Opening speech at Singapore Medical Council Physician's Pledge Affirmation Ceremony

24 Sep 2011

By Mr Gan Kim Yong
Venue: Yong Siew Toh Conservatory of Music, National University of Singapore

1. It is my pleasure to be here with you today. The Physician’s Pledge Affirmation Ceremony is an important milestone in the career of doctors. The pledge is widely considered as a rite of passage for practitioners of medicine, that not only affirms your commitment, but also celebrates your achievements, recognizes your contributions and heralds the next phase in your career as you become fully registered practitioners.

Medical manpower

2. With us today, are graduates from the Yong Loo Lin School of Medicine and for the first time in the ceremony’s history, the first cohort of graduates from the Duke-NUS Graduate Medical School. The Duke-NUS Graduate Medical School plays an important role in boosting our healthcare workforce as well as adding diversity and vibrancy to our medical education landscape.

3. Towards the end of 2010, we had a total of 9,030 registered medical practitioners in Singapore. This is about 500 more doctors than in 2009. Still, locally trained doctors are insufficient to meet the growing needs of our population. Hence, we are glad that doctors who received their training overseas are also here with us today. All of you will soon fulfill, or have already fulfilled the requirements, to become fully registered practitioners in Singapore. This ceremony is testament to your achievements.

4. We will continue to ramp up our local output of healthcare workforce to address our long term healthcare needs. The Yong Loo Lin School of Medicine has been progressively increasing its training capacity, and will eventually reach an output of 300 students a year. Duke-NUS Graduate Medical School now takes in over 50 students a year since it accepted its first batch of students in 2007. Singapore’s third medical school, the Lee Kong Chian School of Medicine, will begin its first intake of 50 students in August 2013 and will gradually increase its intake to 150 students each year. At steady state, about 500 locally-trained doctors will be added to the medical profession annually. Besides increasing our local pipeline, we are also stepping up efforts to bring Singaporeans studying medicine overseas back to supplement our pool of doctors. We introduced the pre-employment grant last year and gave out a total of 68 awards. The pre-employment grant was well-received by Singaporean medical students in Australia and the United Kingdom. Going forward, we hope to attract more medical students back in the coming years to further increase our supply of doctors.

Professional development & training

5. The medical education landscape is evolving. We are in the second year of implementing the residency system for specialist training. We have adopted best-practices from US-style residency programmes and customized the contents according to local needs. Residency has strengthened the structure and improved the focus of specialist training. This will enable us to produce better specialists to meet our local healthcare needs. We will create more opportunities for our medical graduates to pursue postgraduate training. Many of you may have applied, or are already pursuing postgraduate residency training.

6. For those who have not yet decided, consider where you will be most needed and where your contributions will be most valued. As Singapore’s population ages, there will be increasing prevalence of chronic diseases. Therefore, a key focus will be on managing chronic diseases in the community and delivering health services seamlessly for the patient across health sectors.

7. In order to do this well, we will need to play to the strengths of our healthcare workforce. Doctors, nurses, pharmacists and allied health professionals will need to work together and complement one another.

Family Physicians

8. Our healthcare system has placed a lot of emphasis on developing acute care tertiary institutions over the years. These are important and must continue in a coordinated manner. In the next lap, primary care will play a critical role. The vision for primary care is for every Singaporean to have a family physician, who will deliver patient-centered care that is integrated seamlessly with community health services.

9. We have taken the first steps towards this vision by establishing the Register of Family Physicians. The Register recognizes medical practitioners with relevant qualifications and sets the standards for the practice of Family Medicine. Together with the Family Medicine residency programme, we are confident that these would lead to further improvements in Family Practice and pave the way for Family Physicians to take on more responsibilities.

10. We will continue to develop the discipline of Family Medicine so that family physicians can manage complex cases in the community and assume overall responsibility for patient care across healthcare sectors. Family physicians can be expected to deliver quality care especially when specialist care is no longer indicated. I urge you to consider taking up this challenge seriously.

11. We must continue to support the growth of family practice. Existing partnerships will be strengthened while new collaborations will be developed. For example, we are looking to provide support services such as eye screenings and laboratory facilities to the GPs in the community. With access to such services, GPs will be able to manage chronic diseases like diabetes more comprehensively.

