The evolving healthcare landscape
Long before I was elected as the 59th SMA President, doctors have been facing mounting pressures from all sides. The policy changes and various healthcare developments discussed below are just a few examples of what has transpired in the recent years.
Regulatory issues
The proposed Healthcare Services Act (HCSA) going online by the end of 2020 will be replacing our age-old Private Hospitals and Medical Clinics Act. With it in place, we will be moving from premise-based licensing to service-based licensing.
Being one of the few countries in the world to have the National Electronic Health Record (NEHR), the HCSA aims to make it a requirement for all doctors to contribute patients' data to it, with a hefty penalty to be imposed on those who refuse to comply.
Clinic licensees had to register for CorpPass, a digital identity akin to the SingPass but for corporate transactions. Many applicants faced multiple rejections and it was only later that we realise that there were some missing data that hindered the registration of clinics.
The Enhanced Screen for Life (SFL) is a subsidised health screening programme implemented in Community Health Assist Scheme (CHAS) GP clinics. However, the massive response overwhelmed the existing CHAS submission portal on day one and IT support was not responsive after implementation for months; all while clinic licensees were still learning the workflow of the scheme and claims submission procedure.
Medical practice
In 2016, the Health Insurance Task Force studied the rising costs in healthcare over the years and released their report and recommendations. One of the causes was attributed to the increase in doctors' fees. When SMA was forced to withdraw our Guideline on Fees in 2007, we warned that doctors' fees will rise as there is no longer a guide on what constitutes overcharging. Nevertheless, we welcome the upcoming implementation of the new fee benchmarks to guide our charging of medical fees.
Third-party administrators (TPAs) have limited the way we practise medicine by controlling costs and restricting who we can refer our patients to under their schemes. With the revised version of the Singapore Medical Council (SMC) Ethical Code and Ethical Guidelines (ECEG), TPAs no longer calculate administrative fees based on a percentage of the bill but must use a fixed quantum, and this has worked well so far. It was a harrowing experience for doctors: some resigned from various TPAs at short notice while some re-joined after TPAs changed the way they justify and calculate administrative charges.
With regard to medical negligence cases, the modified Montgomery test was introduced. This test considers whether the patient has received useful medical information that was material to him/her especially with regard to consent. This is as opposed to the commonly accepted Bolam-Bolitho test that is still applicable to treatment and diagnosis.
Additionally, patients want to be empowered in the decision-making process in the treatment and management of their conditions. They access the internet for related medical information and challenge their doctors with the information gathered. However, are they able to determine the reliability of the information or news?
Technological advances
Advancements in technology have given us telemedicine, with the expectations of convenience to patients as they consult doctors from the comfort of their homes or offices, and have electronic medical certificates and medication couriered to them. However, are doctors who signed up for telemedicine services aware of the perils of prescribing medicine without physically examining a patient? The SMC ECEG and National Telemedicine Guidelines both strongly emphasise that the standards in telemedicine consultations should be similar to those of face-to-face consultations.
Another concern is with how artificial intelligence (AI) could potentially replace doctors. It is said that AIs are now capable of collating and analysing data from medical libraries worldwide, simulating human emotions and performing deep learning.
Effecting change
Hence, it is definitely not surprising why some of my contemporaries have given up their medical practice to work as locums, go into early retirement or move out of the medical field entirely. How can we make the practice of medicine viable and satisfying so that we can continue to practise evidence-based medicine, provide integrated and team-based care, and make it an attractive career option to our juniors?
Some things will have to give as we are not perfect. Is doing our best and in good faith no longer acceptable? I think the key is that we need to know what is the best that we can do for our patients and refer the rest to those who are better at it.
Firstly, we need all stakeholders to be realistic and pragmatic in their expectations of medical doctors. Doctors are human too; we have our basic needs, as well as our moments of weakness. We will do our utmost for our patients but we also have to satisfy our basic needs and protect ourselves from burnout. We need to take care of ourselves well before we can take care of others well. If we are in a compromised state, I do not think that we can treat our patients and make the right judgements to the best of our ability.
Secondly, we need to have a training curriculum with a heavier emphasis on ethics instead of "just getting the job done". It is sad that the art of medicine may no longer be relevant if science-based medicine takes over. However, it may not surprise us that the art of medicine would be able to hold its own against the head-on charge of AI in medicine.
Thirdly, we need to constantly upgrade ourselves both formally and informally. As medicine progresses with time, we as practitioners of medicine should be cognisant of the changes that medicine is undergoing and upgrade our knowledge in parallel. Never give up on yourself and never think that you are too old to learn new tricks. Don't be afraid to ask "stupid" questions, for we would be fools to ignore our ignorance when holding critical responsibility as practising doctors. Be aware of the changes around us and be active in trying to contribute to the improvements in our society.
Fourthly, we need to open our eyes and not just stay within the confines of our silos and our comfort zones. The fresh air, warm smiles and bright sunshine will help to invigorate us, the changes will intrigue us, and hopefully, we will in turn be able to give our patients the best advice we can.
By doing some of the items listed above, we as medical doctors can renew our efforts to remain relevant in our society. We should engage actively with various stakeholders and prevent problems by identifying and solving them "upstream".
Lastly, do share warmth, knowledge and collegiality with your friends and colleagues because our fraternity can only be strong if we help one another to get out of the rut and move forward.