SPEECH BY MR EDWIN TONG, SENIOR MINISTER OF STATE, MINISTRY OF HEALTH & MINISTRY OF LAW, AT THE SMC PHYSICIAN’S PLEDGE AFFIRMATION CEREMONY ON SATURDAY, 2 MARCH 2019, 2.15 PM

Professor Tan Ser Kiat, President, Singapore Medical Council,

Colleagues from the medical fraternity,

Ladies and Gentlemen,

Good afternoon.

1.              It is my pleasure to be here with you today at the Singapore Medical Council’s (SMC) Physician’s Pledge Affirmation Ceremony. The Pledge is a solemn Oath to be taken by all doctors, including all you seated here today, before the Singapore Medical Council to uphold ethical and professional standards throughout your professional career as a doctor.

Equipping our doctors to meet future healthcare needs

2.               Singapore is expected to face a number of healthcare challenges in the near future. As a developed country with a population that has long life expectancy –  and that is due in no small part to medical advances that we have made and the contribution and dedication of doctors in Singapore – we also have low birth rates, and a combination of those two factors means that Singapore has a rapidly ageing population, and a declining economically active population. One in four will be aged 65 and above by 2030. Singapore is also expected to face a growing chronic disease burden and an increased demand for healthcare services of higher complexity. Our healthcare system needs to adapt to cope with the shifting healthcare landscape, and the shifting healthcare demands as well. This includes equipping our healthcare providers with the appropriate skills to support this change and also service the population that we have in Singapore.

3.               Most of you will just be embarking on your journey as medical practitioners.  You will also be adjusting to new practice environments.  Allow me to take a few moments to touch on a few core issues as you step into the practice of medicine.

High standards of care

4.        Societal expectations towards healthcare have changed. If you pick up any journal today, look at the newspapers and you will see that the doctor-patient relationship has evolved.  A high standard of care is expected of everyone working in the healthcare sector, particularly of the doctors, although not only doctors. This means keeping your medical knowledge up-to-date, translating this knowledge to actual clinical practice, and journeying with your patients, to understand their needs to best advise them of options so that they receive the best outcomes from the interventions you have recommended in consultation with them.

Value-based healthcare

5.      Yet, keeping your finger on the pulse of latest medical development and advancement, does not necessarily always mean that the latest and most expensive, and the most forward-looking treatment options should be provided without looking at the particular patient’s needs and considerations carefully. On this, I would like to emphasise the importance of providing value-based care to the patient. It is not about pricing, or necessarily choosing the cheapest option, but rather finding the best evidence-based option that would provide the best care outcomes at the best cost, in the context of this particular patient. 

6.        To guide responsible utilisation of healthcare services and encourage the provision of appropriate and cost-effective care, the Agency for Care Effectiveness (ACE) was set up to evaluate the cost effectiveness of treatments based on evidence, and publish their recommendations through Appropriate Care Guides and Drug Guidances. These are readily available online and I encourage you to acquaint yourself with this resource so that the clinical choices you make, that you can consider in the spectrum of options for your patients, are both evidence-based and cost-effective.

Teamwork

7.               While doctors may train in different sub-specialities, the illnesses that present in patients do not always conform to this sort of categorisation.  Patients with multiple co-morbidities are now the norm, and they will require care from different healthcare professionals both within the hospitals and in the community.  Care should be integrated and accessible for patients and it is your duty to be able to plan and coordinate the care of your patient with other healthcare professionals.  This requires good working relationships not just amongst yourselves as doctors, but also between yourselves as doctors with nurses, pharmacists, medical social workers, therapists and other allied healthcare professionals, and it requires a deep understanding of the healthcare ecosystem.  

Informed consent

8.               Prof Tan spoke earlier about the need for informed consent.  This is critical, because as you embark into practice and see patients and consider what is in their best interest, you will understand that the treatment options you suggest and the various courses of treatment available for them all must have the patient’s interest at the centre of all that you recommend. The interests of patients are paramount, and that is why we have informed consent because this can only be achieved if your patients know and understand the treatment that they are receiving. 

9.               The question as to what makes for informed consent has been in the news of late, sparked off by several cases, most recently an SMC decision involving an orthopaedic doctor.  There has also been some public discourse and discussion in the public domain, in the newspapers, in other medical journals.

10.           What this tells us is that it is important to be clear on what it means to take informed consent. A patient must know what the treatment options are, and understand the benefits and material risks associated with those options.  A doctor has to provide this information and, based on this, the patient decides on his or her course of treatment. 

