In the past four decades, many important advances have been made in the areas of medical knowledge, medical technology and in the tools that we, as physicians, have available to us to improve the care of our patients. Improvement in our diagnostic capabilities have occurred in such rapid sequence that even the most informed physician has difficulty sorting out which study is specifically indicated. Diagnostic Imaging is a special case in point. The quantity, quality and specificity of medications at our. disposal have been increasing by leaps and bounds. Especially noteworthy is our increased understanding of how and why these medications work. These advances have been so numerous and so specific that it has required individuals to concentrate specifically in one area, resulting in increased sub-specialization beyond what we already believe to be unreasonable and detrimental to patient care. We not only have sub-specialists such as the Emergency Room Physician, but we also now have the "Intensivist," the "Traumatologist," and the "Shock Trauma" specialist.

Many times these promising advances are dramatic, over-publicized and not fully evaluated but are naturally very attractive to our young future physicians. Students are being encouraged by their faculties and medical schools to enter these fields because of benefits to them by increased research grants and the resultant publicity the schools receive from this front page type of exposure.

In the United States we have a perfect example of this. There is a rather well-known medical publication that distributes advance copies of select articles of their next issue to the press, so that every Thursday morning our newspapers have headlines of a new "cure", "miracle medicine" or irradication of a long standing disease. A "cure-a-week" phenomenon that is usually not heard of again after Saturday, and, if the article is read carefully, one finds almost no support for such promised optimism. Where are our guardians of medical literature who are supposed to assure the quality and reliability of the medical printed word? Even as physicians who have been trained to select the worthy from the unworthy printed word, we are having trouble because of the many economic, public relations and political forces that are influencing our medical publications.

While this kind of literature is a serious problem for the medical profession, it has even more serious consequences to the public and especially our patients who get to read the end results of such literature in their popular magazine.

The public is confused and wants to know when these "weekly" cures will benefit them, and, if there are so many cures, why do we still have so many sick and dying people. How many times have patients come to their family physicians seeking the "instant care" that they read about and have to be told about the difference between research studies and what is actually available on the market. Does this create public confidence in the medical profession and where does it place the individual physician who has to interact on a one-to-one basis with his patient?

While the above phenomenon was occurring in the medical profession, patient care was also being influenced by new forces— "social, economical, political and industrial." These forces are becoming increasingly involved in the determination of policies and actual delivery of health care. The popular notion that health care for all was an unqualified right which no one could philosophically oppose, became a very popular political tool. Time, however, demonstrated that those who pushed this concept had not given much thought to the costs involved, ways to provide all of the services promised, or as to who would assume the final responsibility. In our country, at first it was assumed that government, national and state, would assume the burden which they did for a while. But, soon their two major programs — Medicaid and Medicare—faced serious problems which to this day are still growing, and increasingly more costly and most worrisome to all administrations.

During this time another health care phenomenon was occurring, namely the "third party" payment concept. Guaranteed health care for special groups on a pre-payment, card carrying basis" became the responsibility of not only our governments, but also by so called "not-for-profit" private, entrepreneur insurance companies. The promise of gain was so great that for the most part what was offered was not always based on sound actuarial data, medical or economic, and certainly not epidemiologic, that could clearly project current and future health care needs. The greatest example of this failure to listen to epidemiological predictions was the failure to prepare for the increasing numbers of the elderly and chronically ill.

Next industry became involved in health care by providing increased health care packages for their employees. It seemed that employers found it more advantageous to provide or increase health care fringe benefits rather than salary increases. But, again, not much attention was given to what was promised and the eventual cost should those covered take full advantage of the opportunity.

What was going on in our general economy while these medical events were happening? There were great changes going on, with some areas of the economy going up and some areas going down and a great fluctuation in employment. However, there was one common demominator "everything cost more". Everyone was paying more for services, goods and our future security. This also occurred with medical costs because generally medical costs are determined by the general economy. The credit card — "plastic money" —became a way of life with all of the added costs that their use entails. Therefore, the direct payment by a patient to his physician for services was "giving way" to the medical plastic card and the "third party payer."

