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In praise of GPs, unsung heroes of the healthcare system

Primary-care doctors are like the Cinderella of healthcare: overlooked and under-appreciated. But they are key to the healthcare system overall.

Ever mindful that medical specialists are usually not as good as primary-care doctors in treating problems that are outside their main area of expertise, I would often consult Dr Alvin Lum whenever my patients with mental health problems develop some medical illness.

Alvin had initially wanted to be a psychiatrist but he later decided that he would rather have a generalist approach to medicine and that his calling was to be a primary-care physician.

For a good number of years now, he has been a general practitioner in a clinic in the heartland of a Housing Board estate, providing care for his patients who come from diverse backgrounds and who have an even greater diversity of illnesses.

Many have been his patients for years - like the elderly woman he has cared for over several years and for whom he is always the first port of call whenever she is unwell.

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"Once, she came to see me because she had been having frequent runs of loose stools," Alvin narrated to me not too long ago. "The physical examination was normal and though I felt that her complaints were likely to be related to an underlying anxiety, I thought it would be prudent to refer her to a gastroenterologist to rule out something more ominous, given her age and persistent loose stools - before I suggest seeing a psychiatrist."

He discussed this with the patient and her son, who agreed to go along with his recommendation and asked him to choose the specialist.

The gastroenterologist came to the same conclusion that the patient's symptoms were due to some underlying psychological cause, and referred her to a psychiatrist.


A busy GP clinic in Toa Payoh North. One crucial component of the recent reorganisation of Singapore's healthcare system is the ramping up of primary care. Currently, with only two in five Singapore residents aged 18 to 69 years having a regular family doctor, the vision of the Ministry of Health is to have "One Singaporean, One Family Doctor". ST FILE PHOTO

Throughout, Alvin kept in touch with the patient and her son and was at hand to offer whatever counsel and support necessary. The patient improved with some anxiolytic medication, and has since returned to see Alvin for her follow-up.

It is this sort of coordination and follow-through that is one of the defining aspects of good primary care: helping a patient navigate a hyper-specialised healthcare system which comprises a private and a public sector; ensuring that the patient goes for her specialist appointment; calling after that appointment to find out what has happened; and being available to answer any questions that the patient might have.

When I asked Alvin why she had asked him those questions that she ought to have asked the specialists, he took a while to think. "Maybe, she feels more comfortable with me," he said. What he was alluding to is that old and time-honoured intimacy and trust between doctor and patient. It is this sort of relationship that would make a patient feel comfortable enough to seek help earlier for potentially serious symptoms, instead of putting it off until it is too late.

And indeed, studies have shown that a patient is far more willing to seek help earlier if there is a regular doctor who the patient trusts as someone who understands the experience of being sick, and gives reliable and honest advice - a relationship that contributes significantly to better clinical outcomes, including lower death rates.

As a doctor providing primary care, Alvin is at the front line of our healthcare system, attending to the common - and occasionally uncommon - ailments and problems of people of all ages in the community; and a good portion of that practice is looking after patients over the long term.

It is not confined to a single consult within the limited time the doctor spends with a patient in the clinic; it is about acquiring a deeper knowledge of the patient accrued from repeated visits over time, encompassing the efforts and time in making phone calls, holding family meetings and coordinating patient care with specialists when necessary - all of which are neither chargeable nor reimbursable in any way.

Doing all these is tough for GPs in Singapore, especially those running a private general medical practice. (There are more than 2,400 GPs in the private sector and collectively they take care of 80 per cent of the primary care in Singapore.)

There is not just the care of patients but also the business side of the practice: balancing the books, paying the staff, purchasing medications and equipment, filing insurance claims, meeting the regulations of the Ministry of Health.

Other than escalating overheads, there is fierce competition among GPs themselves, from the polyclinics with their subsidised care, from other medical specialists, and even from the thousands of traditional Chinese medicine practitioners and homeopathic healers.

The competition is a double-edged sword: It keeps the consultation fees relatively affordable for patients but it compels GPs to make up with volume and that often means working long, punishing hours, seeing as many patients as possible and perhaps eschewing the more difficult and complex cases; or moving to an area like aesthetic medicine.

INCREMENTAL CARE

The expertise of GPs is broader than it is deep; and they have to grapple with whatever complaints presented by their patients and decide whether to treat, or wait, or to refer to a specialist; and they have to know every medication prescribed by any specialist that their patients come back with.

Despite the obviously intellectually and professionally demanding nature of what they have to do to keep up and not slip up in their care of patients, the status of GPs is generally viewed to be lower on the totem pole of medicine; they are generally paid less than other specialists; and there is that unfair perception that the smarter medical students would go into some specialities; and those who cannot, or who could not make up their mind, would end up being GPs who would mainly see those proverbial "cough and cold" patients.

"The common error in thinking about primary care is to see it as entry-level medicine... and because of this, rudimentary medicine - for mostly (say) the common cold and imaginary illnesses. This is a false notion," writes Dr Eric J. Cassel, who was a clinical professor of internal medicine at Cornell University in New York, in his book Doctoring: The Nature Of Primary Care Medicine. "Everyone knows, however, that knowing when you don't know requires sophisticated knowledge."

In his recent essay in The New Yorker, Dr Atul Gawande, a general and endocrine surgeon in Brigham and Women's Hospital in Boston, wrote of his initial impression that primary care seemed "squishy and uncertain".

Chastened by a colleague who sent him a slew of studies that showed that primary care could have very significant overall impact on the general health of the population, including lower mortality and better health, and lower medical costs, Dr Gawande admitted that "primary care… does a lot of good for people - maybe even more good, in the long run, than I will as a surgeon".

He called these doctors "incrementalists" because they give care incrementally over the course of the patient's health; treating not with those dramatic and heroic life-saving interventions that snatch a desperately ill patient from the jaws of death, but walking steadily with a patient and with nudges - to exercise, lose weight, quit smoking, eat right, et cetera - along the way to steer the patient out of trouble, and recognising problems before they happen, which quietly and almost invisibly add years of healthy life to the patient.

TRANSFORMATION OF PRIMARY CARE

The Government knows this and one crucial component of the recent reorganisation of our healthcare system is the ramping up of primary care. Currently, with only two in five Singapore residents aged 18 to 69 years having a regular family doctor, the vision of the Ministry of Health is to have "One Singaporean, One Family Doctor".

Part of this transformation will include the establishment of models of team-based care, where doctors, nurses and other allied health professionals work together to deliver comprehensive, continuous and high-quality care in the community.

With time, the old bread and butter of primary care, the one-on-one visits with a sole GP, might become an anachronism; and the complex task of looking after a patient would be shared among the primary-care team, which can look after more patients - and there will be more patients with the influx of the baby boomers into the healthcare system as they get older and sicker with chronic illnesses like arthritis, hypertension and diabetes.

Beyond inserting new models of care, there must also be transformation across different fronts: from addressing the public's belief that specialised care always means better care and the consequent predilection to go straight to specialists; to that attitudinal shift among experienced GPs and new medical graduates that they will not only be a healer to anyone seeking help but also a team leader, manager and mentor of a team; and to changes in the work life of these doctors, their compensation, and their professional and public standing.

These doctors are doing what is arguably the most challenging and difficult type of doctoring. Dr Gawande's piece is fittingly titled "The Heroism of Incremental Care"; for long, these primary-care doctors have been the unsung, embattled and often battered heroes.

A version of this article appeared in the print edition of The Straits Times on May 20, 2017, with the headline 'In praise of GPs, unsung heroes of the healthcare system'. Print Edition | Subscribe