11.           But if we are not clear on what comprises informed consent, or become worried about what that standard might be, and as a result start to advise the patient of every little detail, big or small, relevant or irrelevant, this would lead ultimately to the practice of defensive medicine.  This is neither in the interest of the doctor nor the patient.  It would only increase the costs of healthcare and also compromise patient choice and safety.  And that, I think we can all agree, is not what we want to see.    

12.           The Ministry of Health will therefore be undertaking a thorough review of the taking of informed consent by doctors.  We will review the legal position, as well as the practical aspects of taking such consent – what it entails, the context on which it is taken, what the standards are or should be  with a view to providing appropriate guidance for doctors.  We intend to consult with doctors, whether in public or private practice, to understand their concerns and also canvass their views.  But let me be clear – that whatever we do, this consultation and review, and however we might decide to make or recommend changes – this is not about going soft on or compromising on patient safety.  Acting in the patient’s best interests is non-negotiable in medical practice and remains a paramount consideration for all doctors and healthcare workers.  What we do not want to have is the practice of defensive medicine, and, as I have explained, being clear on informed consent helps both the doctor and the patient.    

13.           We understand the need to have as broad a range of views as possible.  To this end, we have met with members from the Singapore Medical Association, the Academy of Medicine and the College of Family Physicians, to outline our plans and to also work with these professional bodies to reach out to the broader medical community.  Collectively these three professional bodies represent almost all the doctors in Singapore, and we are confident that working with these bodies and the leaders in these bodies, we will be able to canvass the views of the medical community broadly and also take on their views and suggestions.

14.           At the same time, we will also take the opportunity to review the SMC’s regulatory processes and systems.  We intend to carry out a very comprehensive review of the medical regulatory landscape which is overseen by the SMC, from the filing of complaints, appeals, composition of the Complaints Committee and Disciplinary Tribunals and also the decision making processes of these bodies. This is timely, as we seek to constantly improve on the appropriate regulation of the medical profession.  The SMC and its processes must have, and must be able to maintain, the confidence and trust of medical professionals, patients and the general public. As we do the review, we will have that in mind to ensure that we maintain a strong and fair balance between what is the public interest and what the medical community comes back on.

15.           In order to help us with the above exercise, we will be setting up a Workgroup.  This Workgroup will comprise medical and legal professionals as well as laypersons from as broad a spectrum of interested stakeholders as possible to help us to review the existing position, canvass the views of the medico-legal community, identify improvements, with a view towards considering what, if any, of the changes that will need to be made..

16.           MOH will make further announcements on this at the appropriate time.

17.           Finally, I wish to stress that as all of these consultations and views that we seek to canvass, they can really only be as strong as the people who contribute towards it. So I would like to reach out to all of you and ask each of you to take part, support, participate and give your views to this process. That can only make the overall end product that much stronger.

Physicians, heal thyselves

18.           More often than not you will find work demanding. And as I conclude my speech this afternoon, I want to remind all of you that the journey starts today. I hope you do not see this as a milestone but as a stepping stone. You will find yourself juggling the different demands, all of which take up almost all of your time – juggling teaching, practice and mentoring responsibilities as well as research commitments. There is a danger of being overwhelmed, being burned out, if you don’t also take care of yourself. You know the phrase, “Physicians, heal thyself”. You do need to also look after your own physical and mental well-being as you step into a profession that is both demanding and at the same time also extremely rewarding.

Conclusion

19.           Being a good doctor in today’s context requires having a wealth of medical knowledge and good clinical skills. You must demonstrate care and compassion for patients, effectively communicate with your patients so that they understand what is in store for them and what it is that you are recommending them; and work in a team with fellow colleagues – so having good collegiality and relationships not just with fellow doctors but with other healthcare professionals in the ecosystem is of vital importance. Finally, each of you have to uphold high ethical and professional standards in your practice. That’s the only way we can maintain the public’s trust and confidence in the medical profession. 

20.           Once again, my warmest congratulations to each of you. It’s taken some time to get here but I hope that you will see this as an achievement to serve the community in as much as it is to pursue your own personal dreams of being a medical practitioner. It is a milestone, and the journey ahead remains long, challenging, but I am sure you will find lots of meaning to it. I wish you all the best, as each of you play an important role in ensuring that we deliver the best healthcare possible to our citizens and residents in Singapore. Thank you very much for being a part of the system.