While it can be clearly shown that this practice has increased the overall cost of medical care, it also introduced an even greater problem by placing between the physician and the patient, a "third party" who has become very powerful in determining and negotiating health care policy. Medical care was no longer an understanding between a patient and his physician where the individual patient needs were better addressed. Now, medical care has become a political tool and a big business for "third parties". We have come a long way from the "not-for-profit" philosophy of medical care support to the point where political and private medical business interests determine patient care policy without much if indeed any input from patients or their providers. While all of these changes were taking place, the medical profession was being maneuvered into a position of being blamed for being the major cause of health care costs increases. As individual physicians with control over what we do and order for our patients, we do have a responsibility to do everything possible to control costs. However, there are many aspects of health care costs that are out of direct control of the physician. The development of an unrealistic, unbalanced and expensive payment system for physician services that is focused on procedures is a major factor. At the same time, the system does not adequately support cognitive and preventive services that would not only decrease overall costs, but potentially reduce the incidence of disease and injury.

What is the position of the patient in this scheme? For the most part, they are confused and have a feeling of being "let down." They find themselves "pawns" caught up in the system. While a small percentage of the public gives priority consideration to their health care, most do not consider it until they develop a medical problem. Therefore, the Dublic is increasingly losing the right of "choice" in his own health care decision-making. The patient is looking for someone for advice, consideration of his special needs, and guidance in a system that he does not understand. There is one thing however that the patient does understand, and that is that he is paying more of the total bill in the systems being introduced, and is beginning to object and wants to be heard.

What is happening to the role of the physician in these evolving systems? Well, for some time our conservative demeanor prevailed because we were all doing reasonably well and we felt that, based on past experiences, somehow things would work themselves out without our being too actively involved. But our attitudes are changing and increasingly we are having serious concerns. We are being confronted by activities that a few years ago were considered highly ethically suspect, such as marketing, advertising, select physician programs, competition, physicians engaged in "for-profit" health care systems, patients' lack of free choice, over-involvement of hospital administration in patient care, etc., etc. We can now see that unless we become actively involved on behalf of our patients, more changes are likely to take place and the patient will be the loser. We are asking ourselves tough questions so that we can become more effectively involved: Questions like are we providing the kinds of comprehensive heath care services our patients need and want? Have we, as physicians, been as efficient and available as we should be? Do we always provide our services on a reasonably economic basis? Have we utilized medical services, facilities and consultations appropriately? Are we as dedicated to our time-honored reputation as a discipline of "service?" What actions are necessary to improve our health care system? How have we assisted the public in understanding their health care needs? And, finally, what are we doing to improve the training of our young physicians to meet our patients' health care needs?

I am pleased to note that under the leadership of the College of General Practitioners, the family physicians of Singapore have studied the background of the issues I have just discussed and how they apply to the people of Singapore. They are taking very positive actions that will provide significant assurances to the people of Singapore that their health care needs will be met in a high quality manner and is in step with all the medical advances that are being made. They will do so by making available the best predoctoral — undergraduate medical school and postdoctoral— graduate vocational residency training possible for all those students who choose family/ general practice as a career. The reason they have selected this goal is based on the fact that any successful health care system must have a sufficiency of broadly trained, high quality family physicians/general practitioners. Family Physicians who are properly trained and dedicated to provide comprehensive and continuing care. Family Physicians whose special training makes it possible for them to care for m re than 9090 of their patients' needs, and enables them to properly consult for any needed care beyond their personal capability. It is being demonstrated around the world over and over again that health care systems with a core of very capable family physicians provide an efficient, high quality service at a lower cost, and, most notably, with a greater degree of patient satisfaction. It has been my personal observation in studying health care systems of the world that any system that instituted shortcuts at its inlet by utilizing less than highly trained physicians was not efficient, had higher total costs and uniformly resulted in a very dissatisfied public which lead to an early collapse of the system.

There is a sequence of events that must be present in the education of the kind of family physician that the Singapore College has as its goal. The student must first feel that there is a real demonstrated need for family physicians. He or she must be the kind of student who feels very comfortable in being close to people, families and communities. They require an exposure while in medical school to family physician role model teachers, and a high quality, equal Family Medicine curriculum. They should want Family Practice to be recognized in their medical school. They have to have assurance that after medical school they will have available a good residency training program that will prepare them for their life's work, and at the end of this special training, recognition in the form of certification as specialists in Family Medicine. Such special training and subsequent recognition will go far in encouraging medical students to choose a career in Family Practice which, in turn, will assure the people of Singapore the high quality of service that they deserve.

