Introduction When we think about medicine, just like we do about other things in life in the past and the present, we usually refl ect on the good old days. On hindsight, the past always seems brighter than the present. Sometimes, it is worth looking back to see how things have changed. There may be many elements in the past that are worth bringing back to the present and carrying into the future. In this paper, I will fi rst discuss some of the changes that we have seen in our lifetime. I will then outline new opportunities and challenges we face with the practice of medicine in the 21st century

K Ranga

Rama Krishnan

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April 2011, Vol. 40 No. 4
201
7th College of Physicians Lecture — The Changing Face of Medicine, Medicine – 
Past, Present and Future
K. Ranga Rama Krishnan,1MB, ChB
 1Duke-NUS Graduate Medical School Singapore 
Address for Correspondence: Prof K. Ranga Rama Krishnan, Duke-NUS Graduate Medical School Singapore, 8 College Road Singapore 169857. 
Professor Ranga Krishnan is Dean of the Duke-NUS Graduate Medical School Singapore, which is a strategic collaboration between Duke University (USA) 
and the National University of Singapore.
This is a summary of the presentation made at the 7th College of Physicians Lecture: The Changing Face of Medicine. The Lecture was part of the College of 
Physicians Medicine Review Course 2010 held on 23 to 25 July 2010 at Tan Tock Seng Hospital.
Introduction
When we think about medicine, just like we do about 
other things in life in the past and the present, we usually 
refl ect on the good old days. On hindsight, the past always 
seems brighter than the present. Sometimes, it is worth 
looking back to see how things have changed. There may 
be many elements in the past that are worth bringing back 
to the present and carrying into the future.
In this paper, I will fi rst discuss some of the changes 
that we have seen in our lifetime. I will then outline new 
opportunities and challenges we face with the practice of 
medicine in the 21st century.
Changes over the Past 30 years
Just about 20 to 30 years ago, the family doctor was the 
mainstay of our physicians’ practice. The family doctor knew 
the patient, his family, his upbringing and his community. 
The doctor-patient relationship was one that lasted a lifetime. 
The environment in which physicians worked gave them 
considerable freedom. The doctor was king, his word was 
gospel and no one questioned his actions. Doctors were 
seen as independent and highly trusted, and were often 
placed on a pedestal by those they treated. In many ways, 
the doctors deserved the honour — as many of them worked 
long hours and put patients before their family. 
In those times, the doctors showed that they excelled in 
the art of medicine. They worked based on their clinical 
experience, despite the relatively modest evidence based 
on research for many of the treatments. Clinical skills were 
the most valued; and many patients appreciated the great 
bedside manner of the doctors, and took comfort in them. 
From the patients’ perspectives, caring was the calling card. 
In addition, everything that physicians needed to know 
was kept mostly in their memory. There was no expiry 
date for how long physicians could practice. Doctors kept 
up-to-date through their personal journal subscriptions, 
going to libraries (if available), and occasional continuing 
medical education meetings. But there was no formal need 
for upgrading.   
Current Trends and What They Mean for the Practice 
of Medicine
Time, however, has changed the way physicians serve 
the public. First, the knowledge base in medicine has 
greatly expanded. It is no longer possible for a single 
physician to stay current in medicine as a whole, may be 
not even in his or her own speciality. As the knowledge 
base and the technical skills developed, there has been an 
inevitable specialisation (fragmentation) of medicine. The 
increasing sub-specialisation is here to stay. This increased 
sub-specialisation has changed the practice of medicine. 
The second factor that has changed is the model of payment 
systems in medicine. In the past, there was, in essence, 
a direct contract between the patient and the physician 
wherein the patient directly paid the physician for the 
services rendered. Physicians often provided free care when 
patients were unable to pay. Now, there are intermediaries 
like insurance entities and government agencies etc that 
set and drive the systems of care. Physicians now work in 
increasingly specialised settings, in teams and in healthcare 
clusters, and in an environment that is greatly driven by 
technology. Moreover, the doctor is no longer a free agent 
in the management of patients, but is constrained by 
compliance requirements enforced by government agencies 
and health insurance organisations.  In this new environment, 
the doctor is a cog in a complex web of the healthcare 
system. In addition, the new generation of physicians are 
beginning to look more at a work-life balance. There are 
new priorities — family over work life and they live in an 
era of increasing accountability. 
This has led to the patient and the doctor becoming 
“strangers”. One patient sees many specialists and when 
you ask the patient, he doesn’t quite know who his main 
doctor is. In this sense, the treasured special doctor-patient 
relationship seems to have diminished. 
While clinical skills still remain valued, they are now 
closely audited and managed — doctors always have 
someone looking over his or her shoulder, almost like 
a big brother looking over their practice. The clinical 
approach has become more technical, guideline focused, 
 Changing Face of Medicine—K Ranga Rama Krishnan
Lecture
202
Annals Academy of Medicine
 
