Reading and Writing Chee Yam Cheng – 12 and 26 Years Later

Long, long ago, in a galaxy far, far away, before George Lucas cashed out and sold his empire to Disney, there was the Last Jedi Master, CheeYam Cheng (that was way before he decided to dress up as Elvis and crooned Love Me Tender recently. Shows you what staying in the public sector can do to you after 40 years).

In 1987, Prof Chee (aka known as “Elvis” wrote in the SMA News)about his hopes for the future. The article was known as Vision 1999. He had arather view of the future. 13 years later in 2000, then Editor of the SMA News,Dr (Now Prof) Cheong Pak Yean asked this hobbit to write a response to Vision 1999 circa1987. I know this sounds of confusing. It happens when you realise the British science fiction series in the seventies, “Space 1999” was completely wrong –the Moon was not cast away from Earth and Moon-base Alpha is only a planning target when our population reaches the hypothetical figure of 6.9M.

Anyway, it’s now 13 years since this hobbit wrote a response to Prof Chee’s Vision 1999 and 26 years since Vision 1999 was published in 1987.Dr Cheong has recently reminded this Hobbit that maybe it’s time to revisit there-visitation in 2000, something akin to a cross between the movies “memento”and “inception”

In 2000, this hobbit simply took 10 quotes from Prof Chee’s Vision1999 and commented on them. The article as published in 2000 and it was titled“Reading and Writing Chee Yam Cheng” The quotes and comments are re-produced below. For 2013, this hobbit has added in another response to the original 10 quotes and 10 responses. This hobbit unreservedly apologise if anyone finds this article rather misty-eyed in tone. When the PSI is 321, even hobbits get misty-eyed….

Quote 1
Master 1987: “The acute hospitals are bearing the burden of housing these poor folks in their last days and it is, to my mind, not cost effective at all”.
Hobbit 2000: Nothing much has changed. Except for a lone hospice that had to be relocated due to the antagonism of a bunch of insensitive residents, acute hospitals are still the place of choice for dying, with theexception of our Malay brothers, who still know the value of a home to thedying.

Hobbit 2013: There has been increased awareness of the need for palliative care, and overall there are more doctors, more hospices, and a good home hospice system. However, the idea of dying at home is still not a comfortable one with most patients, or rather, their loving families, who frequently panici n the last few hours and send the patient back to an acute hospital to die.

Things may have actually worsened on the long-termcare front. Residents and communities have often voiced unhappiness and objection whenever it is announcedthat a nursing home will be built around their place. If people cannot accept the elderly near them, how can they accept the dying?

Quote 2 
Master 1987:
 “Some residual animosity on the part of the outgoing doctor on the doctors left behind in service makes trust and cooperation very difficult”. 
Hobbit 2000:
 I don’t know about the animosity. But certainly, the chasm between the private and public sectors remain just as wide for some specialties.

Hobbit 2013: After learning just how much doctors can learn in private sector, this hobbit can only say that the chasm has only gotten widerthan the mouth of the Sarlacc[1].It has also increased the number of doctors leaving public for private; medical officers breaking bond, specialists leaving for the private hospital so conveniently located just next to their old hospital. But there is no shortage of doctors in public, not at all, as there is active recruitment of NTS doctors to help fill the gaps, thanks to the foresight by MOH. But foreign doctors now make up about 30% of the medical workforce and one wonders how much higher can this figure go up by? Up to 40 to 50%? And if these doctors are mainly to be found in the public sector, then it would not be unreasonable to speculate that foreign doctors make up significantly more than 30% of the medical workforce in the public sector.

Quote 3 
Master 1987:
 “The specialist register would be a reality and so too would continuing medical education be part of every doctor’s life”. 
Hobbit 2000:
 The specialist register is indeed a reality, but to what extent do doctors participate regularly and adequately in CME? Some estimates put this figure as low as 5% or as high as 20% for those obtainingthe 25 points to be given a CME certificate. There are many reasons for these statistics. Certainly more work needs to be done on CME.

Hobbit 2013: The CME requirements continue to be refined, and this hobbit gets a bit confused by the pro-rating, and the different categories of points required. The only sessions this hobbit attend are those with free food. Doeswine tasting count as CME? For example, does anyone really understand if weare required to fulfill our CME point requirements this year while the CME IT systemis being upgraded?

