Singhealth Scientific Meeting

17 Oct 2004

By Dr Balaji Sadasivan, Senior Minister of State for Information, Communications and the Arts and Health

Venue: Swissotel Stamford

Lecture By Dr Balaji Sadasivan, Senior Minister Of State, Ministry Of Information, Communications And The Arts And Health At The Singhealth Scientific Meeting 2004 On Sunday, 17 October 2004 At Swissotel Stamford, 7.50 Pm

Mr Bernard Chen, Chairman Singhealth;

Prof Tan Ser Kiat, Group CEO Singhealth;

Prof Fock Kwong Ming, Organising Chairman for Singhealth Scientific Meeting 2004;

Distinguished Guests,

Friends and colleagues,

I am honored to deliver the Singhealth lecture 2004.

In 1990, a Minister in the United Kingdom assured the public that British beef was absolutely safe. To prove this, the Minister persuaded his 4 year old daughter to join him in eating hamburgers in front of the TV cameras. We now know that British beef did cause mad cow disease in humans. Fortunately, I understand that the Minister, now a back-bencher, and his daughter are doing well. In July this year, a report on the SARS outbreak in Hong Kong led to the resignation of two top officials because the report was critical of their handling of the SARS outbreak. Hong Kong Chief Executive Tung Chee Wah praised the two officials but he did not reject the resignation offers. He said he accepted the resignations after careful consideration. In Singapore, a doctor is currently being sued because a child was born with Down's Syndrome. The predicament of the British Minister, the Hong Kong officials and the Singapore Doctor is related to a subject that is increasingly becoming important -Risk Communication. Deficiencies in risk communication, whether real or perceived, are the cause of their predicament. I have selected "Risk Communication in Healthcare" as the topic for tonight's Singhealth Lecture and feel that it is timely for the medical community to reflect on the aspects of risk communication that are relevant to healthcare.

Risk communication is a risky topic to lecture on to an audience that is so eminently scientific because risk communication is a soft science. So individuals can draw a range of conclusions about this subject and there is no definite right or wrong conclusion. However, in the spirit of our times, where PSLE students have to answer open-ended science questions which don't have a single right answer and so a range of answers is accepted, I shall speak on this topic on which there is no certainty what the right conclusions should be.

This was most evident to me when last month, WHO held its first meeting on risk communications in disease outbreak in Singapore. Its aim was to try and develop a document that could serve as a template for risk communication. One issue that came up during discussion was - should an official cry openly? Some said it was good to cry because it showed the official was human and helped connect with the public. Others said it would erode the public's confidence in the ability of the official to deal with the crisis. The WHO document would probably have to conclude that sometimes you may cry and sometimes you may not. This is why risk communication is a soft science.

Actually, doctors are in the business of risk communication almost on a daily basis. Over the last thirty years, from the time when I started as a medical student, there has been a philosophical shift in the doctor-patient relationship that has made risk communication more important to medical practice. Traditionally, doctors have followed the Hippocratic Oath. The Hippocratic Oath says that the physician should benefit the patient and protect him or her from harm. It is based on a paternalistic philosophy. Paternalism is an action that is taken for the benefit of another person and that is done for the welfare of that person. This is what parents do for their children. Medical paternalism is part of the Hippocratic tradition. This tradition does not factor in benefit based on the patient's judgment.

Thirty years ago, this attitude in doctors was accepted as shown by a case that was before the General Medical Council in the 70's. Dr Brown was a 63 year old GP. He was a family physician for a young lady and had looked after her since her birth. This young modern unmarried lady wanted to go on the contraceptive pill. She quite correctly decided that the old-fashioned Dr Brown would not approve of this and went to a family planning clinic where she got a prescription for the contraceptive pill. It was standard medical practice to inform the family physician if one writes a prescription for a patient who is normally under the care of another. So Dr Brown received a letter informing him that his patient was on the pill. Dr Brown claimed he was worried about the total well-being of his patient, in particular her "moral health". He consulted his colleagues, got their advice and than informed the young lady's father. The young lady was not pleased. The clinic physician who wrote the prescription was not pleased. Dr Brown was charged before the General Medical Council with violation of patient confidentiality. Dr Brown introduced the Hippocratic Oath in his defense. He said he truly believed that his actions were beneficial to the patient. The patient's views on this did not count and he was acquitted by the General Medical Council.

