SPEECH BY MR ONG YE KUNG, MINISTER FOR HEALTH AND COORDINATING MINISTER FOR SOCIAL POLICIES, AT THE SMC PHYSICIAN’S PLEDGE AFFIRMATION CEREMONY

The Latest Pillar of Medical Manpower

Professor Kenneth Mak, Director-General of Health and Registrar, SMC

Members of the SMC

Distinguished guests

Ladies and gentlemen

1.              I am pleased to join you this afternoon at the SMC Physician’s Pledge Affirmation Ceremony.

2.              Congratulations to all our young doctors, for working hard and successfully completing medical school. In a few moments, you will be taking the physician’s pledge – a solemn promise to do your best for your patients, to learn throughout your career and to uphold the trust that society places in you.

3.              You will begin your career at a very exciting time. Because of rapid population ageing, the Singapore healthcare system is responding by embarking on a historical transformation, and you will be in the thick of it 

4.              You would have heard of all the changes – population health, Healthier SG, Age Well SG, leveraging AI and technology, shifting care from hospitals to community. Today, I will talk about a less-discussed aspect – transforming the care team in hospitals. This change will have a profound impact on your work and your medical career choices.

Need for Care Team Transformation

5.              The care team model in our public acute hospitals has traditionally been specialist-led. So if a patient is in hospital for say, a knee replacement surgery – which is what I went through - the team looking after him will comprise the anaesthetist, physiotherapist, nurses and then an orthopaedic surgeon – the specialist who leads the team.

6.               This model has worked well, especially when we had a much younger patient profile, and hospital visits tended to be acute and episodic. Like the young man, or me, going for a knee replacement. I had one problem which is my knee – I go in, it's fixed, and I'm out, one-day stay, and you just need the specialist to fix a specific condition within a very short period of time.

7.              But over time, this has become the default hospital care model, in Singapore and also around the world. Patients have also come to expect that the specialist – the ‘dua lo kun’, the big doctor, will oversee their care, regardless of their clinical needs.

8.              Take for example my late mother, she developed a heart condition in her 40’s and she started seeing a cardiologist. As she aged and developed multiple conditions, she still ran to the same cardiologist for every condition, who then referred her to other organ specialists. The cardiologist is her ‘dua lo kun’ – her big doctor, who took care of her very well. But it is not the ideal model, especially when we are going to have many more seniors with multiple, complex conditions.

9.              Consider an elderly patient with a head injury. Under our current system, he goes to a hospital he might see many specialists upon admission to the hospital – one to manage the head injury, another to investigate what caused the giddiness that led to the fall and injury of the head, and yet another to manage his underlying chronic illnesses.

10.         Each specialist will tend to focus on his or her respective area of expertise. For the patient and his family, this may mean speaking to multiple specialists, repeating his symptoms each time, being prescribed many treatment plans and medications, and trying to make sense of them all.

11.         Upon discharge, he may have to navigate numerous follow-up clinic visits. Sometimes, patients may end up waiting a couple of hours for their turn to see the specialist, only for the consult to be over in a few minutes if his condition is stable – and this experience is repeated across clinics.

12.         It is better if we can consolidate and coordinate the various treatments, and for the patient and his caregivers to have a holistic view of the patient’s health, and to be advised on the integrated health plan and care plan. This requires a major transformation of our care teams in hospitals. It will take some years, but the process has started and there will be momentum in the change.

The Broad-Based Principal Doctor

13.         Earlier this year, we introduced a new care team model across selected disciplines in all our public hospitals – general surgery, orthopaedics, paediatric surgery and so on. 

14.         We moved away from multiple specialist-led teams operating in parallel, to a unified care team under one lead Principal Doctor. For the Principal Doctor to be able to coordinate and integrate care across specialists, he will need broad-based competencies and experiences. 

15.         Many experienced specialists who have treated patients of varying conditions and beyond their area of specialty are able to play the role of the Principal Doctor. That is, however, not enough. Now, we need to consciously train clinicians to acquire broad-based competencies, as a career pathway distinct from being a specialist.    

