Access thebmj.com - The BMJ logo

Lidia Luna Puerta: Patients are still not seen as potential partners in Singapore

“Trust your doctor?”

I found this question on a flyer posted in the elevator in a hospital in Singapore and reflected that it might contain a message about the current state of play in the country’s healthcare, where traditionally the relationship between patients and the public has been one of subservience and unquestioning faith in health professionals.

I was in the hospital to conduct a series of interviews with health professionals on the challenges and opportunities for patient and public involvement in healthcare, which is the subject of the PhD I am working on. I am Spanish and in my third postgraduate year exploring how public involvement in Singapore could develop. The topic attracted me because it offers the opportunity to discover Singapore’s fascinating capacity to consider, adopt, and adapt some Western practices, but set it in an Asian context. I am also interested to know how future research in the country may develop if patients and the public were to have an active role in it.

Most of the people that I interviewed, including members of the public, agreed that the “consensus not conflict” rule (one of the five shared values that the government put in place in 1991 to organize Singapore as one society) is taken to the extreme by most citizens, especially in their interactions with experts. Questioning authority is discouraged from an early age, and this learned behaviour is taken into the consultation room where patients tend to be reluctant to voice their opinions and preferences with the doctors they see.

My recent conversations with health professionals suggest, however, that things may be changing. One psychiatrist I interviewed highlighted that the patient movement has developed in mental health, and that public expectation of transparency and accountability from healthcare providers is growing. This observation fits with what I heard from the members of the public that I talked to where I got a clear message that “blind confidence” in doctors is no longer the status quo. Singaporeans may not question doctors directly, but if they don’t like what they hear they go on seek second, and third opinions (if they can afford it) until they get what they deem to be a “satisfactory” answer to their problems. Members of the public that I talked to shared their strategy to self-diagnose, and make decisions on medication based on online searches, or “kopitiam talk” with members of their patient communities.

Singapore has started to confront this change in public attitude towards healthcare providers and has recently adopted a policy of patient-centred care (as stated in the Healthcare 2020 Masterplan), where patient’s values, needs, and preferences are placed at the core of the services they receive. This is reflected in the philosophy of care: Patients at the heart of all we do.

But while policy may be changing, my impression is that little is changing on the research front. In Singapore, patients and the public are still not seen as potential partners in research. Health research is dominated by a biomedical model and paternalistic practices. In my interviews with health researchers most talked about research participants as “subjects”; and the citizens themselves felt that their status in terms of research subject was more like “laboratory rats” or “guinea pigs”. That said a few of the health researchers I interviewed agreed that top-down research “for” the people is outdated and reported that they had  started conducting studies “with” the people.

While I am a relative newcomer to Singapore, I have observed that the country, which has become a global research hub, is on the path towards radical cultural change and that this provides the opportunity to promote patient and public involvement in healthcare, not least research. The country has already committed to providing patient-centred care and this could lead to patient-centred research. The challenge is to identify and work with patient and community values to build mutual understanding, promote empowerment and partnership in clinical care and research, and capitalise on the opportunities this will bring.

Lidia Luna Puerta is a PhD Candidate in the Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, exploring public involvement in an Asian context.

Competing interests: None declared.