I have watched this department grow in stature.  Its patient-load has grown and the skills of the doctors have matched the best in the world. I particularly admire the high ethical standard and the institutional values that Prof Foo has imparted to his disciples.  At the dinner, Prof Christopher Cheng, current Head of the Department stressed his doctors’ commitment to their patients, whether private or subsidized.  I got to meet many of Prof Foo’s disciples.  Whether they remain in public service or go into private practice, Prof Foo’s values and influence remain palpable.  This is an accomplished kung-fu master who has what political scientists now call “soft power”. 

15 In Singapore, we are blessed with many such accomplished kung-fu masters in the medical world: Prof Seah Cheng Siang, Prof SS Ratnam, Prof Wong Hock Boon, Mr N Balachandran, Prof Nambiar, Prof Y Y Ong and many, many more.  They are what makes our healthcare system exceptional.

16 Building a hospital is relatively easy and can be done in a few years.  Building institutions is much harder.  It needs exceptional leaders who are exemplary in character and actions and who mentor and lead by example over long period of time.  They are legendary in their insistence on keeping up to date in their profession, high standards of work, respect for patients and colleagues and doing their best for their patients.  They are upfront and forceful when articulating the values they stand for.

17 To these days, those who had worked for Prof Seah Cheng Siang tell stories of his grand rounds: MOs going to the wards an hour before morning rounds to make sure that all relevant information about the patients would be available, his insistence on beds be properly lined up, crumpled case notes be ironed, and instructing housemen to do hourly glucose monitoring for patients over night.  Prof Seah nurtured many doctors who in turn become role models and teachers to others.  His legacy lives on in many.

Basic Mission

18 We are transforming our healthcare system, giving greater emphasis to prevention and disease management, achieving greater integration among all the stakeholders in the healthcare family, supporting clinical research in a targeted way and introducing structured specialist training programmes.  But the basic philosophy of serving our patients well, protecting their interests and maximizing their welfare remains our fundamental mission in life. 

19 As the elderly population expands, end-of-life matters will also feature more and more prominently in our daily working life.  How to help the patients and their carers cope with the limitations of modern medicine will demand from us the noble calling that attracted us to the healthcare sector in the first place.  Without a strong trust between the doctor and his patient, the medical advice, for example to simply let nature takes its course, is likely to be misunderstood.

20 This book that we are launching today compiles the stories of many prominent doctors, their lives and their experiences in the world of medicine.  Their stories touch on the fundamental values and ethos of medicine, their selfless dedication to their patients and their unyielding commitment to advancing their profession. 

21 The practice of medicine has changed immensely with modernisation.  Traditional values are increasingly challenged by the commercialisation of medicine.  The growth of the lucrative practice of aesthetic medicine is a good illustration.  I was surprised to read that 60% of our GPs engage in aesthetic medicine.  Drilling down the survey, I found that the more correct figure is that only about 6% of their daily work involves some aesthetic procedures.  Moreover, many of such procedures are quite legitimately medical practices and not frivolous.  I was relieved.  But we must not be complacent as we can easily go off-track and forget our primary purpose and calling. 

22 A Family Physician related to Prof Foo a real life story of an executive he treated recently.  He saw the patient for a left sided back pain and urinary infection on a Monday evening.  He treated him with antibiotics and advised him to drink sufficient water and return a few days later for review.  However, the patient was inpatient and anxious.  He went to consult a nephrologist the next day.  A series of tests and CT scan of the lower abdomen found no significant cause.  The patient was then referred to an orthopaedic specialist who did an X-ray of the spine and an MRI which were normal.  So he referred him the next day to a gastroenterologist who promptly did ultrasound of the liver and gall bladder and a gastroscopy and found them to be normal.  By Friday, when he returned to see the Family Physician, he had passed out two small stones by himself.  He could have simply followed the sound advice of the Family Physician and avoided all the unnecessary specialist consultations, not to mention the loss of thousands of dollars!

23 Prof Foo related another example of a 60-year old pharmacist who having attended a health talk on prostate disease, followed up with a check of his prostate specific antigen (PSA) and found it to be raised.  A biopsy of his prostate was promptly done and this confirmed cancer.  He had radical surgery to remove his prostate, which unfortunately rendered him incontinent (which happens to about 5% of patients) and impotent (which happens to the majority of the patients).  Has he benefited from the PSA test?  Without surgery, there is a 14% chance of him dying of prostate cancer in 8 years, with surgery the chance is reduced to 9%.  Is it worth it in return for the side effects and the small risk of dying at the operation, not to mention the cost?

24 In both incidents, were the specialists unethical in prescribing what they did to the patients?  There is no clear cut answer.  They are doing their job as a specialist and they have to investigate to rule out any pathology, and to intervene, even though more often than not, the intervention may not make that much difference to outcome.  As patients become more demanding, ethical issues are becoming more complicated.  

25 We need wisdom in the medical leadership to help us preserve our high medical ethos in this complicated world.  Fortunately, we have strong and sound leadership at the helm of the key institutions, including the SMC, the Academy of Medicine, the Colleges and the various Clinical Departments.  We are building a pipeline of potential successors.  The medical profession’s self-regulation of aesthetic medicine is an example which gives me comfort. I had thought that it would be controversial and they would take ages to manage turfs and reach any compromise.  But no, between the SMC, the Academy of Medicine and the College of Family Physicians, they forged a quick consensus on a set of good guidelines, which can be a model for the rest of the world.

26 We must however be mindful that there will always be black sheep in any flock.  The ethical majority must not allow a few black sheep to stain their noble profession.  They must be prepared to come out, whistle-blow and not simply look the other way.  Some of us are prepared to be the bad guy and to pull the trigger, but we need you to blow the whistle.  If sound values and medical ethics are perversed, our journey to a healthier society would be jeopardized.     

27 There is a part for every one of you to play in preserving the traditional values and ethos of medicine.  I applaud SingHealth’s effort in capturing the heart and soul of medicine with the personal reflections of doctors who have passed through its doors.  This would allow the younger doctors to understand better what has changed and what must not change even as the world around them changes.

28 Medicine in Singapore has a glorious past.  Past masters have earned the respect of their patients and demonstrated why society should hold doctors in high regard.  I am confident that Singapore medicine will have an equally bright future, through its continued commitment to the profession’s values and ideals.