Quote 4
Master 1987:
 “Those specialists within government institutions should strive to attain a level of knowledge and skill that is the best available world-wide before embarking into private practice. There should be no obstacle to going into private practice. The only self-made obstacle is for the intending doctor to question and examine himself– is he of an acceptable standard, can he last the 10 – 15 years in private practice doing good work before he calls it a day…..remember then that the public cannot be fooled anymore, not that they were fooled before. But they will be better educated and more aware of improperly trained doctors…” 
Hobbit 2000:
 2 pluses and a minus here. Certainly, there is no obstacle about going into private practice now. The public are also certainly more aware and less tolerant of medical errors, as given by the recent publicity over this. The minus is the number of 10 – 15 years of private practice. Specialists are finding it less rewarding than ever to stay in the public sector. A 10 – 15 year period implies that specialists go into private practice when they are between 45 – 50 years old. Nowadays, most specialists go into private practice in their late thirties or early forties.They will remain in private practice for about 20 years. In fact, talk to a young registrar or senior registrar and you will find that none of these colleagues of ours have any plans about retiring in the public sector. Could public service be made more attractive and a lifelong service in public sector a desirable career option?

Hobbit 2013: Things have worsened in this area since 2000. The natural life cycle of a specialist seems to be BST-AST-public consultant- private consultant. Of couse, the natural habitat matters. It is noted that in some environments, the BST phase takes very long before an AST phase, while in others, doctors remain stuck in AST before turning into a public consultant. In some places, the transformation of public to private is a matter of years, while some places manage to nurture public consultants for life. It will take a wiser person than this hobbit to understand why. It can’tbe all about the money, can it? It is also interesting to note that as we migrate to a Residency program, most trainees in various programs are not quite certain how they “exit” training and achieve specialist accreditation. This may nicely solve the problem of them ever going private as there is just no way to do so. Nor will they ever be able to migrate overseas and practice there, asACGME-I is “Uniquely Singapore”. This is compounded by the fact that with the shortened period of residency training,folks become specialists at an even younger age than what was previously possible. Are they truly ready for private practice after say, one year of housemanship and 4 years of general surgery residency?

Quote 5
Master 1987:
 “Our local graduates deserve more than what they are getting today: I believe we are not equipping them to face the harsh realities of life… Worse still if they feel that longhours, hard work and years of experience are unnecessary relics of the past”. 
Hobbit 2000:
 I was a houseman not so long ago. We had no call allowance, we gave IVs, did 120 second hypocounts and even injected potassium into saline bottles. Now I understand that housemen don’t do such menial tasks anymore. Good for them. Thanks to some of our colleagues in SMA and MOH, they even get a $70 call allowance! But has this translated into better care for patients? I hear of housemen quitting housemanship recently because they cannot take the hardship (no IVs and no hypocounts!). This was simply quite incredible to us ‘older’ folks. Maybe its because people are getting generally softer, or is it because $13,000 university fees attract a different breed of people than from my time (they can afford to pay up hefty bonds), I don’t know.

Hobbit 2013: I just found out recently that starting HO pay is $3200.Wow. It has been a long time since I was a houseman. More “houseman” work in my time has been further delegated to nurses- my HO now does not know how to startor titrate warfarin as the hospital “Anti-coagulation clinic” will do it; IV cannulations, blood cultures, inserting chesttubes, the list goes on. The current HO faces the problem of learning how to do online documentation, remembering passwords for the various systems needed to order a test, trace results from another cluster or polyclinic, making referrals to step-down care. Rather than learning medicine,or learning skills that is relevant to clinical practice, it feels like an internship for IT and technical support. I wouldn’t repeat housemanship now or ever, no matter what the pay, even though now houseman work less hours than ever before. Hardwork never killed anyone (exceptin Japan), but meaningless work kills the spirit.

Quote 6
Master 1987:
 “How can we remunerate doctors for humanistic qualities that are difficult to quantify?….Society cannot keep rewarding richly only services that can be quantified easily”. 
Hobbit 2000:
 Nothing has changed. We still reward those who contribute to the bottom line. I always wondered as a student how much of mytuition fees went to people who really taught me medicine, like Robert Pho, Ng Han Seong, William Chew, Tan Cheng Lim, Low Cheng Hock, my registrars like Wee Siew Bock, Agasthian, Teo Sek Khee, Low Chee Kwang and the like and how much of the fees went to paying some glory/money seeking academic who never gave me a tutorial or even returned my greeting in the corridors? For all the talk about elderly, we still do not have a geriatrics department in our tertiary hospitals and our only medical school does not even have a single geriatrician under itsemploy on a full-time basis. I understand that William Chew, Ng Han Seong and company only get a few hundred bucks a month to teach medical students andfrankly, they did more than they were paid for. We have long talked about recognising good teachers, acknowledging role models for our young doctors and developing geriatrics. But believe me, where decisions are made, the bottom-line of a balance sheet  seems paramount. And with DRG-based payment,Chee Yam Cheng’s fear of society rewarding only quantifiable services is morereal than ever. The talk is never walked. Talk is cheap and socially correct talk is cheaper.