and anchored on evidence-based management (EBM). 
Evidence-based management when applied properly 
integrates the evidence from the clinical trials and other 
literature and then extrapolates that evidence as best as 
possible to the individual patient. When improperly utilised, 
it can become impersonal.
Physicians have also become highly accountable to the 
public, to hospitals and have to be performing evidence-
based medicine. The rapid expansion of evidence-based 
medicine and systematic review of evidence has slowly 
begun to transform our healthcare practice. It is no longer 
the length of time or experience that are the sole factors 
predicting a physician’s competence. It is the ability to 
constantly adapt and manage in an ever-changing evidence-
based environment that has become a hallmark of physicians 
in recent times. Doctors now are required to continually 
upgrade their knowledge via Continuing Medical Education 
(CME). In many countries, for example, in the United 
States, specialty certifi cation has become time-limited. And 
there are examinations and other requirements to maintain 
certifi cation. 
Knowing science, appreciating science and understanding 
science are critical and this is the basis for the medical 
profession. But the medical profession is more than knowing 
science (information) and must include the “art” of medicine: 
the ability to empathise, care, work with and communicate 
with patients and their families.
The one thing that physicians and patients do not appreciate 
is the Black Swan — the unpredictable consequences which 
have far-reaching effects. Many events which we think of 
as rare may seem to be of higher frequency — the so-called 
Fat Tail. And therefore, physicians should be humble, and 
acknowledge that they do not possess all the knowledge 
to treat everyone all the time. 
What does this New Era Mean for Patients?
For the patients, there is a feeling that the bedside manner 
has become less warm, less personal. In addition, the way 
in which patients approach doctors and medicine has also 
changed. With Google and the Internet, knowledge is now 
just a fi nger touch away for everyone. Patients can access 
rapidly changing information and knowledge, even while 
this is constantly being updated. With this, the asymmetry 
of information in doctors’ favour has decreased, and 
undermines the separation that has traditionally existed 
in healthcare.  
The easy access to information has brought the 
democratisation of information. Access to knowledge or 
context continues to best reside within the doctor. However, 
there is the potential danger of those outside the healthcare 
world interpreting information without knowledge and 
context. This has actually led to less trust placed in 
physicians and greater expectations on the part of patients 
and, in patients wanting to participate and actively getting 
involved in decision-making. 
What does this New Era Mean for Medical Education?
Medicine and healing are complex and adaptive. The 
skills that are needed by doctors are not only technical skills 
which we can teach very well but also adaptive skills, the 
ability to change, the ability to understand and to adapt to 
the situation. This is not taught formally but with the help 
of a wise mentor, it can be learnt effectively on the job. 
With the establishment of the Duke-NUS Graduate 
Medical School in Singapore, we have a unique opportunity 
to examine how medical education should work in the 
changing era set in the context of Google and the Internet. 
Traditionally, medicine started as a study of the natural 
sciences—anatomy, physiology, and biochemistry, 
pathology, followed by the application of these natural 
sciences to solve medical problems. What has become 
evident with the rapid change of knowledge is the two are 
not well connected. In many instances, in the minds of 
trainees, they are independent and many often forget the 
fi rst before they go to the second. 
The School’s approach is to set a lifelong pattern of 
learning to heal, which is inculcated in our students. Our 
Education Offi ce is helmed by a team of senior clinical and 
educational leaders, who joined our school from the United 
States: Dr Robert Kamei is our Vice-Dean for Education; 
Dr Sandy Cook is Senior Associate Dean (Curriculum) and 
Dr Frank Starmer, an early pioneer of medical Information 
Technology at Duke, is Associate Dean (Offi ce of Innovative 
Solutions).
The Duke-NUS Medical School's mission is not only to 
train physicians to practice medicine, but also to play a role 
in improving medical practice. Thus, we impart skills beyond 
just medical knowledge, and these include critical thinking, 
team work, leadership, professionalism, communications 
and in our context, the ability to understand and conduct 
research. People are more than the sum of diseases, parts 
and specialties. Patients are part of a larger social world 
and so are doctors.
The Duke-NUS curriculum structure is the same as that 
in Duke’s in Durham, US. All students can be admitted  to 
