In this August issue, I would like to share some heartfelt reflections about the doctor-patient relationship; how I feel as a doctor, how I feel as a patient, and what I worry about for the future.
What is the ideal doctor-patient relationship?
I think back to movies showing doctors carrying their little black bags, making house calls and patiently attending to sick children and worried mothers, firmly chiding drinkers with bloated bellies and yellowing eyes, or holding a vigil to ease someone's passing. In return, the grateful villagers gave the doctor whatever vegetables, eggs or home-baked pastries in thanks. Even the crotchety alcoholic (although he is likely to be sharing a bottle of whisky!)
Why do they do that? Because they clearly felt the doctor's love and care. The hands-on approach, the direct laying-on of hands and the communication.
What is so different in the current practice?
Team-based care. Consultant-based practice. The use of technology and electronic health records. Increasing business influence in healthcare. Dr Google and badly written search engine optimised (SEO) articles. Ratings-based review system used by Google and various marketing agencies.
Is it all wrong? Of course not. It is 2022, going on to 2023, and we really should move with the times. We are not living in villages, and we have definitely moved past barter trade! Some changes should be embraced, but others have interfered with the delivery of patient care.
In a consultant-based practice, the registrars, medical officers, house officers and residents under the care of the consultant work as a team to do rounds, make orders, follow-up on results, etc. Depending on how closely knitted the team is, the level of training, accountability and communication make that posting either a really great one or one from hell (speaking from personal experiences here). For the patients and their families, it makes a world of difference to have clarity on the overall treatment plan and intended outcomes.
As for the use of technology, handphones are certainly way more convenient than pagers! However, have you ever received an SMS for code blue, or a WhatsApp message for an "urgent referral for haematemisis", only to be scrubbed up and not check your messages until a few hours later, arriving in a panic to see the trail of documentation as below?
0130 h Messaged on-call reg, nil response;
0145 h Sent 2nd message, nil response;
0155 h Texted on-call Reg2, still nil response.
How many of us have had to stare at the screen and try to plough through badly transcribed National Electronic Health Record admission notes to hopefully find out why a Hakka-speaking patient is in front of you today with a foreign domestic helper.
Several years ago, I was devastated when I saw in an administrative briefing that patients were described as "clients", and doctors as "service providers". Devastated. That was when I decided that I would do what I could to reclaim the doctor-patient relationship, for us all.
Complexity of the healthcare system now
In having a team-based care, the nurses and allied health professionals who take on much of the healthcare needs should be recognised. We should have the patients know that these are all professionals, who are trained to deliver specific interventions and health outcomes. As an example, patients at times do not see the importance of physiotherapy after surgery and thus neglect to maintain their range of movement which results in a frozen limb, and may end up blaming the doctor for a bad surgery.
In the move towards Healthier SG and having "One Singaporean, One Family Physician", I hope that there will be strong support for doctors. This means good information technology (IT) support, adequate monetary reimbursement, and legislative support in the event of unexpected complications in trying to implement changes - for example, in the cybersecurity of electronic health systems, be it the clinic's own records, or the national system.
Complexity of the doctor's role now
I further postulate that one of the main reasons why the modern doctor is so disillusioned and tired is the fact that we are taking on so many roles and responsibilities without adequate relief or protection.
The doctor is no longer just a clinician. He/she is a teacher, a researcher, an administrator, a public speaker, a mentor and maybe even a business developer. Those of us running our own practice also have to take on part-time roles as accountants, IT/cybersecurity experts, lawyers and marketing agents. Last month's SMA News covered some of the ground problems that doctors face with IT on a regular basis.
Negligence versus neglect
People speak about medical negligence whenever there is an adverse health outcome. It is a natural tendency to scrutinise doctors as the most visible representatives of the healthcare system. However, keep in mind that it is a much more complex system now!
I would also venture to say that there should be shared responsibility by the patients, and their families as well, in ensuring that health problems are detected and treated early, rather than years of neglect ending in organ failure and bad outcomes.
In my practice, I always teach patients about the value of health screening -specifically the role of mammogram (MMG) screenings, which is to help detect early abnormal changes in the breast. It might have taken months for atypia to develop before progression to ductal carcinoma in situ (DCIS), and finally to invasive cancer. Some patients who do not go for screening may present themselves only when they "suddenly" feel a lump - which is usually already 2 cm to 3 cm in size, indicating a stage two breast cancer.
However, with regular MMG, it is possible to detect micro-calcifications, some of which may be an abnormal deposit of calcium. Differentials include fibrocystic changes, atypia or DCIS. Remove atypia, and we have successfully stopped the progression of cancer. Even with DCIS, this is stage zero cancer for which the prognosis is excellent, with 20-year disease-free survivals reported.
Other than MMG screening, I brief patients on all other types of health screenings and strongly encourage them to have a regular family doctor. Starting from a simple measurement of the body mass index, blood pressure and blood tests to screen for high cholesterol and high sugar levels, we can help to diagnose early signs of metabolic syndrome, and lifestyle modifications may be implemented to change the course of the disease. Appropriate use of medication in the early stages will also adequately control conditions, which prevents the onset of end-stage organ disease.
For patients who come to the hospital for the first time ever with end-stage organ failure, I am deeply saddened. Why the years of neglect? Was it due to a lack of awareness or lack of resources? How about the role and responsibility of the immediate family in reminding the elderly person to go for regular check-ups, advise compliance with medications and to take active steps to modify this behaviour?
一人做事一人当 (Taking personal responsibility)
On the one hand, we see some patients who have chosen not to know anything about their own bodies. On the other, we also see some people who google incessantly and take bits of information with inadequate context - even to the extent of arguing with healthcare professionals about what the correct medical care is. I wonder if people argue with lawyers or bankers this much in legal or financial matters. What is the right balance?
I have always believed that education is key: good basic health education and understanding of the system and how the body gets ill is essential to keeping oneself healthy.
Establishing a good doctor-patient relationship and having mutual trust in each other gives much better patient outcomes and satisfaction. The rise of badly written SEO articles is severely detrimental to the doctor-patient relationship. So many articles share half-truths and myths, even fearmongering. My pet peeve is, "If you have breast pain, see a specialist NOW, before it's TOO LATE!"
It takes so much time to unravel the whole web (pun intended) of lies that the patient has been fed before we get to a meaningful discussion of the actual real health condition.
I will continue to advocate for this: good education and allowing doctors to do their work well with adequate support.
Each and every one of us has to play our part well in taking responsibility for our own health and our own knowledge. For doctors, we have an additional professional duty and responsibility to deliver good care, communicate well, and perform our own self-governance.