When I was a young doctor, many senior doctors had the same paternalistic attitude of Dr Brown. Patients were told what would be done. They rarely were asked to make a choice. The choices were made for them. Patients appeared satisfied with this approach. In the Hippocratic tradition, the doctors communicated much empathy, sympathy, care and concern but the physician made the decision for the patient.

In 1961, in the United States, a survey was done asking US physicians what their usual policy was regarding telling the truth to terminally ill cancer patients. Eighty-eight percent said their usual policy was not to tell the patient if the diagnosis was a malignancy. They were concerned that the news would upset the patient and following the Hippocratic tradition, they did not want to upset the patient. Less than 20 years later, in 1979, a similar survey showed the percentage had shifted dramatically from 88% to 2 %.

There has been a shift in attitudes. Today, medical ethics is based more on the concept of patient autonomy and the patient's right to know and decide using his free will. This is based on the philosophy of the 18th century German philosopher Immanuel Kant. Kant was born in Konigsberg, Germany and never left his province. He was a very orderly person and maybe that is why he never married. He lived a most uneventful and routine life that the residents of Konigsberg could correct their watches by him as he passed their window on his daily walk. Until he became elderly, he did not count for much. But between the age of 57 and 66, he produced works on free will, autonomy and the liberating possibilities of human reason and social progress, that form the basis for our current day views on autonomy, free will and the rights of the individual. So for those of you who have not yet reached the age of 57, the best is yet to be. This liberal political philosophy of Kant as applied to medicine was expressed by an American judge in the following words: "Each man is considered the master of his own body and he may expressly prohibit the performance of life-saving surgery or other medical treatment."

The ethics of political liberalism stands in contrast to the ethics of Hippocratic paternalism. Can doctors in Singapore do what Dr Brown did? Do we have a choice of which ethics to follow? No, we do not because the SMC Code now explicitly states that a doctor shall respect a patient's choice. In this, the SMC Code upholds the principle of patient autonomy and right to self determination. Except for unusual situations where the doctor can still apply the concept of therapeutic privilege, it is the general rule that it is the patient and not the doctor who will be in control. It is therefore very necessary for doctors to communicate risk to patients so that the patients can make the right decision. When patients make the wrong decision or have a wrong appreciation of the risks, or when the outcome does not match their expectations, patients may get upset, setting the stage for complaints and medical litigation.

The riskier the medical specialty, the greater the need for risk communication. There are four general rules of risk communication in medicine.

Rule one: Respect the patient. The patient is an intelligent person trying to make the best decision as it is his health, and his life that is at stake. Avoid patronizing language and medical jargon. Avoid being simplistic: operation - good; No operation - bad. This insults his intelligence because he can comprehend complex ideas if it is explained to him in non-medical language. Patience is needed and more than one round of explanation may be necessary. It is always better to spend time with the patient than with the lawyer from the medical protection society.

Rule Two: Be accurate. The information must be factually accurate as well as accurate in a subjective emotional sense. Conveying emotional accuracy is an art and often it requires presentation of the same information in different ways. For example, when the mortality risk for a surgery is 5%, this same information can be presented in different ways. If the patient said: "Doc, 5% is too risky", the doctor may respond that without surgery, the patient is almost certain to die but with surgery, 19 out of 20 patients do well and so the odds are in the patient's favor. On the other hand, if the patient said: "Doc, 5% is low risk", the doctor may state that the risk is not low because 1 in 20 patients dies after surgery. If 20 such operations are done each month, on average each month, there will be one death. The aim of presenting risk in different ways is to convey to the patient the correct subjective appreciation and insight into the risk.

Rule three: Empower the patient. For example, before surgery, patients can be given a spirometer to reduce their risk of chest infection. A spirometer is a plastic devise with 3 columns and a ball in each column. When the patient inhales, the balls will go up. With a weak effort - only one ball goes up, with a strong inhalation, 2 balls go up and with a really strong inhalation after practice, all 3 balls will go up. This is something patients can work on to help themselves. Empowerment makes patients feel they are part of the team in control of their health. It is easier to communicate risk to a patient who feels he is a member of the team than to a patient who feels he is the object of interest of the team.

