Inaugural-speech-President-Ashok-Philip-2024-2025

Helsinki Inaugural
My dear friends and colleagues, I am very grateful to you for the honour you have bestowed
upon me by allowing me to assume this prestigious post. In particular, my gratitude goes to
my long-suffering wife, Premah, and my somewhat bemused children, Mira, Anila and
Rohan. I would also like to mention Andrew Gurman and Leah Wapner, who helped to clarify
my mind about seeking this post. The Presidents before me also helped me make this
decision. I also thank the Malaysian Medical Association for their nomination and support.
What I say now represents my own views, but I believe many of you, my colleagues, will
hear my words and recognise the problems I speak of, and perhaps agree with my sentiments.
The issues that face the profession are many and serious. For instance, antimicrobial
resistance threatens to push us back to an age when the slightest scratch or sniffle might
presage death. Climate change has begun to affect our health and may threaten the continued
thriving of our species and many others. The security and future development of the health
workforce faces challenges around the world. Non-communicable diseases are sweeping the
world. The next pandemic is coming. You will be relieved to know that I have been given 10
minutes to talk, so I must set these topics aside for another time.
I would like instead to focus on another topic which I believe is fundamental to the entire
practice of medicine – professional autonomy.
We have all heard of it, we all want it, we all have some restrictions preventing us from
having full autonomy. To a greater or lesser extent, I believe most of us feel it is under threat.
I agree with that assessment.
Before we can discuss it, we should define what we mean by it. Professional autonomy
means primarily the freedom to make clinical decisions about the care of individual patients.
This is what most of us think of when we mention autonomy, and in my opinion is the aspect
most under threat. However, the right to have a voice in health policy development and
healthcare system change is also a part of professional autonomy. These aspects are perhaps
not under such threat.
The WMA Declaration of Seoul goes into great depth and detail about why autonomy is
important, and I recommend that document to you if you get into an argument or discussion
with administrators or insurers.
Professional autonomy developed and continues to exist because it serves the interests not of
the profession but of the patients. We doctors wield this autonomy for the benefit of patients,
and we stand in a fiduciary relationship to them, always considering what investigations,
interventions and treatments are best for them, not for us and not for the healthcare authority
or insurance company. If we let this autonomy be taken away or diminished, our patients will
suffer – and eventually everyone will be a patient, so everyone will suffer. When you are sick,
that extra profit you made your company, the bigger bonus you got, the political agenda you
advanced will not help you when your doctor’s hands are tied.
Why is autonomy threatened? A major reason is that it is becoming more and more expensive
to treat patients. In part this is a result of the success of medical science. People live longer,
so we have an increasing pool of sick elderly people who can be quite expensive to manage.
Diseases that were impossible or difficult to treat even a few decades ago are now
manageable if not curable. Unfortunately, though, these new treatments are often extremely
expensive. Healthcare systems may end up paying more and more to treat fewer and fewer
patients.
Financing these treatments will be difficult whether the government or private insurers do the
paying. When governments are the payers, profit is not a consideration. However, issues of
accessibility and rationing may arise, and again it is our responsibility to bring evidence to
the table to help guide policymakers in making their decisions. We must also be alert for the
intrusion of political agendas into healthcare.
When private enterprise pays for medical care, the situation can be complicated by the profit
motive. This is not to disparage something that has helped build the world, but we should
very carefully consider if profit seeking as seen in the commercial arena should be allowed
free rein in medical situations. Nobody chooses to get sick. Patients have little choice but to
take the treatments available. Allowing supply and demand to set prices seems unkind, even
cruel, and may lead to some patients not getting the treatments they need. There must be
guidelines, independent of purely financial considerations, to decide how patients are treated,
and these guidelines must be drawn up by doctors. Additionally, flexibility to vary treatments
and avenues for appeal must be built in and must be responsive. Ill health cannot wait for 5 to
7 working days.
Delivery of care has always involved teams of healthcare professional led by doctors. We
have noticed movements towards removing or excluding doctors in some situations,
ostensibly to handle shortages of doctors, but more obviously to reduce costs. This is also an
abridgement of our autonomy and must be resisted at all costs. Every team member is
valuable, but a leaderless team is ineffective. The natural leaders in healthcare should be
those who can look at the whole picture, and that generally means doctors. It is not in the best
interests of patients individually or systems as a whole that doctors be removed from their
leadership roles.
We have not yet lost our professional autonomy, but I believe the chains to bind us are being
forged. They might be chains of gold, but they will bind us none the less, and our profession
and our patients will suffer. We must be on the alert. Those seeking to bind us will do so
covertly, under the benevolent guise of improving healthcare access. Let us always look
deeply into any such moves, and let us always remain involved in policy and guideline
development. It may be tedious and take us away from direct patient care, but in the long
term it protects our patients, and that is what we have sworn to do.
Please note that I am not advocating carte blanche for doctors in everything. Our autonomy
only applies to the management of patients, broadly construed. It must be based on agreed
professional opinion. There may be varying opinions, but these must rest on sound scientific
and ethical foundations. Doctors are entitled to their own opinions, of course, but where they
differ significantly from the accepted professional view or views, this must be made clear,
and it should be understood that the shield of professional autonomy no longer protects them
in such a situation. Where maverick doctors use professional autonomy to advance non
evidence based (or even anti evidence based) views, associations such as ours must be
prepared to speak out and correct public perceptions. If we hesitate to do so, the public can
rightly ask if it is our patients or our colleagues who are our priority.
I know I can count on every one of you, as associations and individuals, to do the right thing
and lead the way to a better future for our patients, our communities and our profession. I
look forward to working with you, in the next year and beyond.
Thank you again, and to our hosts, kiitos.