this school after completing a basic degree.  
In both schools, the fi rst year basic sciences are taught 
in an integrated fashion. In the second year, they enter the 
clinical arena (do clinical rotations/clerkships). Students 
then devote their third year to research. And their fourth 
and fi nal year is a clinical year, in preparation for residency. 
Changing Face of Medicine—K Ranga Rama Krishnan
April 2011, Vol. 40 No. 4
203
The programmes differ, though, in the mode of curriculum 
delivery. Duke-NUS uses a team-based learning method, 
we call TeamLEAD, to deliver much of the fi rst year.
Why teamwork? Physicians are no longer solo practitioners 
and researchers, so teamwork is a very important skill. Why 
the approach?  
It is now impossible to master all of medicine in medical 
school. It is also diffi cult to keep up with the changing and 
ever growing new discoveries. The key to current education 
is to understand and introduce content so physicians will 
know how to search, sort, critically analyse as well as to 
know when to use this information, and to become skilled 
at self-directed learning.  
Most medical schools use traditional lectures to deliver 
content; however, we know that lectures do not work very 
well and there are a number of factors that can affect recall 
of content. Giles et al1 tested both immediate and long-term 
(4-month delay) recall of lecture information in a group of 
preclinical medical students. They compared the recall of 
visually and verbally presented lecture information and of 
information presented during different time periods in the 
lecture. Recall of visual information was superior to verbal 
information both in the immediate and long-term duration. 
Information presented between the 15th and 30th minutes of 
the lecture was recalled best whereas the worst recall was 
found for information presented in the fi rst 15 minutes. 
Seating position of the student in the lecture theatre was 
associated with the level of immediate recall.1 Many of 
these factors are probably related to attention.2    
The data are clear: passive education does not work 
effectively. Cognitive learning theory has emphasised 
combining group learning and individual activity. Active 
learning, in which new information is used, is retained longer. 
Our fi rst year students have to understand the language and 
science of medicine. There is both information acquisition 
through guided independent learning (i.e. no live lectures 
but instead, self-directed review of a variety of modalities 
(readings, recorded lectures, articles, websites, etc.) that 
are provided beforehand). Class time is spent in conceptual 
reinforcement of that content using problem solving, 
explaining to others and most importantly, repetition.  
This approach at Duke-NUS is dubbed TeamLEAD. 
TeamLEAD starts off with clear-cut goals and objectives 
being stated. We do not have formal lectures. Consequently, 
most of the time is spent in individual and group learning. 
The principles of the approach are:
1. Students do independent preparation, guided by the 
faculty on core concepts.
2. Students are held accountable individually for this 
learning through an individual test.
3. Further learning is emphasised through team assessment 
(on the same test).
4. Faculty conducts debrief to ensure students understood 
and got to the right answer for the right reason.
5. Then students are given problems to solve, using the 
content learned. 
So what this encourages is learning for performance, 
promoting cooperation and teaching students to learn to 
work in teams. These are all based on the concept of adult 
learning.
The initial performance data here seem to suggest students 
do indeed learn better. So this is one step in how medical 
education can evolve to fi t the changing times. The same 
approach can be extended into learning in the postgraduate 
setting and further on into lifelong learning of physicians. 
We hope that over time in Singapore, we can gradually 
extend this approach into the lifelong learning of physicians.
The values that matter in the 21st century and those that 
one begins to learn and live with are key skills: sorting, 
analysing information, creative thinking and teamwork. But 
at the same time, retaining the art and soul of medicine, 
empathy and caring are also important.
REFERENCES
1.  Giles RM, Johnson MR, Knight KE, Zammett S, Weinman J. Recall of 
lecture information: a question of what, when and where. Med Educ 
1982;16:264-8.
2.  Pollio HR. What students think about and do in college lecture classes. 
Teaching-Learning Issues. No. 53. Knoxville: Learning Research Center, 
University of Tennessee, 1984.
 Changing Face of Medicine—K Ranga Rama Krishnan


7th College of Physicians Lecture -The Changing Face of Medicine, Medicine - Past, Present and Future

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7th College of Physicians Lecture -The Changing Face of Medicine, Medicine - Past, Present and Future

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