DR. LEONG VIE CHUNG, MBBS, FCGP(S)

Preliminaries

First, I must thank the President and Council of the College for nominating me to deliver the Third Sreenivasan Oration this year. I am deeply appreciative of this very great honour.

Although he has unwittingly embarrassed me with so many lavish praises, I must nevertheless thank Dr. Koh Eng Kheng for his gallant attempt to show me in the best possible light.

Lastly, I must thank our distinguished guests, our College members and friends for their kind presence this evening. They have added distinction, grace and colour to make this occasion truly memorable.

The topic of tonight's oration is MEDICAL JOURNALISM IN SINGAPORE. Let me by way of introduction make some preliminary remarks on Female Fashion.

Female fashion, I am told, depends on two clever devices for its attraction. The first is to put the emphasis on certain natural features and the second is to allow partial exposure of others. This deliberate veiling and unveiling according to the nature of attractions desired is always a winner in the highly competitive world of fashion.

An oration is very much like a fashionable female dress. It puts the emphasis on certain features and at the same time allows the partial exposure of others. Alas! what I have to deal with are non-anatomical features. They cannot have the same degree of excitement or attraction for you.

Dr. B.R. Sreenivasan

In 1961, two eminent physicians and medical teachers met socially in the home of Dr. G.O. Home. This meeting proved to be the beginning of a deep and life-long friendship between Dr. B.R. Sreenivasan after whom this oration is named and Sir Derrick Dunlop of the "Textbook of Therapeutics" fame. Both men had the additional quality of being highly literary and cultured. When they met it was as if each had rekindled the literary flame of the other.

Across the dinner table the two men vied with each other at quoting from the Bible, Shakespeare's plays, Boswell's Life of Johnson and the satires of Alexander Pope. They were so engrossed with these literary works that they became almost oblivious to the normally expected small talk of such a social occasion.

Shortly before Sir Derrick Dunlop died, he recalled with deep feelings his first meeting with the late Dr. B.R. Sreenivasan and lamented that he and his wife no longer enjoyed reciprocal visits between Edinburgh and Singapore.

In a very typical gesture, Dr. Sreenivasan, when he died, left the whole of his library to the College of General Practitioners. This consisted not only of a large number of medical textbooks and bound volumes of local and international biomedical journals, but also a large number of the classics of English Literature. The renowned qualities and professional abilities of Dr. Sreenivasan were as much attributable to his general literary reading and cultural exposure as to his purely medical and scientific training and experience.

It is regrettable that the criteria for medical student selection have swung so much in favour of the purely scientific bent to the virtual elimination of literary ability. Our graduates appear to have less and less literary and cultural background. These qualities are essential in the making of a "good" doctor, especially a good family physician.

Reading a best seller such as "Kramer vs. Kramer" probably tells anyone involved in marriage and family guidance more about at least one aspect of their daily work than half a dozen textbooks could ever convey.

General reading of this type would provide our doctors with a background and understanding of the whole cultural scene to which our professional lives are so closely bound, possibly more rewarding than any number of scientific journals, text-books or seminars.

In 1974 I was thrilled to receive an invitation to tea from [)r. Sreenivasan. He was delighted to see that in one of my articles in the Medical Newsletter I had quoted from the works of Shakespeare. We spoke of many things. I reminded him how as medical students, we were deeply impressed by his humility in wanting our signatures in his well treasured leather-covered book which contained the names of all medical students "he is privileged to teach" as he put it. I wonder where this book is now. I am certain the College of General Practitioners will be greatly honoured to have it in its possess) on.

Let me digress for a moment to explain why this book means so much to us. In a hospital setting, the medical student is considered the "lowest form of animal life". The presence of an isolated pathogenic bacteria is invariably greeted with joy and jubilation. The presence of a medical student on the other hand is tolerated with dismay. Who indeed had ever deemed it worthwhile to treasure the signatures of the "lowest forms of animal life"?

The Singapore Family Physician

Just as it is the vogue of every newly emergent country to start its own international airline, it is also the aspiration of every newly formed medical body to immediately start its own medical journal or at least a "newsletter".

The College of General Practitioners was no exception. It was founded in 1971 and Dr. Sreenivasan, the Founder President, was naturally keen to launch a College Journal as soon as possible. The first issue of the journal named the GP was published in March 1973. Some suggested that it was premature as the expertise for running such an ambitious venture was not immediately available. On the other hand, prestige aside, it was obviously essential that such an august body should have as early as possible its own journal. Other important considerations were the need to announce its establishment and objects, the necessity through its medium to recruit membership and the prudence to provide fertile soil for the roots of its academic growth.

