16th Gordon Arthur Ransom Oration. Navigating in the sea of science and technology.

Let me begin by saying how deeply honoured I feel to be invited to deliver the 16th Gordon Arthur Ransome Oration. I thank the Master and the Council of the Academy of Medicine, Singapore, for bestowing on me this cherished honour. Like many colleagues of my generation, I have always held Prof Ransome in the highest respect and admiration. I had the extreme good fortune and privilege of working under him on my return to Singapore from London in the mid 60s. Not having had the experience of learning and practising medicine in Singapore myself, I was struck by the wealth of clinical materials, the florid clinical presentation of patients and the relative shortage of resources for laboratory diagnostic support and therapy. Operating in this demanding and challenging environment was physician extraordinaire Professor Ransome. His clinical prowess in diagnosis was legendary. His intuitive power combined with a sharp eye for details and inordinate patience characterised his approach to any diagnostic problem. His philosophy was to bring the maximum power of all his senses, including the sixth, to bear on the clinical challenge before him and to come to the correct diagnosis by the bedside with the minimum of laboratory or radiological aid. Perhaps it was the relative shortage of the latter that had helped to hone his diagnostic skill to that extraordinary level. In him we had an example of innate talent and capability blossoming under pressure of circumstances. A lesser person could never have risen to his level of attainment. As I fondly remember, it was an inspiring experience to learn from this master diagnostician. He was very kind, generous and patient in sharing his vast clinical experience and wisdom, but most of all, he taught by example, by what he actually did at the bedside. His clinical credo was to go to the laboratories only after an exhaustive bedside investigation and a clinical diagnosis. Ultimately, it called for judgement based on keen observation, rigorous analysis and intuitive insight. It is interesting to speculate how Prof Ransome would view the practice of medicine 40 years later in the new millennium, and whether he would continue to enjoy pre-eminence in our present-day context if he was working in our midst. The exponential growth in medical knowledge and the consequent development of diverse specialties, the massive infusion of technology and the substantial increase in diagnostic and therapeutic capabilities have radically impacted the way medicine is practised. And the driving force behind these developments is the accelerating application from the growing body of scientific knowledge in the practice of medicine. This is likely to gain greater momentum in the foreseeable future. The science of medicine is poised to grow. How the profession responds to the growth and its ramifications will determine the quality of care we deliver to our patients. The most obvious issue that confronts all of us today is that of information overload coupled with the rapid obsolescence of knowledge. New ideas and concepts about diseases are proferred, the latest and most sophisticated and powerful equipment promoted and breakthrough drugs with better efficacy announced. The constant bombardment has to be sorted and assessed, to separate the wheat from the chaff. This is a major task quite beyond the capability of individual doctors. Clearly it has to be done collectively, preferably at the institutional level to ensure independence, fairness and objectivity as is attempted in the UK by NICE (National Institute for Clinical Excellence). In practice, problems relating to scope of coverage, speed of the process, quality control and ultimately provision of adequate resources have emerged. They need to be expeditiously resolved. Such a sieve is essential to assist doctors in keeping up with the rapid changes and benefit from the real advances that come along. It is also important to know whether a given advance incurs additional cost and whether this can be justified by the benefit accruing to the patient and society, e.g. shorter hospital stay and earlier return to work. The benefit in human terms such as quality of life should clearly be considered although this is less amenable to quantification, and can be a contentious issue in the balance against cost. The rise of health economics in this context is therefore not unexpected. However, the availability of independent authoritative guidance, though highly valuable, is in itself not sufficient to ensure quality patient care. It can only supplement, not replace, clinical judgement and a holistic approach. 16th Gordon Arthur Ransome Oration