The Singapore Medical Council Physician's Pledge - What motivates doctors nowadays?

Pointing the finger at the SMRT for their Freudian slip prodded me to think about what motivates our doctors nowadays. Or at least what should motivate our doctors nowadays.

It seems to me that many doctors nowadays are quite happy to regard their practice as a business. Quite understandably so since every other aspect of health care has become such a business. Ever since the mid 1980s in Singapore, when Medicine became defined as one of the pillars of our economic growth, the practice of medicine has become increasingly premised upon a business-like quid pro quo relationship between doctors and patients.

Yet the very ethos of Medicine is not built upon any kind of a business model. In fact the Hippocratic traditions de-emphasized the rights (pecuniary or otherwise) of the physician and instead focused on the duties of the physician. The Hippocratic Oath was really all about the duties of the physician. Likewise, our SMC Physician's Pledge is heavy on duties and does not even mention payments for services rendered.

In fact the very first line of the Pledge reads: "I solemnly pledge to dedicate my life to the service of humanity". Some will of course argue that this is wholly unrealistic, and that doctors do have to make a living, and perhaps even to live in the lap of luxury. But they forget that this was the pledge they took. Theirs was to dedicate their life to the service of humanity. If this was unrealistic, perhaps they should not have taken the pledge.

The great Canadian physician Sir William Osler, made it equally clear - “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.”

In today's world, this calling is so easily brushed aside in favour of the allure of "Income Opportunities". I do not mean to belittle the sacrifices of many doctors who do have their hearts in the right place. Indeed there are many of them. Many I have had the privilege of knowing as teachers, friends and colleagues. But I think even they would not disagree that the practice of medicine in Singapore has to a large part, degenerated to a mere trade or business.

What is the purpose of the Physician's Pledge if we are not to take it seriously?

On another note, I wonder why hospital CEOs are not expected to take a similar pledge of service and duty to patients. After all, it is their management performance indicators that compel doctors to behave after a certain fashion. Can we expect a doctor bound in service to a hospital to put the patient's interest first, and disregard the clarion call to seize the hospital's "Income Opportunities"?

Can an organization such as the SMRT commit a Freudian slip? Of course...!

In psychology there is a term, parapraxis, that refers to the situation when you do something that was really not what was intended. In layman terms, this is often referred to as a 'slip of the tongue' when you say something unintended. We excuse ourselves through the maxim, 'a slip of the tongue is no fault of the mind'. This is of course quite untrue. Slips of the tongue often reflect a primary fault with the mind, and often betrays what the the speaker is covertly thinking, albeit subconsciously. At cocktail parties, we laugh at such Freudian slips when people chatter about meaningfully under the influence of alcohol. At other times, such Freudian slips occur when a persons guard is let down, or he/she is operating under duress.

So I was quite amused by the recent gaffe by SMRT when it sent out the message to taxi drivers during the breakdown of train services. "Income Opportunities" headed the message that the SMRT had trumpeted to taxi drivers. Quite insensitive and inappropriate. Of course the SMRT quickly came out and apologized for the message. It was a template message which had been wrongly used. Of course. In normal conversation, this is exactly what happens when someone says something unintended. He/she had used the wrong template message in his mind. It is nothing more than parapraxis. A slip of the tongue. A Freudian slip that revealed what the speaker had been thinking about.

So the SMRT really did have a Freudian slip. One could of course argue that an organization such as the SMRT, not being alive, does not really have a mind, and is incapable of committing a Freudian slip. But in reality it does have a corporate mind and a corporate consciousness. So the Freudian slip gave us a rare glimpse of the SMRT corporate mind. And the image is not at all attractive. "Income opportunities". Is that what it is all about? We know that SMRT has a duty to return shareholder value, but we should seriously question the SMRT about its raison d'etre.

At a broader level, we should be concerned that our society has become so preoccupied by "income opportunities". Sadly it seems like things are only worth doing if it has a clear potential for revenue generation. Tragically the practice of medicine seems to be rushing down that road too.