Tribute must be paid to the pioneering editors of the chrysalis journals, the Straits Medical Journal and the Proceedings of the Alumni Association which in the fullness of time underwent metamorphosis into the Singapore Medical Journal, a "third generation" journal, in the words of the present editor. It was the first medical journal in this region to gain acceptance and inclusion in the prestigious Index Medicus and the MEDLINE system. It has blazed a trail.

In January 1980, the editor of the Annals of the Academy of Medicine announced with justifiable pride that it too was accorded acceptance and inclusion in the Index Medicus and the MEDLINE system. Our direction of growth has been clearly etched before us.

The contributor to the Singapore Family Physician which is now the legitimate successor to the GP need not despair that his article will be lost to medical literature. Since January 1980 it is now indexed under the Family Medicine Literature Index (FAMLI) which is the new index to the world literature in family medicine. FAMLI is a quarterly index with an annual cumulation and is the result of years of work by the Bibliography Committee of WONCA (World Organisation of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians) in association with the National Library of Medicine of the United States. FAMLI not only provides the references relevant to family medicine from the Index Medicus data base, it also indexes family medicine journals which are indexed in no other source. This combination provides an invaluable resource in family medicine not only to individuals but also to libraries with an interest in family medicine.

The Editorial Column

In discussing the Editorial column we must distinguish between two types of medical publications. Medical publications may come from medical bodies (academies, associations, colleges or societies) or from commercial enterprises.

We don't normally expect a medical publication from a commercial enterprise to have an editorial column. Here the discretion of silence is certainly the better part of business acumen. The whole philosophy of publication is viability. It cannot afford to offend or to offer out-of-place and thankless views and opinions.

An Editorial column in publications from medical bodies is the vogue rather than the exception. Many doctors believe that the editorial represents the official views and policies of the publishing medical body. Just as many doctors believe that the editorial represents only the views and opinions of the editor or the editorial board.

Any uncertainty as to whose opinions are reflected in the editorial is convincingly dispelled by the history of one of our local biomedical journals and the current practices of three of them.

Our oldest and most revered medical publication, The Singapore Medical Journal (SMJ), started off with a regular editorial column. When the next editor took over the journal, he decided despite strong protests that there would not be a regular editorial column. During his tenure of office, the editorial was conspicuous by its absence. When he stepped down, the next editor recommenced the editorial.

The decision of the editor, in his official capacity, to omit the editorial would strongly favour the view that the column represented only his views and opinions and nothing would be amiss if he did not choose to write in it. It would be inconceivable that during all the time of the absent editorial, the Singapore Medical Association had no official views and policies on the many and varied affairs then affecting the medical association.

The Annals of the Academy of Medicine makes no reference to the editorial other than stating that "Statements in articles are the responsibility of the authors". Volume 21, No. 5, OCT 1980 of the Singapore Medical Journal prominently displays on its first page this statement, "All articles published, including editorials, letters & book reviews represent the opinion of the authors and do not reflect the official policy of the SMA or Institution with which the author is affiliated unless this is clearly specified." The Singapore Family Physician consistently inserts immediately below the editorial the following statement: - "Views expressed in the Editorial are not necessarily the official views of the College".

The editorials of two medical publications have been highlighted by the Straits Times in October 1980 much to the chagrin and discomfort of the executive officers of the publishing medical bodies. Perhaps there is a genuine misunderstanding of what these editorials represent. In the light of these misunderstandings, there is a clear need to state the exact relationship between the editorial and the publishing medical body to avoid misrepresentation.

If doctors don't dare to speak out on medical matters, who can speak on them? We must forego the comfort of silence in matters affecting the health and care of patients. The constructive and useful role of medical editorials must be seen in this light.

Medical Journals and the Media

Medical topics are news to the media. There is an amazing appetite for medical information, instructive or sensational, which has to be satisfied.

In an informative and authoritative booklet entitled "The Media and You", Canadian Janet Cochran writes: "People like to be informed . . .about medicine and health, which in terms of interest rank second only to local news". In Singapore they perhaps take pride of place.

Editors of biomedical journals are sometimes hard put to avoid some degree of conflict with the press over what can be reprinted or summarised from their journals for public consumption. Different local medical journals appear to cope with the problem in different ways. The Singapore Family Physician protects itself in this respect by including in every issue the statement, "The contents of this publication are not to be quoted in the press without permission of the Editor". This of course offers no complete immunity.

