Life as we know it has changed in 2020.
Foremost in our minds is the havoc the pandemic wreaked on our economy and working life. People have lost their jobs, companies have folded, and small and medium enterprises have shuttered along with the lost hopes and dreams of a generation. The financial damage is, of course, incalculable, but what is often forgotten and yet even more immense is the human cost.
The pandemic has changed the way we interact, meet and greet each other. It's changed how we meet up and have meals, also our exercise and shopping habits. It's changed the way we visit our elderly parents, celebrate births and weddings, and mourn deaths. It's changed the way we stand in lifts.
And so, it's also changed the way we practise medicine.
An important relationship
Fearful of getting “the virus" patients have stopped coming to the clinic. They top up medicine over the counter, tele-consult, or buy medicine from the pharmacy. Anything to give the clinic a wide berth.
Even when they turn up in clinics, gone are our warm handshakes and long conversations. Instead, we dispense awkward greetings, a shy, uncertain shuffling of hands betraying an aborted handshake, spoken words muffled with cloth, and uncertain smiles hidden behind three-ply face coverings. Quick, cold clinical consultations (not more than 30 minutes!) are the order of the day.
I miss my patients. I miss our friendships and interactions. It seems a strange and almost petulant thing to complain about amid the deaths and economic destruction that the pandemic has wrought, but a simmering disquiet suggests to me that we are perhaps missing something more important: we are losing the patient-doctor relationship.
If we have learnt anything from the digital revolution, it is that you can't form friendships over Facebook, talk over Twitter, or wed over Cisco Webex. It just doesn't work. And so it is with the patient-doctor relationship.
The GP is arguably more village shaman than medical professional. Patients come to us with their cuts and scraped knees, but also their broken relationships, hopes and fears. They seek out a GP's second opinion not because they think their GP is more capable than the specialist, but because they trust their GP more. In the GP's office, an appropriately dispensed hug is more important than the cough mixture we prescribe.
In no other arm of medicine is the patient-doctor relationship more pivotal, and this is exactly what the pandemic strikes at in the time when we most need it.
You can't "lah" over telemedicine
The pandemic has accelerated the rise of telemedicine. In a pre-pandemic world, telemedicine in Singapore made no sense when we had a GP clinic on almost every street corner. Telemedicine struggled to gain traction despite the millions that venture capitalists poured into marketing. Now suddenly everyone is piling onto the bandwagon and telemedicine applications are popping up like lalang after rain.
Setting aside the obvious problem of not being able to examine your patient, there's also the issue of not really getting to know a patient over a teleconference. The lack of direct human interaction makes it difficult to form any sort of lasting friendship. Simply put, the "lahs", "wah laos"and "liddats"of day-to-day speech translate poorly over telemedicine applications.
This should alarm the regular GPs more than it currently does because research clearly shows that all doctors make mistakes, and what prevents patients from suing us into poverty is not defensive medicine, but a solid patient-doctor relationship. In the middle of the pandemic when we're trying to make patients do things they don't want to do, this relationship is ever more important.
Healer, not handler
The exigencies of public health have drastically changed the role of GPs. The pandemic has thrust us into the role of enforcer. Cumulatively, hours are spent cajoling patients to comply with five-day medical certificates, uncomfortable nasal swabs and Stay-Home Notices. Days are spent on administrative minutiae for reporting. Unfortunately, nobody is more poorly equipped to fill this role than your regular neighbourhood GP.
Most of us run small, lean practices with very little systemic redundancy or financial depth. Appointment reminders are just notes in a Google calendar and the stray laboratory result is relayed to the patient manually over the phone by our clinic assistants. It's not a system built to report every acute respiratory infection we see en masse. We keep costs per patient down by not having to pay for a swanky text reminder system, hiring a surfeit of administrative staff and forgoing the need for a chief operating officer (COO). The GP's salary covers the remuneration of the chief executive officer, chief financial officer, COO, clinical director and front-line doctor all rolled into one.
The (funding) gap between the living and the dead
Decades of a strict public-private funding divide have ensured that despite GPs caring for most of acute and chronic primary care, little government funding flows through to GPs relative to the polyclinic and regional health systems. We remain largely fee-for-service directly from patients, corporate and insurance clients. This has been partially addressed with recent efforts vis-a-vis the set-up of the Community Health Assist Scheme and the Agency for Integrated Care, but the pandemic has ruthlessly laid bare the need for much more robust administrative and reporting systems.
Meanwhile, in the sphere of direct patient care, public health needs dictate the regulation of appointment timings and physical distancing of patients, just as privately funded GPs start to cut operating hours due to rising costs and a drastic fall in patient flows and income.
There is an ongoing struggle between the business world and the needs of insurance and third party administrators, and medical practitioners who are simply trying to treat their patients. This is especially so in the middle of the pandemic due to corporations nervously eyeing the sinking economy and their shrinking bottom line.
The GPs stand in the midst of all this, holding their ground because we know that if we don't stand in the gap, nobody else will.
Ready for next time?
A friend complained to me recently about how no GP got an award during SARS and how we were unlikely to get an award for COVID-19 either. My unspoken reply: "Eh, you really want a piece of glass from the Ministry of Health declaring you a healthcare hero? Or some fighter jets flying over your clinic?" (Although, if employees of Pan Pacific Hotels are reading this, we wouldn't mind if you extended the free staycations to GPs as well.)
The truth is, the privilege of being village shaman is good enough for most of us. We revel in the love that our patients shower on us and wouldn't exchange it for the world. However, being village shaman is proving insufficient to meet the demands of public health and to crunch big data on healthcare outcomes.
The nation needs GPs to move beyond the quaint little silos of our practices; what remains to be seen is whether there is the will for us to come together before the next "tsunami" – because we know it's coming.