A very important role that the SMA plays is advocating for the profession. However, advocacy is by no means confined to advocating for the doctor without taking patients' interests into consideration. In fact, the starting point of advocacy for the profession is to consider the long-term interest of the patient. In this way, we cannot be misled by the short-term interest of doctors that may be at odds with the long-term interest of the patients or society. In a sense, this principle is like the lighthouse that guides the path of SMA. Without this beam of light, we would surely be waylaid by a multitude of treacherous obstacles.
Understanding the concerns of the profession
The bulk of these obstacles would be moral hazards which we face on a daily basis. In the private sector, we often have patient scenarios where there is a fork in the road. Either path that one chooses can be argued justifiably; the balancing of risk versus benefits can be so fine that a case may be made for going left or right. However, one road often carries more financial incentive for the doctor, be it due to procedures, treatments, imaging, drugs or biologics. It is in situations like these where one's ethical upbringing is tested, where the patient's decision may be swayed, or where the financial incentives could override the greater good of the patient. Needless to say, these moral hazards keep most of us up at night.
The public sector may also face certain hazards and there is always the divide between subsidised and private patients. Choosing to see private patients over subsidised patients may be tied to certain incentives such as remuneration. Prescribing certain drugs or treatments may be tied to incentives such as the opportunity of being invited by pharmaceutical firms to travel to conferences or present papers abroad.
Healthcare is strictly sociopolitical in nature, as opposed to dentistry where the bulk of the sector is privatised. Invariably, there will be differences in the views of the national leadership and the medical profession. How these differences should be driven must be for the greater good of the patient in the longest term. It may sometimes seem that the profession is fighting for itself, but the reality is that what is good for the goose is often very good for the gander. Without patients, we as doctors will be forsaken and adrift.
Engaging stakeholders
In my two decades of committee work at SMA, I have sometimes found the Association having different tacks from the national leadership. We often identify a trend, policy or decision that is likely to produce a less-than-satisfactory outcome in the long run; an alarm goes off in our collective leadership and we can see the problem that will loom in the future. We will then go into an analytical phase where we look at the issue and the likely outcomes – negative or positive – that can arise. The analysis is very critical with no vested interests, no holds barred and often draws on institutional memory and sometimes a phone call to a past SMA President or office bearer. This analytical phase can involve endless rounds of email and text messages, phone calls and research by our secretariat, all culminating in a robust session at a council meeting.
The robust session is argumentative, with all council members present chipping in and arguing various points, and with different persons playing devil's advocate. Our council meeting starts at 9 pm and often ends past midnight. We often end with a unanimous decision, but if there are still dissenters, we call for a vote and collectively stand by its outcome. The outcome is usually a decision to write letters to communicate and make a case for our concern. In preparing our letters to the press, we would involve our media consultant to get a layperson's non-jaundiced view of the situation. Sometimes, the outcome can be to call for a meeting with relevant authorities or to make a phone call to a key decision maker in the national leadership. On certain occasions, we write a position paper to defend and stake out our position in no uncertain terms.
Once we have engaged our opposite number, there is often a time for quiet negotiations to understand, study and comprehend each other's positions. These meetings are usually held behind closed doors, and are important to enable points of view to be exchanged and concerns to be raised. Many a time, there is a certain degree of tension in the room. However, I believe that tension is not a bad thing but instead necessary to attain the best outcome. The tension is carefully managed and calibrated to prevent any outbursts, though we have seen our fair share of raised voices, pointed fingers, accusations and that rare thump on the table for emphasis.
The aftermath of such meetings is that both parties leave with a good idea of what each is trying to say and impart. Sometimes, both parties may not be happy during the process but that is the nature of negotiations. The most important result is the outcome. Very often, we see that outcomes may take a while to materialise. The time horizon could be in matter of months to even years.
There are occasions where the negotiations cannot produce a satisfactory outcome for both parties. In such cases, the collective leadership can well take further action by issuing position papers, commissioning a study or conducting surveys. Very rarely have we asked members for direct feedback in forms of a multitude of letters. It seems today that a very common way of expressing protest is to have an online petition. I recall three recent petitions, the first regarding the Kawasaki case. It was started by senior members of the profession and it did end up with a national leadership meeting with the petition originators. The other two recent petitions were done online yet attracted sizeable response in terms of a majority of registered medical practitioners. We certainly do not condone go-slows, walkouts, strikes or demonstrations by members of our profession. That will certainly damage our standing with society and jeopardise the social contract the profession has with the greater public.
I do recall tough situations that we have collectively lived through where we had to run the gamut of analysis, negotiations and some forms of protest. This involved several pandemics, the Night Polyclinic issue and the changing of the constitution of the Disciplinary Tribunal to be chaired by a judge. Despite all this, SMA has its place in the national health ecosystem, championing the greater good of society and our patients, preserving the ethics and professionalism of our colleagues, calling a spade in no uncertain terms, and saying things that need to be said without fear or favour. Time will judge whether we have indeed fulfilled what we have set out to do.