News-hungry reporters always have "ways" of getting information, even from closed-door meetings. A very embarrassed Vice-President of an Old Boys' Association whose speech, delivered behind closed-doors, was made public in the Straits Times, posted the usual protest and remarked on "the resourcefulness of . . . journalistic sleuths".

We have always complained that the press does not understand our problems. Do we genuinely understand theirs? A better understanding and relationship can be established between biomedical journals and the press. Our side of the story must be told and their side of the story must be heard. If we strive hard enough and sincerely enough, an understanding can be reached whereby our "ethical principles" are not compromised when medical news have to be given to the public.

In the United Kingdom,many major newspapers employ full-time medically qualified journalists to write and edit original articles of a medical nature for their papers. These men/women understand professional discretion and are able to select and publish suitable abstracts from biomedical journals without offending medical ethics. There is mutual professional trust and few are the occasions, which have come to grief.

In Singapore, our English language newspapers employ part-time medical consultants. Their work appears to be confined to writing occasional medical topics and running such popular features such as "Doe's Casebook" and "Doctor in the House". Generally, non-medically and non-scientifically qualified reporters are assigned to the "medical" and "health" beats. Most of them are competent enough in their own sphere but when specialised knowledge and delicate judgement are required they don't seem able to pull it off. A further weakness is that they are allocated the beat for a relative short period of time. As soon as a good understanding relationship has been established, she is transferred to another beat. Like poor Sisyphus, the difficult task of building mutual rapport has to be repeated.

Janet Cochran, referred to earlier, offered this advice to any editor or author who had got into a "tussle" with the media: "When things go wrong do nothing until you are over your first flush of anger! "

Copyright

Copyright is a "sensitive" issue in Singapore. Our Republic does not appear to enjoy an enviable reputation especially in international literary and musical circles. However, we can take comfort in the knowledge that the world over, even the most stringent international copyright laws tend to be somewhat loosely interpreted and applied.

In the general literary world, if two or three lines of a poem or the lyric of a song are to be reprinted, then no specific acknowledgement to the author or publisher is expected. If an extensive quotation is made, then formal application is expected accompanied with a copyright fee.

Most biomedical journals take some steps to protect the copyright of the material they publish. The Singapore Family Physician uses a phrase which reads, "The contents of this publication are not to be published in the press without permission of the Editor". The Annals of the Academy of Medicine states, "Permission to abstract must be obtained from the Editor". The Annals of Internal Medicine has formulated an elaborate policy statement on copyright and re-publication which includes a form of assignment to be signed by all authors. The journal enjoys full copyright. Most international biomedical journals including the British Medical Journal will not raise objections if not more than ten percent of an article is quoted verbatim. If tables, diagrams and photographs are included, the matter would have to be cleared with the editor and a royalty expected.

Relationship with the Pharmaceutical Industry

The financial solvency of many local biomedical journals depends to a certain extent on pharmaceutical advertisements and other acceptable ethical advertisements. The matter is not entirely a one sided affair. Such advertisements do indeed boost the sales of the advertised products. On the whole the local biomedical journals enjoy a mutually beneficial and cordial relationship with the pharmaceutical industry.

The Editor of the Singapore Medical Association Medical Newsletter reported in the 1 0th Annual Report 1979-1980 that "one of the frequent complaints from our advertisers was the infrequency of the Newsletter". He has summed up very neatly the same problems which beset other local biomedical journals. He expressed the hope that successful steps would be taken to avoid this in the future. We certainly would like to share this hope with him.

In the U.K., the "Data Compendium" which is regularly published and updated, gives an accurate assessment of all drugs on the market. This is approved jointly by the Government sponsored Medicines Commission and representatives of the Pharmaceutical Industry and has the force of law behind it.

In the absence of such a relationship in Singapore, the role of editors should at least be some kind of "pharmacovigilante corps" as suggested by two members of the Department of Pharmacology of our university. It has been suggested, not without reason, that advertisement accepted for publication should not include the names of authors who claim to have been involved in investigations, clinical or otherwise, on the drug concerned.

"Vancouver Style"

Since the beginning of 1980, the British Medical Journal (BMJ) along with hundreds of biomedical journals converted from the old-style "Harvard" system of bibliographic presentation to the "Vancouver" style to ensure uniformity in the technical aspects of editing, such as references.

The history of the change-over and the details of what it entails in the submission of manuscripts to these "Vancouver" style journals is contained in a comprehensive paper entitled "Uniform requirements for manuscripts submitted to biomedical journals" prepared by the International Steering Committee of Medical Editors. This was published in the Annals of Internal Medicine, the Lancet and the BMJ. Reprints are available to editors of biomedical journals free of charge and to authors at a cost of 50p (including postage) from the BMJ.

