The doctor-patient relationship is the bedrock on which the practice of medicine rests. It could be said that without its existence, the medical profession cannot be called a profession, much less a calling. Yet, there are few attempts to define or codify what it is. It’s presence and effects are often taken for granted. Even for certain specialties that often do not have direct patient contact, the relationship exists, albeit indirectly or vicariously.


For something that is so all-permeating, it is also quite elusive. It is a relationship and like most relationships is not something physical or material that one can lay your hands on or measure quantitatively, like a stethoscope or measuring body temperature. It is also more than a contract between two parties, unlike say a contractual relationship between an insurer and a policyholder, yet there is no document that directly spells out the exact limits and responsibilities of both parties in the doctor-patient relationship. Some have attempted to do so, such as in the case of Parson’s Sick Role, but even in this example, it is a very limited and inadequate attempt to describe something that is at once important, abstract and complex.


Yet almost everything a doctor does for the patient is predicated on the existence of the doctor-patient relationship. I will give you two simple examples to illustrate this.


One can walk into a supermarket or provision shop and buy paracetamol tablets and no questions will be asked. But one cannot do that at any medical clinic. Why?


This is because under the law, a special exemption is given for “the supply of a medicinal product by a doctor or dentist to his or her patient” [Medicines Act Section 27(1)(a)]. In other words, a doctor can only supply a medicinal product to another person if that other person is his or her patient.


To prove that this person is a doctor’s patient, the person then must give his or her particulars to the clinic to be registered as a patient of that clinic and the doctor who is prescribing the medication. Hence, under the law, when it comes to medications, a doctor in Singapore has prescribing and dispensing rights, but he does not have the rights to sell or trade in medicine. That is, the prescription and dispensing rights must be applied in the context of a patient, and not just anybody.


In the wake of some questionable practices involving the issuance of Medical Certificates (MCs) by doctors and clinics, MOH issued a circular reminding doctors of the ethical and practice considerations that must be considered when an MC is issued. (MOH Circular 30/2024 dated 22 April 24). In this circular, it was stated,


“Integral to the issuance of an MC is that it must be made in the context of an existing patient-doctor relationship and is premised on the duty of care the doctor owes the patient arising from this patient-doctor relationship. Arising from this doctor’s duty of care to the patient is that doctors must practise and demonstrate a standard of care that is appropriate. In other words, the issuance of an MC under a particular circumstance is not a standalone activity that can be divorced from, but is instead reflective of, the duty and standard of care that doctors must uphold in their management of patients.“


What this means is that a doctor-patient relationship must exist so that the doctor owes the person/patient a duty and standard of care. In turn, the privilege and decision to issue an MC (or not) is then made based on the duty and standard of care.


In the context of the recent controversies involving the issuance of MCs after very short teleconsultations lasting less than a minute, or even lasting only seconds, the important question of ethics that needs to be asked is – Was an effective doctor-patient relationship created in the first place during that short period of interaction between a patient and doctor over a teleconsultation?


This brings us to the practical considerations that we must face when we attempt to define a doctor-patient relationship. When does it start? When does it end? While the doctor-patient relationship is of fundamental importance to the practice of medicine, no one really documents when the relationship begins. It is more or less implied. The ending of the doctor-patient relationship is obvious when one of the two parties passes on. However, if both parties continue to exist, the relationship is presumed to continue, even when the two interact infrequently, so as to facilitate continuity of care.


A stable and long-term doctor-patient relationship is a desirable thing in healthcare. This is obvious in the government’s policy of encouraging everyone to have their own family physician and stated so in government programmes such as Healthier SG.


However, there are limitations and obstacles to having a stable and long-term doctor-patient relationship that we should be cognisant of.


Some of these are patient-centred factors. These include the undesirable culture of doctor-hopping. Or simply the fact that patients prefer some doctors over other doctors, often a question of choice that involves selecting a doctor who is perceived to be more skillful and effective over another. It could also be due to very simple considerations of the patient moving to another part of town and it all boils down to convenience and accessibility.


There are also health system and physician factors. An oft quoted example is that of subsidised healthcare in Singapore. Patients are assured of receiving appropriate care but they often see different doctors every time they go for a consultation at our polyclinics and subsidized Specialist Outpatient Clinics (SOCs). There is therefore no long-term doctor-patient relationship in such cases. The reasons behind these could be structural and intractable. The public healthcare system needs to continually train doctors and these doctors need to be rotated so that their training will have the necessary breadth and depth to make them better doctors. Another reason could be that of resource constraints and rationing. There are only so many professors and senior consultants and not everyone can have access to them. Access to them will be determined by ability to pay, as in private healthcare; or in the case of subsidised care, determined simply by random chance or by the complexity of the patient’s condition.


Even in the case of private healthcare where the patient is essentially paying for what they are getting or want to get, they often do not see whom they want to see. This happens in patients using health insurance. With insurers using preferred doctor panels, policyholders or patients do not have the freedom of choice to see who they want. For a newly diagnosed condition, a patient has to choose within his insurer’s doctor panel so as to enjoy the full benefits of the policy. This is perhaps not so bad because no pre-existing doctor-patient relationship had existed hitherto the diagnosis or presentation of symptoms. But the considerations and consequences are more far-reaching when a patient has to discard his existing doctor for a new one just because of insurance policy or doctor panel considerations. This could happen when the insurer removes a doctor from its panel. Insurers not infrequently change the composition of their panels by removing or adding doctors and sometimes existing doctor-patient relationships have to be abruptly terminated or the very least, penalties have to paid for the continuation of the existing doctor-patient relationship.


As we revisit and reinforce the importance of the doctor-patient relationship in the delivery of healthcare, it is also important that the medical profession does not take it for granted. A stable long-term doctor-patient relationship is to be cherished and protected, both by doctors and patients. The medical profession can only be better protectors and defenders of this tenet if we also recognise that there are systemic, structural and even commercial obstacles that lie in this path. We have to accept and live with some of these obstacles, but sometimes we also have to countervail and even overcome others.


Happy New Year.