Challenges to medical practice

12. You as doctors will be faced with new challenges. As patients become increasingly educated and as society becomes more affluent, commercialization and consumerism in medicine will become more apparent. Clinics and institutions may find themselves increasingly compelled to publicize their services to differentiate themselves and to gain more patients. The Advertising Guidelines was amended under the Private Hospitals and Medical Clinics (Publicity) Regulations in May 2004 to allow greater flexibility in advertising and to enable public access to information. This had a downside. We have observed a surge in advertisements, especially for lifestyle-related medical services. SMC’s Ethical Guidelines requires such information to be factually accurate and must be substantiated if challenged. Laudatory statements which may mislead the public or encourage use of services must not be made.

13. Unfortunately, these Guidelines are not always followed. Some consumers may be influenced by these advertisements to undergo non-essential medical procedures unnecessarily. Some healthcare licensees had to be disciplined for making laudatory or misleading statements.

14. Although there is now easier access to medical information, the information needs to be contextualized and individualized. Information needs to be translated by a doctor into the right treatment for the right patient. In spite of the advances in technology, the information asymmetry between doctors and patients remains substantial. Patients remain vulnerable and still need a doctor whom they can trust to help them make sense of all the information they receive.

Ethics and professionalism

15. The challenge arises when your personal interests and the patients’ are not aligned. I am sure you will face such moral dilemmas from time to time. When that happens, patients will need to rely on your sense of professionalism – that you will “do the right thing”, in their best interests.

16. Unfortunately, some doctors fail to act in the best interests of their patients1. The New York Times published an article in December 2010 on a cardiologist who faced legal action from hundreds of his patients. Investigations suggested that he might have implanted 585 cardiac stents which were medically unnecessary over a period of 3 years. Technical competence and medical expertise without a moral compass, will be a great danger to patients. Your professionalism and ethical values will be tested. The question is -- how do we prepare and train our doctors to make the right decision?

17. Medical educational systems in many of the developed countries consider professionalism a critical component of a doctor’s practice that is comparable to other fundamental competencies such as Patient Care, Medical Knowledge, and Communication Skills. Similarly, our residency programme incorporates professionalism as a core competency for training and assessment. As much as doctors need to be trained to make medical diagnoses and administer treatments, they must also be trained to become “competent” in professionalism and ethics. Through such structured training and assessment, we hope to produce doctors who are both technically and ethically-proficient.

The pledge

18. MOH takes a serious view of professionalism and medical ethics. We amended the Medical Registration Act and Regulations so that taking the Physician’s Pledge is now required before full registration2. The pledge which you are about to take is wisdom of the ages. It can be traced back to the Oath of Hippocrates which originated more than 2000 years ago. The Oath has evolved just as medicine has progressed. However, the fundamental ethical principle of “patients before self” remains and still guides practice today.

19. You have entered the profession in exciting yet challenging times. Innovative technologies, new treatment modalities and other opportunities are at your disposal. However, patients expect their doctors to be knowledgeable and skilled; to have good communication skills, empathy; and to provide good service and value. As you embark on your medical career as fully registered practitioners, more responsibilities will be entrusted to you; more will also be expected of you. This pledge is a covenant that you are committed to protect the health and safety of the public and to practice ethically and professionally, even in these testing times. Your patients, colleagues and society will hold you by this pledge, to make the decisions which uphold the integrity of the profession.

20. In closing, let me congratulate all of you again for your achievements and contributions. I encourage you to strive for excellence not only in knowledge and technical skills but also in ethics and professionalism. I wish for you nothing less than a fulfilling career, built on the values embodied in the Physician’s Pledge.

21. Thank you.

1 Doctor Faces Suits Over Cardiac Stents. December 5, 2010 http://www.nytimes.com/2010/12/06/health/06stent.html?_r=1
2 Regulation 16 of the Medical Registration Regulations (MRR): 16.—(1) A medical practitioner who wishes to be registered as a fully registered medical practitioner under section 20(1) or (2) of the Act shall, prior to being registered as a fully registered medical practitioner, take the physician’s pledge on such day and time as may be specified by the Medical Council.