The BMJ in its last issue of 1979 published a touching and nostalgic poem entitled, "Harvard Requiem" by Grace Williams bidding goodbye to the old system.

The Annals of the Academy of Medicine, Singapore has already converted to the Vancouver style or format. The Singapore Medical Journal has given notice that it hopes to convert to this new system entirely in 1981. The advantages of uniformity are obvious and it will not be long before the Singapore Family Physician will conform with this change.

Readable English

The editors of our biomedical journals must ensure that not only their own contributions in the form of editorials, commentaries and so on are of the highest standard in English grammar, style and literature, but also that they insist on an equally high standard from their contributors. This can be achieved in various ways: by rejecting outright badly written papers; by requesting badly written sections to be re-written; or to make the necessary corrections and improvements themselves where indicated without reference to the contributors.

An excellent standard of proof-reading is essential for the presentation of a high-class article in literate English. We have a very low standard of proof-reading in many current Singapore biomedical journals/publications. A Medical Newsletter short article of less than 150 words was so badly mangled that it became unreadable. There were a total of nearly 40 grammatical, spelling and other unclassified errors. This article is a mute and presbyopic testimony of illiterate proof-reading.

In the criteria for medical student selection we must look for candidates who are good at finding fault. Such a student is likely to be a good proofreader in subsequent years. One of the most important attributes of a good proof-reader must be an infinite capacity for finding fault and looking for errors in other people's works. I wonder if this attribute is ever looked for by our medical student selectors. I should like to think that at least one candidate in this year's intake of medical students might end up as a local full-time professional biomedical editor in the great tradition of the famous American Dr. F.J. Ingelfinger, who led the New England Journal of Medicine to be acknowledged as possibly the greatest ever journal of its kind in the world.

I wonder what Dr. Ingelfinger's "bet/pan aptitude rating" would be if he was an applicant for a place in the medical course of the National University of Singapore.

Sir William Osler's "bedpan aptitude rating" would certainly be even lower. He had a propensity to mischief. In school he was a vandal and delighted in unscrewing desks and putting them up on the loft; he was abusive and fond of shouting insults about the headmaster through a keyhole; and he could be considered antisocial because he once led a flock of geese into the classroom.

We have all along been selecting medical students who are conformists. It is time we choose some who are non-conformists. Out of these there may be one who will wield the pen rather than the knife or the syringe.

Technical Aspects of Writing & Editing

In February 1980, the British Medical Journal lamented that a large number of papers submitted for publication had to be rejected out of hand, many for technical reasons including major faults in presentation. In a fascinating article entitled "The Birth of a Paper", Dr. Alex Paton, Consultant Physician at Dudley Road Hospital, Birmingham, analyses and rewrites in detail a scientific paper submitted to the British Medical Journal for publication. The final rewritten and "polished" form of the paper is published in the same issue. This exercise in editing should be compulsory reading to all potential authors and amateur biomedical editors.

Dr. Stephen Lock, the Editor of the British Medical Journal has very kindly offered to send to this part of the world, at a mutually convenient time, a small team of specialists, led by himself, to organise a "biomedical writing and editing" seminar on quite an elaborate scale, provided there are enough support for the venture. If it is to be viable financially, it will have to be made available to other centres of the region namely, Hong Kong, Malaysia, Indonesia and the Philippines.

An opportunity like this should not be missed and it is worth while to make strenuous efforts to welcome such a visit which will help to upgrade the standard of biomedical journalism in this region.

Book Reviews

For various reasons, two of which are circulation numbers and readership markets, book reviews in local biomedical journals are limited. International publishers rarely send their new books written by authors with international reputation to "domestic" journals unless there is some special reason for doing so.

To stimulate the interest of readers, the editor may direct the review of an important and well written book in his biomedical journal. He may also employ book-reviewing as a method of soliciting articles from talented writers who would not otherwise have voluntarily contributed to the journal. These two ways of book reviewing have been successfully tried out in the Singapore Family Physician.

Book reviewing is a specialised technique and a general practitioner reviewer must always bear in mind these very instructive lines by Pope taken from "The Dunciad":—

"The critic eye, that microscope of wit,
Sees hairs and pores, examines bit by bit;
How parts relate to parts, or they to whole,
The body's harmony, the beaming soul,
Are things which Kuster, Burman, Wasse shall see
When man's whole frame is obvious to a flea".

A Plea for Standardisation of Chinese Authors' Names

The standardisation of Chinese Authors' Names in biomedical journals is long overdue. In any list of references and bibliographies attached to biomedical journals published locally or internationally, Chinese Authors' Names are quoted under a multitude of systems.