Hobbit 2013: I like how the U2 song goes, I still have not found out where my undergrad tuition fees went. Post-grad training: no tuition fees per se, but yearly fees to JCST, and again I’m not quite sure what for. Do any of my teachers get the money? There is still no real monetary incentive for teaching; and true teachers will continue to teach regardless of the rewards, or lack thereof. Unfortunately, that means that they are approached by many students- undergrad, post-grad, and overseas clinical fellows! There are only so many hours he can devote to teaching; no good doctor will allow patient care to be compromised. Meanwhile, teachers who are not so “popular” may be smarter at clocking in teaching hours and getting recognized. There are many lessons that are not learnt by a sit-down classroom lesson, or even a stand-around bed hour-long tutorial. The way a surgeon operates, the way a palliative doctor breaks bad news, the way a renal physician convinces his patient to be compliant to medications- a good student learns these from mentorship, from observation; and there is no way to track that.

The real danger is that we are reaching a breaking point in the system that no “structured”system like the residency can address– the dearth of role models as the older legends of medicine retire and they are not replaced by younger ones, as practically most of the younger ones leave for private practice at an ever faster rate. Ideally, a clinical department should have two or three legends in their late fifties and sixties, quite a few “masters” in their forties and early fifties and many junior consultants in their thirties. What has happened often is that the “master” level is hollowed out, leaving one or two legends (also awaiting retirement) and a bunch of inexperienced junior specialists holding the fort. Some folks think that this was caused by the release of two new hospital sites which led toanother few rounds of specialists resigning. But that view is simplistic.The enemy is always within – if you cannot face internal problems squarely and fix them, people will always leave in droves, whether there are new hospitals or not. In Philippines,few private hospitals have been built in the last twenty years, but doctors still leave – they become nurses (no kidding) and go to America.

Remember – the really bad guy in the latest Star Trek movie is not the terrorist Khan, but the Starfleet General…..chew on that…..

Quote 7
Master 1987:
 “A GP is not a dropout of the system meant to train specialists… there should be… a proper register for general practitioners”; “If he opts to be a family physician, that should also be recognised as a specialist post”. 
Hobbit 2000:
 Again, a complete failure after 12 long years.GP/Family Medicine as a specialty is as distant as Siberia. We talk of putting the family doctor as the centre of healthcare, but let us look at the starkfacts: Hong Kong, Australia etc recognises Family Medicine as a specialty, wedon’t. After 5 – 6 years of having M.Med (Family Medicine) exams in Singapore, we still don’t have a Consultant-Grade Family Medicine doctor in the polyclinics.It must be the only MMed degree in Singapore without a consultant. There is still no department of Family Medicine, although half of each cohort of undergraduates ends up as GPs. In the meantime, we have bought a Gamma Knife,some Excimer lasers, expanded our Singapore National Eye Centre; we are in the midst of building a new National Heart Centre and last I heard, thinking of buying a PET scan. The MMed (Family Medicine) is possibly the most economically irrelevant NUS MMed degree today. It is irrelevant because the government wants Family Medicine to be “affordable”. But what can Family Medicine in Singapore afford today, I ask?

Hobbit 2013: The GDFM and MMed (Family Medicine) is having more recognition and pick-up among young doctors now. Many of them appreciate the structured training available, and of course, most healthcare groups offer abetter salary for those with these qualifications than a fresh MBBS, However,when the upcoming LKC school was perceived to be a school to rain GPs, there was a mini-stir with everyone quickly disclaiming that it trains doctors as usual,with a more integrated primary care. I firmly believe that a strong primary healthcare is essential to a healthy nation, and provides the foundation for a good healthcare system. Now if only everyone believes too, and make it happen.The jury is also still out on the new FMC model of practice introduced by MOH. It can either help Family Medicine/GP in a big way or drive another nail into the FM/GP coffin.The devil is in the details.

Quote 8
Master 1987:
 “Who should government subsidise and who should government not subsidise?” 
Hobbit 2000:
 The multi-million dollar question is still unanswered after 13 years. It is a question that no one with only a fleeting interest in healthcare would want to answer. And the sad point is, it will be so if health is in fact run by fleeting stakeholders. Why risk unpopularity during my brief watch in health, the street-wise may ask? And so, in the absence of a means test, or rather the absence of a will to have a means test, our frontline doctors and nurses in the public health care system continue toslog through armies of patients in the polyclinics, many who should not bethere, subsidised specialist outpatient clinics, and subsidised wards. Theflesh is unwilling, the will is also weak.

