Palliative Care as a Model of Care for All Medicine

310315By Dr Jeremy Lim

Summary of talk by: APHN volunteer, Ng Shi Hui

In his presentation, Dr Lim sought to explain why he felt palliative care should be used as a model of care for all medicine, including topics such as the future of palliative care in view of Singapore’s growing silver population.

Palliative care, although only recognized as a sub-specialty in Singapore, is slowly coming of age with stronger government and provider support. There is a growing awareness amongst the population of the necessity of palliative care as a greater proportion of the general population age. Mr Lee Kwan Yew’s recent passing has also highlighted the Advanced Medical Directive policy, throwing into the spotlight once again the value of dying according to one’s own terms. Dr Lim therefore questioned the eventual destination of palliative care – do we wish for palliative care to become a ‘mainstream’ specialty, or does palliative care have the potential to achieve more than that?

Regarding the future of palliative care, Dr Lim felt there were two points that had to be brought into perspective. First is the evolution of medical specialization over the years. Medical specialization originated with the development of medicine, when doctors felt that the greatly expanding body of medical knowledge was becoming too large for a single doctor to master. Furthermore, it was such that many patients often suffered from similar conditions, creating a population of like patients who will be better served by a group of doctors with particular strengths in a certain areas. Vertical specialization was hence introduced and encouraged, where doctors could learn specific knowledge associated to a particular field, allowing them to better serve the population.

While such vertical specialization promotes efficiency and brings about better patient care, horizontal specialization was as a result neglected. It became such that patient care was compartmentalized, and patients facing multiple conditions had to see multiple doctors; each doctor only helped with a specific condition. In such cases, vertical specialization has become increasingly unsustainable. Locally, many patients suffer multiple chronic diseases; it is unpleasant and inconvenient for patients to have to see multiple doctors, and results in wastage in the medical industry. Furthermore, Singapore’s population pool of 5 million is small in comparison to those of large countries such as the United States of America. It is therefore not feasible to train super specialists, where doctors have a large enough patient pool to afford to perform similar operations and treat similar conditions. Locally, doctors with greater breadth are required, in part due to the propensity to see multiple chronic diseases in patients, as well as our small population pool. Dr Lim also further emphasizes this with an example drawn from the 2003 SARS incident, where a general surgery team was quarantined and surgeons specializing in other areas were required to take their place. It was very imperative at that point that these surgeons had the breadth of skills and knowledge required to continue ensuring that patients were being treated in due time. This shows how in Singapore, greater horizontal specialization in the field of medicine should be encouraged.

Secondly, Dr Lim felt that the palliative care paradigm has to be addressed. Currently, medicine has developed a very reductionist model – it is about finding a solution to a problem; a cure to a condition. Such is a very linear way of approaching medicine, and it does not consider the fact that in this era of many diseases, there usually is more than a single cure to a condition. Dr Lim proposes the interpretive model, where doctors seek to earn patients’ trust and know their values, eventually accepting, such as in many cases of palliative care, that there is no war against dying. Dying is instead seen as part and parcel of life, with patient-centric care underlying all medical treatment.

From these two points, one can see that there are diverging medical goals currently seen in Singapore. For one, super-specialization, to an extent, promotes rigorous academic pursuits and medical efficiency. The palliative care paradigm, however, focuses greatly on patient-centric care, and may in certain instances run counter to the concept of ‘curing’ patients, which many associate to efficiency.

A change is therefore required, and Dr Lim feels that the model of ‘knowledge, attitude, practice’ is insufficient and simplistic in such a case. He refers to the seed and soil analogy, where the seed refers to a doctor’s personal skill and mindset, and where the soil is an enabling environment and an awareness of global changes. The professional community needs to be clear about the direction of palliative care, specifically in which way one would collectively like it to lead. Dr Lim feels that healthcare professionals working in the field of palliative care need to decide on how much of palliative care consists of specialist knowledge and skills, vis a vis a philosophy of care. It is only then can appropriate strategies be implemented to embed palliative care principles in medicine and healthcare, furthering the medical industry as a whole, as well as the specialist development of palliative care.