A Hong Kong based regional medical journal lists the five Singapore Editorial Representatives under four different systems. Even in the Chinese Medical Journal (printed in English) there is no unanimity in the usage of authors' names.

It may be the inconsistent way the Chinese authors use their names which has contributed to the confusion. This is further aggravated by the following difficulties:—

1) the inheritance of two surnames or more correctly speaking a surname with duplex characters,
2) the inheritance of only one name or a single Chinese character,
3) the use of initials in place of the name or names,
4) the addition of an English Christian name or names,
5) the unconventional way of putting the names before the surname or surnames,
6) the unconventional way of putting initials before the surname or surnames,
7) the use of a hyphen between the two names; and
8) the practice of joining the two names without the hyphen, a practice which is prevalent in Chinese Medical Journals.

It goes without saying that if one has to permutate from eight or more items, the possibilities are utterly confusing.

Singapore as the centre of medical excellence must consider it a matter of urgency to convene a meeting solely for the purpose of standardisation of Chinese Authors' Names in biomedical journals. The consensus of this convention will lead to the acceptance of "Uniform requirements for Chinese Authors' Names submitted to biomedical journals".

Readers' Correspondence

The section devoted to readers' correspondence in a biomedical journal plays an important part in its success. They reflect the digested reaction to the scientific articles published. They offer fresh points of views, opposite views or confirmatory views. In short it is here that intellectual arguments take place. The British Medical Journal and the Lancet would lose a great deal of their interest and merit without their excellent correspondence sections.

Correspondence in our biomedical journals does not appear to be a tradition. Most of the time, most doctors are either too reticent to agree or too polite to disagree.

It must be pointed out that it is not a personal affront to disagree. Samuel Johnson realised the resistance of the ego to contradiction or criticism when he wrote:—

"those who break out into fury at the first attacks of contradiction, or the slightest touch of censure, conceive some injury offered to their honour, some ancient immunity violated, or some natural prerogative invaded..."

He considered this attitude essentially irrational.

Obituaries

Obituary notices as a mode of writing are not popular with our local medical writers. They are seldom found in our biomedical journals. The occasional obituary which appears is more often the product of editorial insistence than a spontaneous literary outflow of grief or loss. This is indeed regrettable.

Writing an obituary is as challenging as writing a medical article. Twenty years after writing a medical article, the author may regret what he has written. This is because medical concepts often change with time. Death is of course unchangeable.

I don't believe that Singapore doctors have the gift of immortality. Psalms 89:48 reminds us: "What man is he that liveth, and shall not see death?" I also don't believe that they don't die often enough or in numbers so deficient that they cannot occupy at least a small portion of the obituary page.

The British Medical Journal takes great pride and trouble over the section devoted each week to obituary notices. This is certainly not a case of morbid or pathological curiosity.

The obituary page is a roll of honour—the honour accorded to a medical doctor who had spent the prime of his youth preparing himself for a profession which demanded the prime of the rest of his life. It is but a modest and worthy record of his transit to a higher calling.

Alexander Pope immortalised Sir Isaac Newton when he wrote:—

"Nature and Nature's laws lay hid in night.
God said, Let Newton be! and all was light."

The obituary is a notice of conclusion. In deference, let me give you notice of my remarks in conclusion.

Conclusion

If I have covered the natural features of my subject more than I have revealed them, I take comfort in the knowledge that concealment sometimes attracts more than revelation. The imagination is far more strongly excited by subtle hints than by vulgar exhibition.

At the end of an oration, it is not unusual to address the new Fellows and Diplomate Members of the College In keeping with the literary talents of the late Dr, Sreenivasan, it is not out of place to offer them these lines from Pope, taken from "An Essay on Criticism":—

"But where's the man who counsel can bestow,

Still pleased to teach, and yet not proud to know?

Unbiass'd, or by favour, or by spite;

Not dully prepossess'd, nor blindly right;

Though learn'd, well-bred; and though wellbred, sincere

Modestly bold, and humanly severe;

Who to a friend his faults can freely show,

And gladly praise the merit of a foe?

Bless'd with a taste exact, yet unconfined;

A knowledge both of books and human kind;

Generous converse; a soul exempt from pride;

And love to praise, with reason on his side?"

One of the very few Singapore doctors who fits that description was undoubtedly the late Dr. B.R. Sreenivasan. Let me urge the Fellows and Diplomate Members of the College to strive to excel where he had excelled and to strive to achieve what he had achieved.

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