The evidence must come not from tests but from a thorough observation of the patient

Emeritus Prof Sir Gordon Arthur Ransome (1910-1978)

Today one of the four colleges at the Duke-NUS Graduate Medical School is named after Emeritus Prof Sir Gordon Arthur Ransome, remembered by many as the founder of modern medicine in Singapore and admired as an outstanding and brilliant clinician. His contributions to medicine in Singapore went back to 1938, when he was made Associate Professor of Medicine at the then King Edward VII College of Medicine. He also founded the Singapore Academy of Medicine and was its first Master.

The following is taken from an oration to mark Prof Ransome’s retirement in 1971: The life and times of Gordon Arthur Ransome by Seah Cheng Siang in Annals of the Academy of Medicine, January 1972, Vol. 1 (Bolding by HCS)  

Foremostly, Professor Ransome taught by example. Himself a well-trained clinician, he has handed down to hundreds of doctors, clinical methods which were learnt from his teachers and also those innovated by his own increasing experiences.

In taking a meaningful medical history, he has on many occasions, and still does so now, sit by the bedside, eliciting point by point the story of the patient’s illness, with students watching on. From the history and adopting Lord Horder’s methods, a list of possible diagnoses to account for the presenting symptoms, is then compiled.

In front of the students, Professor Ransome will then examine the patient meticulously. A very careful inspection from head to foot is followed by an examination in minutia of the different systems. . .

From the signs culled, and with the results of some laboratory tests, he has nearly in every instance been able to arrive at a definitive diagnosis. A firm diagnosis by this method and not by intuition, is always teachable. He converted many a doctor from practising intuitive diagnosis into exercising a perceptive scientific method.

Another interesting insight into his powers of diagnosis comes from Sir Gordon Arthur Ransome  by Beng Yeong Ng and Jin Seng Cheah in Annals Academy of Medicine May 2008, Vol. 37 No. 5 (Bolding by HCS)

 He taught from first principles and emphasised the importance of the use of the 5 senses in the practice of medicine. He placed importance on the art of listening, the essence of the artistry of bedside medicine. Effective listening involves all the senses, not merely the ears. To succeed in healing, a doctor must be trained, above all else, to listen. His skills as a diagnostician were renowned. He believed that X-rays findings tended to lag behind the physical signs. Without any laboratory tests, he was able to arrive at an accurate diagnosis just by taking a comprehensive history and examining the patient skilfully. He was nicknamed “kosong” (meaning “zero” in Malay) as he would give a student zero marks for poor performance in clinical examination. 

This letter from Dr Quek Koh Choon, one of Prof Ransome’s former students, appeared in the Sunday Times on 26 April 2015 and again highlights the importance Prof Ransome attached to observation – note “Tests and investigations were needed only to confirm the diagnosis. (Bolding by HCS) 

If Professor Gordon Arthur Ransome were alive today, he would be pleased to see how Singapore has become a great medical centre (“Prof hopes S’pore becomes medical hub”; last Sunday). 

I was privileged to have been taught by him, and to also have had the opportunity to work with him.

He taught me that the practice of medicine is not just a science, but also an art. He emphasised the need to observe the patient as he came into the consultation room – to watch his gait and facial expressions – and also advocated listening to the patient well.

These days, many patients say that many doctors are not listening enough to their complaints, and that they are quickly dismissed to undergo a battery of tests and investigations.

Prof Ransome did not think it wise to resort quickly to investigations. He believed that a great deal could be learnt from a patient’s history, and that astute observation and a thorough examination were key in clinching the diagnosis. Tests and investigations were needed only to confirm the diagnosis.

I used to accompany Prof Ransome on his ward rounds, and he surprised me when, at the end, he invited me to sit down with him and asked for my opinion of the various cases.

I was the most junior doctor then, and the experience certainly jolted me and taught me to value mutual respect among fellow colleagues and to be open to consider an opinion, even from a novice.

Prof Ransome treated all patients with respect and kindness, and did his best for them no matter what their status and background were. Once, he was called to attend to a VIP while examining a patient in a C ward. He said that the VIP had to wait as he was still attending to his patient.

He was a doctor devoted to the practice of medicine. He did not care much for accolades and prestige. Patients were his priority.

He was truly one of the great founders of modern medicine in Singapore. His inspirational values should be remembered by all who follow in the tradition of good doctors and healers.

Quek Koh Choon (Dr) 

We can only guess at what Prof Ransome would have thought of today’s Ministry Of Health insisting that all diagnosis be based only on test results and supposedly evidence based medicine. One can sense his disappointment and hear him cry, “What about the patient? The patient will tell you what’s wrong if you just listen! Just listen – with all your senses! I am giving you zero!”


Singapore’s Medical Tourism Fatally Threatened

This article from the November 2014 edition of Singapore Business Review explains how Singapore’s medical tourism is under threat from competition from neighbouring countries. Many people come to Singapore from neighbouring countries to obtain their bioidentical hormone treatment under the care of well-qualified western medicine doctors here. If these hormones are no longer available in Singapore, these medical tourists too will go elsewhere.

[See also]

Medical Tourism

Letters to the press: Let consumers make the choice

Let consumers make the choice, 8 May 2014,  Catherine Cook

This letter again discusses the enormous benefits experienced by a patient using bioidentical and natural desiccated thyroid hormones. The letter was edited before publication, removing the references to the failure of osteoporosis drugs and the description of the writer’s integrative practitioner in Singapore. The writer has allowed us to post the original below.

Please give us back our bio-identical hormones

Dear Editor

Like many others, I am extremely upset that I can no longer receive my bio-identical thyroid and other hormone treatment in Singapore.