The Singapore College is taking the initiative in the development of teachers and appropriate role models required to provide the type of teaching necessary to produce the physician that Singapore needs. They are setting specific goals, objectives, criteria, guidelines and curricular core content. They are also planning specific evaluation tools on a continuing basis by which they can evaluate their efforts objectively, and assure the quality set forth in their goals and objectives.

Of special importance will be the "core content" or basic subject matter that needs to be taught not duplicating the traditional important basic medical school curricular content, but emphasizing those aspects that are not traditionally taught like the specifically identified needs of the health care system of Singapore. This means that it is a current curriculum based on today's and tomorrow's projected needs. This also means that this newly trained family physician would not only have to have a strong cognitive knowledge and skill base, but also that he or she would have to have special management skills that will guarantee their patients a totality of health care. In this way the important requirement of "Continuity of Care" will be met in which efficiency, quality and reasonable cost will be deliberately taught as a specific skill. He or she will learn to be their patient's advocate and spokesman. They will learn how to work cooperatively and efficiently with their specialty consultant peers. They must learn to provide continuing, comprehensive care for their patients in their offices, in their patients' homes, in the hospital, and in the extended care facility and nursing home, as indicated. This type of training will encourage them to be more of a "hands-on" doctor who can complete more diagnostic and treatment requirements themselves in their own practice settings. They will be taught to administer their practice in a manner that enhances their patient care efficiency and their availability and, at the same time, offer them a fair income and time for their families.

All of this teaching will be based on the individual patient in the context of his family and community on a close personal basis. Because the family is the most important fundamental health care unit identified today, the family physician must therefore thoroughly understand family dynamics medically, socially and economically, if he is to be effective.

These teaching efforts will produce top level, highly competent physicians that are necessary for a successful health care system. If this system is further supported cooperatively with complementarily by the speciality consultative disciplines working together, then collectively they will provide a very efficient, exemplary and economic total health care system for the people of Singapore for a long time.

I have observed that the College of General Practitioners of Singapore has a sound basic core of volunteers who have the dedication and determination to achieve the goals that have been set forth.

Some in the medical profession take the position that a most discouraging state of crisis exists in medical care. Some members of our profession's recommendations are dangerously close to capitulation, while others recommend measures that are contrary to time-honored and time-proven ethical codes of the physician and the Discipline of Medicine. However, I do not believe that such a pessimistic attitude, or an attitude of "do-with-us-as-you-wish", is indicated. On the contrary — I would like to point out that over the past 50 years, medical care and the medical profession have faced many crises and many threats, and yet the medical profession is still the free and honourable profession it has always been. The medical profession was not destroyed in any of these past crises, as a matter of fact each crisis resulted in a strengthening of the profession. Why? Because, regardless of the nature of the threat, somehow the medical profession got together with the patients and the public they serve and resolved the problem to the benefit of the patient and the public.

While today our circumstance has more "players"—the basic issues are the same, and the outcome will still depend on how strongly the medical profession will fight for the rights of the patient. Because the patient is the public and in the end, the public makes the final decisions. Again, as in the past vital to this whole process will be the family physician, who has always been most effective in advising counselling and speaking for his patients, his families and his community. By such involvement, he rallies and encourages the public to be heard and to be involved, and to receive the care that they want and require.

After reviewing the career and achievements of the late Dr Baratham Ramaswamy Sreenivasan, for whom this Oration is named, I feel that it is not my words that really honor him, but it is the dedication, determination, and the commitment of the members of the College of General Practitioners of Singapore. They have dedicated their organization to do everything within their capabilities to assure the public of Singapore that they will always have the highest quality of family physician possible to serve them. Is such a goal the most meaningful way possible to honour Sreeni—as he was affectionately known. Dr Sreenivasan who certainly was one of Singapore's outstanding medical pioneers, scholars, academicians, teachers and leaders. He and his loved ones would be most proud of what the College has dedicated itself to—this is truly the real honour that should be recognized and recorded. I am truly honoured to be a part of this dedication.