By Cheong Pak Yean, Goh Lee Gan and Ong Chooi Peng
With the increasing complexity of medical care, medicine is organised into specialty groups based on body parts or treatment modalities. While such groupings are important for medical research and training, there is a danger of dividing patients up based on organ systems for care across the entire spectrum of disease severity. The patient ends up with one appointment for each dysfunctional organ system.
Medicine Not Enough
I remember the forty-year old blue collar worker with a homemaker wife and a young child. He had stopped taking carbimazole for Graves disease* for a few months, because attending a polyclinic for medication meant an ill -afforded half-day off work. One night, he developed right sided weakness, a complication of atrial fibrillation from uncontrolled thyrotoxicosis.
In a home visit I made with medical students after discharge, we found that he had five appointments all on separate dates— one each for the neurology, cardiology and endocrinology specialist clinics, and two others for speech therapy and physiotherapy. He had multiple packets of tablets from each clinic, and the students found inconsistencies between the amounts dispensed and the time to the next appointment dates. Luckily for the patient, the students were able to help reconcile some of these discrepancies.
——A/Prof Cheong Pak Yean
Fragmentation of Care
The drawing depicts a bewildered wheelchair-bound patient with a host of specialist outpatient appointments following an acute admission. Sometimes such splintered care in disparate clinics may lead to a poor outcome. The patient in the vignette subsequently defaults some of his appointments, has another stroke and dies.
We need to integrate clinical silos into the healthcare landscape by some common concepts and common action, aided by patient health literacy. Clinical practice guidelines and care pathways cannot substitute for doctors working in tandem and in harmony. This refers to specialist and generalist doctors. The specialist-centric model needs to give way to a more collaborative partnership with the generalist. The generalist needs new rules of engagement to participate in integrated care.
The question that we need to face is not Who but What. What is a generalist and what is a specialist? We can agree that the generalist is the doctor who is not organ-defined — hence the general physician, the geriatrician, and the family physician. Like specialists, these doctors have undergone structured training and assessment to get to where they are, and they each practice within a definite framework. It is time to recognize that the generalist is not distinct from the specialist. In the integrated new world, the generalist, looking after the whole person, is simply distinct from the one who looks after specific body parts.
—-Drs Cheong Pak Yean, Goh Lee Gan and Ong Chooi Peng
*Graves disease is a thyroid gland disorder that can lead to heart and other problems if untreated. This patient’s uncontrolled disease unfortunately led to a heart rhythm disorder, atrial fibrillation, which led to his stroke. Carbimazole is a commonly used treatment for Graves disease.
Cheong Pak Yean is an internal/family physician and psychotherapist. He is an SMA honarary member, past president SMA and College, and adjunct associate professor of NUS. His current interest is in medical communication and humanities.
Ong Chooi Peng practices in a polyclinic and also in a community hospital. She counts it her blessing to have been part of Family Medicine in Singapore through a time of formation and growth.
Goh Lee Gan is a past president of the College, SMA, as well as the Asia Pacific chapter of the World Association of Family Doctors. He started the academic Family Medicine. Programme in NUS in 1987 and also the Master of Medicine training programs. He considers himself the midwife of Family Medicine in Singapore although many of us think of him as the father!
The commentary and vignette were reproduced with permission from the book “Being Human, Stories from Family Medicine” edited by Cheong Pak Yean and Ong Chooi Peng and published in 2021 by the College of Family Physicians Singapore.
Pictures of illness experiences were drawn by NUS medical students in workshops conducted from 2012-2017 by A/Prof Cheong Pak Yean. Senior family physicians subsequently shared vignettes and commentaries based on the pictures.
