"Why travel? Why wait?" screams a mobile application advertisement in bright and bold orange font. Another says, "No more travel time, no more waiting rooms and no more long lines."
Practice of telemedicine and electronic medical certificates (MCs) are on the rise in Singapore. It's easy and simple. Get online, talk to your doctor and get an electronic copy of your MC. It provides a great boon to patients by eliminating the need to walk to and queue at the nearest GP clinic. It's also a lot cheaper than arranging a house call which can cost hundreds of dollars.
It's fast, cheap and good!
Any child growing up here in the 1980s knows this concept. If it's fast and cheap, it can't be good; if it's good and fast, it can't be cheap. It's a concept I learnt as a child, wandering around the wet market behind my mother's knee while she haggled with the wet market fishmonger in Cantonese. "No such thing as peng leng zeng (cheap, good and fast) lah, aunty!" the fishmonger used to say.
Telemedicine and its good buddy, the electronic MC, however, has proven my mother's fishmonger wrong. Now, it's possible for medicine to be good, cheap and fast; telemedicine and the electronic MC have taken centre stage in the world of medicine. Virtual platforms offering health consultation and electronic MCs have sprung up in Singapore like mushrooms after a proverbial summer rain. A half dozen or so companies now practise telemedicine within the Ministry of Health's (MOH) regulatory sandbox, which allows healthcare providers to "introduce new healthcare models or evolve their models in a safe manner, in partnership with MOH to come up with best practices for the new technology".1
Sounds like a great idea.
The disabled physician
Except – of course – that it isn't a new idea.
Doctors have had the tools to conduct some form of telemedicine for years now. The telephone allows us to "hear", and so we've typically used the telephone to play blind doctor and communicate with colleagues and patients for all sorts of reasons.
Typically, we have done so very cautiously because as health professionals, we understand that only so much information can be communicated via the phone. These have traditionally been restricted to consults with other trained health professionals and minor follow – up questions patients may have after going home. Such phone conversations are not uncommon, but they inevitably always end with the words: "Okay, but if you're not getting better, please come back and see me."
The advent of high definition video now allows the doctor to "see" as well, and the gain of this new virtual sense has spurred a wave of new companies clamouring to take advantage of this. However, a physician who can see and hear, but cannot feel, auscultate, percuss or assess vital signs, is still a severely disabled physician.>/p>
We didn't start the fire
One could argue that the application of telemedicine in the world is hardly a new thing and that there is significant online literature supporting the use of telemedicine. One would be correct to some extent.
However, the vast ream of online literature supports the use of telemedicine – in the chronic and follow-up care settings. The remainder of the literature supports the use of teleconsultations in rural areas where there is a lack of specialised medicine in conjunction with a primary care provider. There is precious little literature to support the use of telemedicine in an acute setting within an urban environment, and certainly not in Singapore where there is literally a GP practice on every street corner.
A legal document
The argument, of course, is that Singapore is different in its requirement of its denizens to produce an MC when they are absent from work. Therefore, it is logical that most patients are able to self-diagnose minor ailments and duly "report" their sickness to the doctor without much medical risk to the patient and legal risk to the doctor. That's certainly a logical argument, but not a very convincing one when you're in front of a lawyer who is cross-examining you for medical negligence. It also severely underestimates the value of the MC – a legal document enshrined in statutory law as a certificate only to be issued by a "medical officer" (defined as a practitioner recognised by the Singapore Medical Council [SMC]) who has "examined" the patient and is sufficiently satisfied that the patient in front of him/ her is truly ill. The difficulty of properly examining a patient over a video call need not be elaborated on, and one can only speculate as to how the law would choose to interpret the word "examine" should a test case ever come to pass.
Recent events have already shown us that the SMC does not take the issuing (or withholding) of MCs lightly, and it would seem reasonable to assume that physicians who issue MCs in a laissez – faire manner do so at their own peril.
A ruling of criminal negligence
In the absence of a local test case, let's perhaps turn our attention to other shores. A recent case in India, involving the death of a patient after a teleconsultation, has resulted in a conviction of criminal negligence.This has given the Indian Medical Association pause to seek clear guidelines from their own medical council due to concerns that the ruling seems to be against the practice of telemedicine.
In the meantime, our own SMC remains fairly clear. According to SMC Circular No. 2/2018, "In summary, diagnosis, prescription of medicine and issuance of MCs via telemedicine... is subject to doctors' professional judgement and the precise circumstances of each presenting case."2 That is to say that telemedicine is allowed, but only on your own professional judgement held to a standard of care delivered no differently compared to when you physically see patients in your own clinic.
That makes me think that perhaps I'd prefer to just see patients in my clinic.
However, a physician who can see and hear, but cannot feel, auscultate, percuss or assess vital signs, is still a severely disabled physician.