When doctors move out of the public sector, it is a loss to the
country, argued Health Minister Khaw Boon Wan yesterday at a
celebration to mark the centenary of medical education in
Singapore
The commemorative book mentions the many excellent contributors to
our health-care sector: Professors Ransome, Sheares,
Shanmugaratnam, Seah Cheng Siang, Wong Hock Boon, S. S. Ratnam and
several others.
Singapore is blessed to have these excellent doctors who are not
only great clinicians, but inspiring teachers and mentors to their
disciples. They could have made more money in the private sector
servicing the rich, and could have had more time for themselves and
their families. But they chose to be with their students and their
patients, many of whom are from the lower income group. These are
dedicated individuals who understood the meaning of public service.
They found satisfaction in seeing a needy patient treated, and a
young doctor properly tutored, beyond what material compensation
could provide.
Regional medical hub at risk
THROUGH their dedication, we have produced several generations of
top clinicians who keep SingaporeMedicine head and shoulders above
our neighbours. Until 15 years ago, our status as a regional
medical hub was unchallenged.
In recent years, however, our neighbours have closed the gap.
Moreover, they enjoy a cost advantage. While we still enjoy a
premium, it is not unlimited. If we are not careful, we will lose
the regional medical hub status.
This is not unlike the competition between PSA Corp and Pelepas, or
between Singapore Airlines (SIA) and the low-cost carriers. PSA and
SIA have shown we can face the competition and still hold our
ground. But we must be prepared to restructure and forge new
strategies. In the competition to be the regional medical hub, the
key is our ability to produce clinicians head and shoulders above
our competitors.
Loss of teachers
FOR this reason, when I returned to the Health Ministry in 2003, I
was a bit troubled by what I saw. Several doctors with whom I had
worked during my previous term were now in private practice: Abu
Rauff, Walter Tan, June Lou, Ng Soon Chye, Krishnamoorthy, Noel
Leong. These are doctors who have devoted many years of their lives
to public service; good doctors and dedicated teachers. I had
expected them to retire in the public sector. Why are they now in
private practice?
Within the ministry, there seems to be the view that the 'loss of
doctors to the private sector is not a loss, as long as they
continue to practise in Singapore'. I do not agree. The loss of
good teachers and clinicians from the public sector is a big loss
to Singapore.
First, it is a big loss for our subsidised patients who cannot
afford treatment in the private hospitals.
Second, it is a big loss for our young doctors who will miss out on
the teaching and mentoring by these senior teachers. Forging the
right values for public service is critical for our medical service
to remain what it is - highly competent and at the cutting
edge.
After all, what is the difference to Singapore between the likes of
Feng Pao Hsii and Foong Weng Cheong doing private practice in
private hospitals or in public hospitals? To their patients, it may
be trivial.
But to the young doctors and junior consultants, it is a big
difference: the interactions with their teachers and trainers, in
the wards, in the doctors' lounge, in the corridor, are an
inspiration and a daily reminder of what public medical service is
all about. This is how good institutional values are forged and
reinforced.
All strong institutions have a critical mass of role models, who
coach and mentor the young. They provide the deep roots from which
we get the new shoots, branches, flowers and fruit. After a century
of medical education, we have sunk some roots, but not quite deep
enough.
Look at the Mayo Clinic, it has deep roots and strong branches. You
can cut off several branches and the institution will continue to
flourish. Against tsunamis, it will not be uprooted. Can our public
medical service survive a tsunami?
Third, it is a big loss even for SingaporeMedicine as private
practice here tends to be solo or, at most, limited groups. While
there are notable exceptions, this model offers few opportunities
for medical advancement.
SingaporeMedicine must have deep roots to compete globally. Our
regional medical hub can no longer just compete with our
neighbours. India has emerged as a competitor and soon it will be
China. They have the talent, the ambition and the large base of
clinical material for their doctors to sharpen their skills.
Competing globally requires us to continually acquire new
capabilities. This means sub-specialisation, research and
perfecting new skills. Progress is more likely to be made in
teaching hospitals and academic medical centres, with departmental
structure and rigorous peer review processes.
As the region and the world raise their medical standards, we must
work even harder to remain leader. Solo practice with its attendant
limitations will not give us this edge.
A perennial problem
TO BE sure, retention of medical talent is a perennial issue. I
have spent many years in the health sector. During this period,
public hospitals have always had to grapple with the problem of
retaining their share of talent. Some years, like in the 1980s, we
bled badly; in recent years, we are coping better. There are now
more specialists in the public sector than in the private
sector.
But talent retention is a continual challenge. It is not just about
money. Medical service in the public sector is a noble career
choice, a calling. While we should pay our doctors well, we must
not chase the market. Whatever we decide to pay in the public
sector sets the floor for the industry. It is fruitless to think we
can close the gap.
The right approach is to concentrate on the basics: focus on
medical service as a noble profession, build strong institutions
and go all out to retain doctors with sound institutional values.
The more we have such doctors, the stronger the institutional
culture. The more such role models, the greater will be their
influence on young doctors. As they interact with the likes of
Balachandran, Tan Cheng Lim and K. T. Foo, correct values will be
reinforced and a new generation nurtured.
Deepening our roots
I ASKED some young doctors how they saw their career progression.
Some were candid: train hard, become a specialist, acquire
sub-specialty skills, build reputation, then leave for the private
sector in their prime. If this is representative of their
generation, then I worry both for the public medical service as
well as for SingaporeMedicine.
I worry because, while we take in 300 doctors every year, to sink
deep roots, we must have the top 20-25 per cent of each cohort
remaining in public institutions until they retire from medical
service. At a steady state, these 3,000 doctors, spanning all age
cohorts, will form the critical mass of our medical talent pool. If
we succeed in this, SingaporeMedicine will be able to compete
internationally, while safeguarding the high medical standard all
Singaporeans, rich or poor, deserve.