Hobbit 2013: There is still no good answer. No perfect healthcare system exists, anywhere in the world. Obamacare has its supporters and haters. Thereis a price for everything; “free” healthcare comes at the price of higher taxes. If more goes into healthcare, something else has to go. The nation as awhole, and maybe doctors specifically, need to be more informed, educated about national budgets; and maybe more importantly, the government has to listen. If doctors who care are asked to shut up, how can there be change ? Does ithelp to employ overseas foreign experts to analyse our problems, where those in the system are trying to identify what is wrong? ? Inputfrom local doctors should be respected and taken into account; after all, we are the ones on the ground.  Being short,I’m actually nearer the ground than Wizards and Orcs, but does anyone listen?? But this hobbit is never giving up in commentaries, because “even the smallest person can change the course of the future.”

The current total spending on healthcare at 4% GDP (with government spending accounting for 1/3 of healthcare expenditure)  is clearly unsustainable.The government’s announcement to up its share of total healthcare spending is certainly to be welcomed. The question is where should this money go to? Should we spend more on developing hospital IT systems that have many nice to have features or should we spend more onlong-term care? Our choices reflect our values.

Quote 9
Master 1987:
 “… come 1999, the Singapore doctor would have benefited from a planned, rational schedule of training and apprenticeship – from housemanship days till he becomes a specialist on the specialist register”.
Hobbit 2000: Certainly, we have more exams to take, but do we have a better training programme? How could it be, when we leave it to altruism to keep good senior staff? People make the difference. When the last of the great teachers retire, what good is a programme on a piece of paper? The last of the Mohicans, like the Master himself, is already in their fifties. In 10 years time, there will be no such icons left. Because we reward by the bottom-line, we will perish likewise, by the bottom-line. How can basic trainees have good training, when we continually expand our services but depend on the same number of 1200 bonded Housemen and Medical Officers? This number has not changed for the last 10 years or more. The population has grown. Newand bigger hospitals have been built and new subspecialties created. Surely the average trainee will now have less time for training and research, since the number of junior medical staff has not changed in the past 10 years and this same number must provide a greater volume of service. Maybe that is why the few Housemen quit in the last few years. You don’t need a Master in Public Administration to figure this out.

Hobbit 2013: 26 years later, we have a better training system- on paper, but only time will tell. In the AST system, registrars have a clear exit path,taking their own relevant papers/clinical exams in due course, etc. However, planning rotations may be haphazard, as each registrar has their preference inplace to train, and of course, the department must have the training post available. In addition, training-job applications may be department-based instead of national based. This means, that a suitable candidate may apply fora job at several institutions sequentially before getting one, resulting in a “delay” in training and subsequent promotions. In the Residency program, the strength of it is that the entire 4 to 6 years (depending on which subspeciality) is planned out from start, and each trainee will have a very structured and standard exposure to various sub-spec deemed relevant and necessary for his own speciality. The currently problems are the balancing of service needs versus training needs, and hospitals are filling in the gaps bygetting the AST registrars to take up the slack, and employing NTS (non-traditional source) MOs. Some disciplines allow M5s to enter into training, ie. Housemanship is counted as a training year. There are some who feel uneasy about it, both trainers and trainees, especially for the surgical fields. We shall know in another 2 years, if a resident is the equal of aAST-trained registrar. And by that time, it may be too late. The recent paper published in the Annals of Medicine about decrease in operative time of residentsversus trainees is certainly a cause for concern.[2]

Quote 10
The Master’s closing remarks in 1987 then were “That isthe challenge ahead. We have 12 years to achieve. I am optimistic we can”.
Hobbit 2000: Where are we and when are we going? Vision 99 was written when Chee Yam Cheng was in his late thirties. It is now 2000. I am afraid he was more wrong than right. I do not share the same optimism about the next 13 years that he had 13 years ago about the next 12. Perhaps I know too much. Perhaps I am a product of the cynical late nineties, when I saw before my eyes the unravelling of the medical profession in positions of influence and power. Vision 99 remains just a vision even in 2000.

Summary 2013 These past 2 years have been a demoralizing periodfor the medical profession, with public cases of overcharging, outrage of modesty, tax evasions;and of course, the recent very public clash of SMA and SMC. Like Frodo, this hobbit is getting very tired, the burden is getting very very heavy. I probably need my own Sam to help take up the burden for a while.

Maybe Vision 99 looks even more distant in 2013 than it was 2000.

However, there is still hope. We must remember those doctors who continue to do good work, the healers,the teachers, the leaders. This year, as we remember those who have fallen inthe line of duty battling Sars, let us all come together and remember what matters most in our profession- our patients.

[1]     A monster with a huge mouth that lived in the dessert of Tatoonie whichappeared in Episode 6 that just about swallowed everything.

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