I have been hypothyroid for 20 years. I took synthetic thyroxine initially but never felt well. I was thus delighted to find, in Singapore, as in other developed countries, a Western medical doctor practicing integrative, functional medicine, to prescribe desiccated thyroid and do the necessary regular tests and resultant dosage adjustments. This treatment provides not only the T4 hormone that synthetic drugs provide, but also all other compounds produced by the thyroid, which some people cannot produce from T4. It was the only treatment some years ago, and is still frequently used in the USA, UK, Europe and Australia.

To alleviate menopause symptoms I took synthetic estrogen but suffered more. I am particularly concerned about osteoporosis but, wary of side effects, I refused to take drugs for osteoporosis. My “intuition” proved correct. US drug companies have recently had to make huge payouts to compensate for some serious consequences of these. After much research, I decided to take natural progesterone, getting my supplies from overseas without medical supervision but feeling much better. When the first compounding pharmacy opened in Singapore I benefitted immensely from being medically supervised with a prescription finely tuned for my body, and adapted for my body at different times, if circumstances changed. As I understand it, unlike synthetic hormones, bio-identical hormones have exactly the same composition as those produced by the body and are a perfect fit for cell receptors. This treatment has been wonderful. My health, and consequently my quality of life, has been excellent with no side effects.

The argument is that “there is no scientific evidence” for bio-identical hormones. Obviously, since they are natural and cannot be patented, money will not be spent on research, while drug companies try to suppress this increasingly widely used treatment. There was “science” behind the much touted drugs for osteoporosis but taking them has proved disastrous for many. Can we not look instead at the results of treatment, at the way patients feel?

Yes, bio-identical hormones carry some risks but so does every single drug. Please let me choose which risks to take. I will now have to get my treatment overseas, at huge inconvenience and cost.

I beg the MoH to give us back our treatment of choice.


Catherine Cook (Ms)





Letters to the press: Consider the merits of anti-aging medicine

Consider the merits of anti-aging medicine, 3 May 2014, Jaap Huigan

This writer points out that:

There is a growing community of medical practitioners around the world that has departed from allopathy, which seeks all or most remedies for medical conditions in drugs, and now practises anti-ageing medicine.

This branch of medicine takes a holistic approach to health and supports balancing one’s hormones via bioidentical hormones and the administration of carefully selected supplements

He also argues that such approaches could cut healthcare costs for the elderly compared to drug treatment.

Letters to the press: Hold dialogue on issues

Hold Dialogue on Issues, 3 May 2014, Madam Julia Morgan

This letter asks for clarification from the MOH and the Health Sciences Authority as to what the letter from MOH to the practices actually means. The writer calls for:

a dialogue between all parties involved – the ministry, HSA, doctors, gynaecologists, endocrinologists and members of the public who use bioidentical hormones – so that all can understand the concerns and move forward based on scientific fact and reason, and not emotion?

As noted earlier, there was no response from MOH.

Letters to the press: Fund studies on bioidentical hormones

Fund studies on bioidentical hormones, 29 April 2014, Ms Elaine Wong

Some more very strong evidence of the benefits, witnessed when the writer’s mother was given bioidentical hormones and a plea for research into, rather than a ban on, such treatment.

I have mentioned the treatment to her other doctors, but most seemed clueless. However, they saw a significant improvement and suggested continuing the treatment, with regular check-ups

Letters to the Press: Why disallow hormone treatment?

As patients and the public learned about the new ruling regarding Bioidentical Hormone Replacement (BHR) and Natural Desiccated Thyroid (NDT) treatment some of them wrote to The Straits Times. There was no response from the Ministry of Health (MOH) to any of the letters.

Why disallow hormone treatment? 25 April 2014, Ms Debra Bray

The writer lives in Indonesia and has been visiting Singapore for treatment with bioidentical hormones and natural desiccated thyroid. Her letter was heavily edited before publication. She has allowed her original letter to be published here:

Medical Tourist seeks other destinations as Singapore Ministry of Health bans customized Bio-identical Hormones

Dear Editor,

Singapore is a world-class city, I have learned from visiting here 6 times in the past 3 years. I enjoy this futuristic city with a knowledge economy, clean water, good transportation, green initiatives, excellent education and health care and a quality of life most can only dream about. However, my impression is changing as I realize the Ministry of Health (MOH) is eliminating the prescription of customized or compounded bio-identical hormones by physicians and local pioneers in the international field of Pro-Aging Medicine. I wrote to the Ministry 3 months ago to ask officials why? I wondered if there had been a policy change? There has been no reply. This ban hurts both patients and doctors. It tarnishes the image of a world-class city. The main reason I have visited Singapore from Indonesia is to see my physician who has successfully relieved my symptoms of an underactive thyroid and menopause with natural thyroid medicine and customized bio-identical hormones. I have been using this medicine for the past 6 years. I am very thankful for both the professionalism and quality of the medicine I found in Singapore.

You may call me a “medical tourist” because I also spend money for hotels, dining and entertainment. And as a medical tourist – I’m free to go where I find the best health care; I left Bangkok 3 years ago for Singapore.

However, the term “medical tourist” doesn’t reflect my understanding and research that led me to a Singapore physician who could prescribe what I need to be healthy now, and prevent the risk of cancer, Alzheimer’s disease and bone-density problems in the future. My career – as a science teacher and part-time professor – flourished – along with my health.

Hormones for women are far more complex than for men, and I wonder if MOH officials are shortsighted, or if health care for women is a lower priority. I would like to understand why the Singapore MOH is eliminating the prescription of bio-identical hormones by local physicians; I wonder if this ban is related to the influence of some pharmaceutical companies.


Ms Debra Bray, BSc, BA, MPhil (University of Cambridge)