Beware The Danger Of Complacency

Recently, there was some debate in the local press regarding the need for marathon runners to submit letters from their doctors, certifying fitness to participate.

I don't have a copy of the Straits Times article, but a Google search produced this statement on NTUC's website.

I'd like to highlight the following comment:

"While a medical certification does not guarantee that medical emergencies would not happen during a run, we believe that the doctor would be best placed to screen and advise the would-be participant on whether he is fit enough to do a physically demanding run."

I have a few burning questions:

1) Can any doctor - including GPs - write this potentially incriminating letter, or are only "experts", i.e. cardiologists, allowed to do so?

2) What are the criteria for certifying someone "fit enough to do a physically demanding run"? A normal general medical examination? A normal ECG? A negative treadmill stress test / CT angiogram? Perhaps a normal coronary angiogram ( also fraught with its own risks, and hardly inexpensive )?

3) What are the predictive values of negative cardiac stress tests / imaging studies? Literature has shown that no investigation - not even a coronary angiogram ( considered the gold standard in detecting coronary artery disease ) - is 100% accurate in predicting future adverse events.

Meaning: You may have a completely normal coronary angiogram, and still die from a heart attack shortly after that.

There's also a significant number of people with undiagnosed cardiac disease whose very first presentation comes in the form of catastrophic events - i.e. massive heart attacks, sudden deaths - with no preceding warning signs or symptoms whatsoever.

These are the same people who may exercise regularly without difficulty, but develop problems under severe duress - that's right, when pushing themselves too hard during marathons.

4) Did NTUC bother to consult any experts before implementing this questionable protocol?

5) What are the implications if someone who's certified fit by his / her doctor kicks the bucket during the run? Will the family decide to sue the physician for negligence? How will the SMC respond?


A medical expert from the U.S., who specializes in emergency cardiac care, recently visited Singapore and delivered a series of excellent lectures on the dilemma faced by doctors who manage patients with possible underlying cardiac disease. A couple of interesting - and rather alarming - anecdotes he shared include:

1) A 12-year-old who suffered an actual heart attack, caused by vasospasm of the coronary arteries, and

2) An adult male who dramatically collapsed at the door of a hospital, just after a myocardial perfusion scan was performed and found to be NEGATIVE. In fact, the poor chap was found clutching the normal report in his hand as doctors resuscitated him.

True stories.


Let's face it - a doctor's letter is woefully insufficient, designed only to protect the organizers, not the participants. It instils runners with over-confidence, and may even result in more deaths if they think it's okay to push themselves beyond safe limits.

Is there anything wrong with signing declaration and indemnity forms?

Your comments, please.