Rule four: Always end on an optimistic note. Patients need hope. No matter how bleak things look, find some light at the end of the tunnel. Sometimes this can be truly difficult. For example, if the prognosis for a condition is a life-expectancy of 6 months, the situation is bleak. But even in this instance, an optimistic note can be found. Since statistics apply to the group and not to the individual, doctors will always have a patient who has done better than the average. An anecdote about a patient who has beaten the odds gives patients hope.

When the international risk communication experts were in Singapore for the WHO conference, they were interested in our policy on risk communication during SARS. The truth was that SARS hit us so rapidly that MOH had no opportunity to develop a formal policy. However, since the practice of politics is similar to the practice of medicine, risk communication between government and the people can be modeled on risk communication between doctor and patient.

Over the years, in politics, there has also been the same shift in philosophy from paternalism to one of greater individual autonomy. This is evidenced by the changes in the style of government from the time of our independence under PM Lee Kuan Yew to the more consultative approach of PM Goh Chok Tong to the current open and inclusiveness approach of our new Prime Minister.

When the SARS outbreak occurred, no one at MOH had any experience in pandemic risk communications. So as the outbreak progressed, the risk communication strategies were developed from first principles. I will not go into the details of MOH risk communication locally during SARS as many of you were on the frontlines and know all about it.

Internationally, in the early days of the outbreak, our risk communication had a political element to deal with as we had to contend with the Western media and their political interpretation of our public health measures. A newspaper in LA called Singapore "authoritarian", and CNN asked me in an interview how Singaporeans were responding to the infringement of their human rights. When the Toronto Star compared our so called harsh measures to those in Toronto, Minister Mentor Lee Kuan Yew remarked: "Let's produce results. Then the PR will look after itself." Events proved the wisdom of this advice.

Risk communication is important both at the micro level of doctor-patient interaction and at the macro level of government-people interaction. Organizations in between like clinical departments and hospitals should not be surprised to find that risk communication is also relevant to their work.

I am not suggesting that Singhealth start a media blitz with more newspaper and TV stories on cluster, hospital and departmental successes. In fact, less hype can be better as was discovered by Benjamin Franklin, the inventor of the bifocal glasses and the lighting conductor.

In his autobiography Benjamin Franklin notes how as a young man he had a habit of autocratic persuasion. On day a friend was bold enough to tell Benjamin Franklin how obnoxious they found him. He was told "your opinions have a slap in them for everyone who differs with you. Your friends find they enjoy themselves more when you are not around. You know so much that no man can tell you anything. Indeed no one is going to try. So you are not likely to know more than what you know now, which is very little."

Benjamin Franklin did not take offence and decided to work on his communication skills and he became a great communicator and diplomat. During the American War for Independence, he persuaded the other great powers in Europe not to support England which helped the Americans win their war. He said that he found that "the best way to convince another is to state your case moderately and accurately." I think we should follow this advice and show accuracy and moderation in our media stories.

Risk communication has to keep up with changes in knowledge and recent developments. Let me give an example. We have had breast cancer screening for many years. It is a good program. When the program started there was little controversy. Today, however, there is a controversy about breast screening. The controversy has even made its way into the front page of the International Herald Tribune. Some respected organizations recommend screening for women over the age of 50 only. Others recommend starting at a younger age. Still others take the position that screening has no value. More than 80,000 women in Singapore have been screened and we should now have local results. Breast cancer screening is a service that Singhealth institutions provide.

If we continue with the paternalistic Hippocratic tradition, than clinicians will continue to make the decision for Singapore women on who should go for screening without consulting the women screened. However if we believe that women are less willing to accept a paternalistic approach and believe in their autonomy and free will, than our risk communication must inform each woman about the controversies before they decide if they wish to proceed with screening.

Since the issue is controversial, just like the recommendations from the different prestigious organizations, which are not uniform, Singapore women may not all make the same choice given the same information. In order to make an informed decision they would also expect to be told the results of screening in Singapore. If we believe in the autonomy of women and their right to express their free will, we will give them choices after we have communicated the risks to them. But this will require a mindset change in doctors and their attitude towards patient rights.

Public attitudes have changed and they expect us to respect their autonomy. The public's expectations are reasonable and justified and we must strive to meet those expectations. This we can only do by improving our risk communication skills. The medical profession should avoid being like David Beckham. According to today's Sunday Times his mouth does not keep pace with his brain, and that apparently, is the source of his problems. I am confidant that our profession can do better and that our communication skills can match our technical competence.

Thank you