As a doctor in private practice for three years, I've noticed that the most common question I've been asked is: "How's your practice doing?" It's the natural question and also one that expresses appropriate concern for my personal well-being. After all, my practice is now directly responsible for feeding myself and my family.
However, that's not the question I'm itching to be asked. Ask me instead: "Are you enjoying looking after patients in your practice?"
The answer is a resounding "Yes." Yes, I enjoy medicine now more than ever before.
I enjoy autonomy, sanity and, most of all, time. Time to speak to my patients and get to know them better; time to ask them about their children's birthdays, their lives and work; time to discuss their hopes and fears; and time to "care more particularly for the individual patient than for the special features of the disease" as William Osler once famously proclaimed.
Yet, how does one go about writing an article in defence of private practice? Is it not, according to Dr John Dean's writing for The BMJ,1 a Gordian knot of conflicting interests which forces physicians to choose personal enrichment over service to their patients? Surely such an article is an exercise in futility.
Surely.
An ethical knighthood
However, is this consistent with what we know? The author of the aforementioned BMJ article waxes lyrical about the many "evils" of private practice, but all his points eventually boils down to just one issue: Are doctors, by and large, able to put their patients' interests before their own? Are the members of our profession so morally brittle that the majority of us are unable to manage a conflict between our patients' interests and our own?
That would be strange, because it seems to me that clinicians face all sorts of conflicts of interests in their daily lives. While in the public service, my colleagues and I regularly worked 80- to 100-hour weeks, often choosing our patients' best interests over our own. Most of us skipped meals, spent little time with family and sacrificed sleep. Long sleepless nights spent on call meant that all of us had hilarious tales of falling asleep at awkward moments and not-so-hilarious tales of narrowly avoiding death while falling asleep at the wheel. Every doctor knows what it is like to miss birthday parties, weddings, funerals and class reunions. On the day my grandmother passed away, I was on call in the ICU – keeping someone else's grandmother alive.
Physicians, it seems, have a record of consistently placing their patients' interests above their own.
Does going into private practice change this?
The numbers don't lie
Based on the prima facie evidence, it looks bad. Some articles in a local newspaper have suggested that not only are we avaricious fellows who have shrugged off our social responsibility of sustaining the public healthcare system (one of the world's most cost-efficient healthcare systems that looks after the majority of the population), we are also apparently responsible for the majority of overcharging, the greatest healthcare inflation, and are out to scam insurance companies and patients of their hard-earned money.2,3,4,5
Sensationalism aside, let us take a look at the data. In 2017, the Singapore Medical Council (SMC) received 182 complaints against 242 doctors. Not all of these have been processed yet, but assuming consistency with previous years, about a quarter of these complaints are immediately dismissed.6 The proportion of complaints that the private sector is responsible for is not immediately clear from publicly accessible online data, but let's assume for a moment that the private sector is responsible for all of these. There are 13,000 doctors in Singapore, of which 20% are foreign and mostly in public practice. 4,500 are in private practice, of which about 2,700 are GPs.7 If we assumed that each doctor in private practice only saw 20 patients a day, six days a week, we would have roughly 19 to 20 million patient contacts a year. I'm not great at mathematics, but private practice has forced me to be proficient at basic arithmetic; even if all the complaints are valid and all are against the private sector, 182 divided by 19.5 million is an insignificant number.
Hang on – you might say – 182 complaints may be just the tip of the iceberg; after all, patients might not know any better. Well, let's assume again that all 242 doctors complained against are guilty and that all of them are in private practice. Let's also assume that just a single complaint is sufficient evidence of irredeemable and eternal ethical failure. Even then, with all these caveats, 242 divided by 4,500 would still mean that only 5% of doctors in private practice seem to be unable to resolve their ethical issues.
