Launch of the Commemorative Book "To Sail Uncharted Seas" in Celebration of the Centenary of Medical Education in Singapore

25 Feb 2005

By Mr Khaw Boon Wan, Minister for Health

Venue: The Auditorium, College of Medicine Building

"A CENTURY OF NOBLE PURSUIT"

I am honoured by this opportunity to launch the commemorative book by the NUS Medical Faculty.  It documents in a captivating way a century of medical education in Singapore.

Role Models

I had earlier browsed the draft version.  Even as a non-doctor, I could sense the pride and satisfaction that our medical community rightly feels.  The book mentions the many excellent contributors to our healthcare sector: Sir Gordon Ransome, Prof Benjamin Sheares, Prof Seah Cheng Siang, Prof Shanmugaratnam, Prof Wong Hock Boon, Prof SS 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 led a more balanced family life in the private sector.  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

Through their dedication, we have produced several generations of top clinicians which keep SingaporeMedicine head and shoulders above our neigbhours.  When I was last in the Health Ministry until 15 years ago, our status as the regional medical hub was unchallenged.

In recent years, however, our neighbours are closing the gap with us.  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 and Pelepas, or the competition between SIA and the low-cost carriers.   PSA and SIA have shown that we can face the competition and still hold our ground.  But we must be prepared to restructure and forge new strategy. 

In the competition to be the regional medical hub, the key is our ability to produce top clinicians who are clearly better than our competitors.

Loss of Teachers

For this reason, when I returned to the Health Ministry in 2003, I was a bit concerned with what I saw.  Several doctors whom I have worked with during my previous term are 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 have expected them to retire in public sector.  Why are they now in private practice?

Within the Ministry, there seems to be a view that the "loss of doctors to the private sector is not a loss, for as long as they continue their practice in Singapore".  I do not agree with this view.  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 continuing interactions with their teachers and trainers, in the wards, in the doctors' lounge, in the corridor, are an inspiration and daily reminder about 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, they have deep roots and strong branches.  You can cut off several branches, 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 practice or at most limited group practice.  While there are some notable exceptions, this model offers few opportunities for medical advancement. 

SingaporeMedicine must have deep roots, if we are 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 as leaders.  Solo practice may 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 were 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 that 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 the young doctors.  As they interact with the likes of Balachandran, Tan Cheng Lim and KT Foo, correct values get reinforced and a new generation of such doctors gets nurtured.

Deepening Our Roots

I asked some young doctors how they see their career progression.  Some were candid: train hard, become a specialist, acquire sub-specialty skills, build reputation, then leave for private sector at 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% of each cohort remaining in public institutions until they retire from medical service.  At steady state, these 3,000 doctors, spanning all age cohorts will form the critical mass of our medical talent pool.  If we succeed in achieving this, SingaporeMedicine will be able to compete internationally, while safeguarding the high medical standard that 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 just want to focus on their clinical and teaching duties.  We should not unduly load them with unproductive paper work.

Some want better recognition of their contribution, and 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 that 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, KL Tan despite their having put in 30 years of their career in public institutions.  Given such uncertainty, they decided that they better start their private practice earlier, while they are at 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 to public service to remain productive in the public hospitals and retire gracefully.

Many such senior doctors, like YY 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 that 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 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 continuing 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 worried about their 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, what is there to be fearful of abuses?  If we start small and expand gradually as our staffing level improves, there is no reason why existing public services will get 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 management and their Board 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 recognized 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 roadmap so that 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 shall 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 up-coming young consultants.  Second, it must also be financially viable for the public institutions.

Adapting to the New World

As we look back 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 of the staff is 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.

Partnering World-class Institutions

Achieving the vision that I have painted requires determination and self-confidence.  We should learn from the best institutions and partner with the best, not necessarily from the healthcare sector.  Many world class companies, like the Toyota, Microsoft, IBM, have much to teach the healthcare sector.  And of course top Medical Schools in the US, like the Mayo Clinic, Johns Hopkins provide useful learning points for us.  In this connection, I am pleased to announce that we have reached agreement with the Duke University to jointly establish a second medical school at the SGH campus.

Duke is ranked number four among the medical schools in the US. Its 4-year M.D. programme is known for its innovative teaching methodology. The 3rd-year in the programme focuses entirely on research. This will provide a strong foundation for the graduates in their quest to become clinician-scientists.  In turn it will foster translational research and support life sciences in Singapore.

The second medical school will leverage on the SGHyyyyyys medical expertise, clinical throughput and physical infrastructure. It will begin in 2007 with an initial student intake of 25, 50 in subsequent years, and I hope 100 soon.  It will be an American style graduate programme, taking in graduate students.  In addition to local students, we will particularly welcome students from other countries to enhance the creative and intellectual environment of the school. 

The collaboration agreement between NUS and Duke is being finalized.  It will be signed in April.  In June, the Dean-designate from the Duke Faculty will set up his office here to begin the preparation work.

Through this collaboration, our aim is to combine our ambitions of making Singapore a regional medical hub as well as a regional education hub.  Our vision is that Singapore will be the preferred place for medical education for the aspiring doctors in the region.  Many foreigners will come here to be trained.  Hopefully, some of the best will decide to stay on to become Singaporeans, the rest return to be our links to the region.

Conclusion

This way, we ensure a continuing high standard of healthcare for our people while maximising the economic value of the medical profession.

I am optimistic that we can achieve our vision of retaining our medical leadership in the region.  Talk to anyone who has worked in MU III about the good old days and their eyes light up.

I am optimistic because I still see in the public institutions many with strong institutional values: Prof 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 that 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. 

I congratulate you for 100 years of proud achievements.  May I wish you another century of success in your noble pursuit.