16.         Hence, we started the Hospital Clinician Scheme across public hospitals. Hospital Clinicians go through a separate path of training and development, to help them acquire broad-based competencies. There are about 150 Hospital Clinicians in our system, with a huge potential for growth. 

17.         We are already seeing benefits for patients and their caregivers when we streamline care in such a manner. Take for example, Mr Haji Osman, he’s a patient at Alexandra Hospital. He has multiple complex cardiac and renal conditions. He used to shuttle between different specialists across hospitals. This placed a significant burden on his caregiver, which is his daughter Hadijah, who had to regularly take time off her work. 

18.         Today, under the care of Dr Neeta Kesu Belani, a Senior Hospital Clinician at Alexandra Hospital, Mr Osman's previously scattered appointments have been consolidated into a coordinated care plan. Where possible, visits to clinics were replaced by teleconsultations. This has made an enormous difference to the daughter Hadijah. More importantly, Mr Osman’s multiple conditions are now better managed.

The Hospital Clinician

19.         To attract more doctors to become Hospital Clinicians, MOH will enhance the scheme. 

20.         One major improvement is to enhance the career track of Hospital Clinicians from three levels currently to four – similar to that of Specialists. The fourth and apex level will be called Senior Principal Hospital Clinicians.  

21.         Let me explain the career path briefly. You join the track at the entry level of Hospital Clinician, where you will undergo training to build up foundational broad-based competencies. The rigour of training is similarly anchored on Entrustable Professional Activities (EPAs), like residency training.

22.         After you attain all the EPAs assessed through workplace-based assessment and achieve the Graduate Diploma in Hospital Practice awarded by the Academy of Medicine Singapore, you will qualify to be promoted to the next level, as a Senior Hospital Clinician. 

23.         As you gain further experience as a Senior Hospital Clinician, you may start assuming the role of a Principal Doctor. That is when you can progress to the third level, as a Principal Hospital Clinician.

24.         Principal Hospital Clinicians will take on professional leadership roles within public healthcare institutions. They may take on roles such as chief of a clinical service, or orchestrating a major institution-wide programme in quality improvement or in education. With these additional leadership responsibilities, you can progress into the apex grade, as a Senior Principal Hospital Clinician. 

25.         For a high-performing doctor, you could achieve the apex grade in your early forties. The remuneration of Hospital Clinician levels will be reviewed and set, to be commensurate with doctors in the other tracks who take on similar roles. I encourage junior doctors, as well as new graduates, who are interested in hospital-based practice to consider joining the Hospital Clinician scheme as an attractive option that offers a fulfilling career.

26.         With these changes, we now have three pillars to clinical practice – in alphabetical order: Family Physicians, who anchor care in the community and develop trusted relationships with their patients; Hospital Clinicians, with broad-based competencies to coordinate and integrate care; and Specialists, with deep expertise in specific diseases and organs. 

27.         Each has strengths and capabilities that complement the others.  Together, they offer career trajectories that are similar in terms of progression milestones and leadership opportunities, and most importantly – meaningful and fulfilling.

28.         With the changes we introduced, we should abolish the term “non-specialists” from our lexicon. We don’t use the term officially; you may sometimes still spot it in certain websites, but officially we don’t use the term, but I think the dichotomy exists in our minds. I am guilty of it. Every time I meet a junior doctor or a fresh graduate, I will ask “Are you planning to apply for residency? Which ones are you considering?” I should really be asking “Do you wish to be a (in alphabetical order) Family Physician, Hospital Clinician or Specialist?”

The Bedrock of Everything You Do

29.         Regardless of which career pathway you eventually choose, remember that ethical practice should remain the bedrock of everything you do.

30.         As you take the pledge, know that you are not only committing yourself to clinical excellence, but are upholding the highest standards of professional conduct and values that define the medical profession. The SMC Ethical Code and Ethical Guidelines, and the Mandatory Medical Ethics requirement for continuing medical education will support you in your journey even as you navigate increasingly complex medical and clinical scenarios.

31.     I wish you a successful and fulfilling career ahead, and may you always hold fast to the values that brought you to medicine. Thank you.