Let's look at inflation next. Are private practice doctors greedy and avaricious? Are they – as the newspaper articles suggest – responsible for enormous healthcare inflation and are paid out of proportion compared to their public sector colleagues? As of 2017, private sector healthcare inflation stands at 9.6%, and this is supposedly double the rise in public sector claims.8 This statistic, however, looks at patients' out-of-pocket bills before Government subsidy. How has the public sector fared before Government subsidy? Not well it seems. Singapore intends to budget $10.2 billion for healthcare spending in 2019.9 By 2020, the expected healthcare costs will have tripled from 2010. That places public healthcare spending inflation at 300% over ten years.10 Public healthcare spending, it seems, is inflating much faster than private healthcare spending.
The next question, of course, is that healthcare spending is indeed inflating, but where is the money going? Are doctors earning the money? Here, the numbers speak well for doctors too. The cost of running a practice has increased 45% from 2013 to 2016 but patients' fees have only risen 16%. In 2017, the average GP paid himself $10,000 a month – a number identical to a 2013 survey.
After accounting for all profits, the average GP earns $15,000 a month.11,12 Comparatively speaking, the average resident physician earns $6,000 to $8,000 a month before accounting for leave, bonuses, medical reports and call allowances, easily bringing the total up to $12,000. This is, of course, ignoring the personal financial risk taken in setting up a clinic, as well as all the extra work a GP does to run his clinic, effectively taking the places of pharmacy technician, staff nurse, care coordinator and dietician in his personal practice.
Two thousand years of private practice
We've inherited the Hippocratic Oath and its values from the Hippocratic tradition. Ingrained in it are the ideals of collegiality, beneficence, non-maleficence and professionalism that Hippocrates practised. These values have guided our principles, every thought and gesture behind our practice of medicine. We have been exhorted to upkeep them by luminaries like William Osler. Two thousand years later, these values were again enshrined in the World Medical Association's Declaration of Geneva which emerged from the 2nd General Assembly of the World Medical Association (WMA) held in Geneva, Switzerland, on September 1948, led by its first Secretary General, Dr Louis H Bauer. From this WMA pledge we have derived our own SMC physician's pledge.
Looking carefully at the text of the pledge, there is nothing in it that precludes the physician in private practice from cleaving to its values and this fact is best argued by the fact that Hippocrates, Dr Osler and Dr Bauer were all, by definition, private practitioners – private practitioners who thoroughly enjoyed a meaningful and ethical practice of medicine.
Two thousand years of private practice have helped shape our profession into what it is today; there's no reason for it to stop now.
The Hippocratic Oath
"I swear by Apollo the Healer, by Asclepius, by Hygieia, by Panacea, and by all the gods and goddesses, making them my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture.
To hold my teacher in this art equal to my own parents; to make him partner in my livelihood; when he is in need of money to share mine with him; to consider his family as my own brothers, and to teach them this art, if they want to learn it, without fee or indenture; to impart precept, oral instruction, and all other instruction to my own sons, the sons of my teacher, and to indentured pupils who have taken the physician's oath, but to nobody else.
I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing. Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course. Similarly I will not give to a woman a pessary to cause abortion. But I will keep pure and holy both my life and my art. I will not use the knife, not even, verily, on sufferers from stone, but I will give place to such as are craftsmen therein.
Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman, bond or free. And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.
Now if I carry out this oath, and break it not, may I gain for ever reputation among all men for my life and for my art; but if I break it and forswear myself, may the opposite befall me."
The Physician's Pledge
As a member of the medical profession:
I solemnly pledge to dedicate my life to the service of humanity;
the health and well-being of my patient will be my first consideration;
I will respect the autonomy and dignity of my patient;
I will maintain the utmost respect for human life;
I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient;
I will respect the secrets that are confided in me, even after the patient has died;
I will practise my profession with conscience and dignity and in accordance with good medical practice;
I will foster the honour and noble traditions of the medical profession;
I will give to my teachers, colleagues, and students the respect and gratitude that is their due;
I will share my medical knowledge for the benefit of the patient and the advancement of healthcare;
I will attend to my own health, well-being, and abilities in order to provide care of the highest standard;
I will not use my medical knowledge to violate human rights and civil liberties, even under threat;
I make these promises solemnly, freely, and upon my honour.