We must try to achieve this. There is no single silver bullet which
can solve all the issues.
Some doctors are fed up with administrative duties. They want to
focus on their clinical and teaching duties. We should not unduly
load them with unproductive paperwork.
Some want better recognition of their contribution. We should find
a way to acknowledge their status and their achievements.
Some want to have a better say in the way their hospital is run. We
should engage them and give them a productive role to play.
Some are keen on research and enjoy the opportunity to pioneer or
train in new procedures. We should try to support them.
More fundamentally, many young consultants who have left told me
they would actually like to remain in public hospitals but felt
uncertain about their continuing employment in later years. They
saw public hospitals not being able to accommodate senior doctors
like Foong Weng Cheong and K. L. Tan, despite their having put 30
years of their career in public institutions. Given such
uncertainty, they decided they had better start their private
practice earlier, while in their prime.
We must remove such uncertainties and reset the career progression
of our young doctors. They must see that we have a viable model of
allowing dedicated doctors who have invested 25, 30 years of their
lives in public service to remain productive in the public
hospitals and retire gracefully.
Many such senior doctors, like Y. Y. Ong, Tan Ser Kiat and Low
Cheng Hock, are happy to do 40 years of public service and retire
in public hospitals. We should assure them there is an important
role for them to play in public hospitals. We can vary the nature
of their role as they enter different phases of their public
service. For example, as they reduce their clinical duties, they
can take on more of a teaching and mentoring role.
But some doctors find the independence of private practice and the
freedom of being self-employed hard to resist. Perhaps, it is
possible for these doctors to have a second career in private
practice but within public hospitals, after they have served their
years in public service.
Why can't we offer these senior consultants the privilege to
migrate, say at age 50, from public service to private practice,
without leaving the public hospitals?
They can run their private practice as they would if they were in
the private sector, running their own clinics, with admission
rights for their patients in our private wards. They would remain
as members of our clinical departments with departmental support
for their inpatients in return for the continued teaching and
coaching of young doctors and trainees.
Private practice in public hospitals is not a new idea. It has been
done elsewhere. We have talked about it but have worried about its
impact. Will there be abuses? Will public patients be
neglected?
If we restrict the privilege to the senior consultants who have put
in 25, 30 years of their time in public service, of what is there
to be fearful? If we start small and expand gradually as our
staffing levels improve, there is no reason why existing public
services will be neglected. In time, as we gain experience and
confidence, we can extend such privilege to senior consultants from
a younger age of 45. But I think we must never go below this age
threshold.
Building strong institutions
BUILDING institutions and retaining talent are the responsibilities
of hospital managements and their boards of directors. In fact,
these are their most important responsibilities.
Let me challenge them to work towards the vision of what our public
institutions can become. We should aim to match the best in the
world in patient care, teaching and research. In Asia, we should be
the best and be recognised as such by our peers, head and shoulders
above all the others.
Being the best, however, does not mean tall shining buildings or
the most fanciful and expensive pieces of equipment. Being the best
means we have the best clinical outcomes, we invent new devices,
new techniques and new processes. We do everything better, faster
and cheaper than others, and patients from the region want to come
here for their treatment.
In short, let us become the Mayo of the East, but without the
costly price tag. Not all our clinical specialties can succeed, but
hopefully a few will produce dramatic results within a few years,
to encourage the rest to keep faith.
Can it be done? Some of our best students take up medicine every
year; some of our best brains are in the health sector. Moreover,
we are not starting from ground zero. After a century of medical
education, we already have some of the assets in place. But we have
to be clearer in our goal and bolder in our approach towards this
goal.
Building strong institutions is a long-term endeavour, beyond
bricks and mortar. It requires leadership, dedication, discipline
and patience. Take a long-term view but have a clear road map so
progress can be measured and, if need be, refine the
strategy.
The ability to retain good teachers and good role models is the
key. The ability to enlarge the pool of such medical talent year by
year will track our progress.
But this must be done in a sustainable way. First, it must not clog
up the medical leadership with limited career opportunities for the
upcoming young consultants. Second, it must also be financially
viable for the public institutions.
Adapting to the new world
AS WE look back at the last 100 years, we can be nostalgic about
the good old days of the old masters like Cohen and Seah Cheng
Siang. Their grand rounds were legendary, attended by all staff
from housemen to consultants. That period was sacrosanct and
everyone enjoyed the teaching and the camaraderie that went with
it. The junior doctors who were ill-prepared would tremble in fear
as they would have to present their cases to the grand
master.
But as Dr June Lou lamented to me: That world is, sadly, gone.
These days, when a round is conducted, half the staff are absent. I
suppose we now live in a new world and we have to adapt. If we do
not, we will be more disappointed, and worse, become ineffective in
our mission.
I am optimistic because I still see many in the public institutions
with strong institutional values: Satku, Tan Chorh Chuan, John
Wong, Tan Ser Kiat, Y. Y. Ong, Chee Yam Cheng, Low Cheng Hock, Soo
Khee Chee, K. T. Foo, Rajasoorya, Lim Yean Teng, Philip Eng and so
many others. There are enough people around who still believe in
the higher calling of public service.
But we need to ensure they have worthy successors in the pipeline.
To do so, we must convince our young doctors to reset their career
progression. It should be to train hard, become world class, serve
the rich and the poor, teach the young, build the next generation
of doctors, retire in public institutions.
Not all doctors will share this career path. But for those with
good institutional instincts, we must do our best to support them
along this career path.
Abridged version
The Straits Times
26 Feb 2005
