2017 – Roosting Ahead (Part 1)

First, a Happy New Year greeting to all readers of this column. 2016 was a torrid or a great year depending on where you came from. It was a bad year for Star Wars fans as Carrie Fisher is now One With The Force, unlike Donnie Yen who is very much alive muttering the same two-liner incessantly in the movie. Frankly, he should have spoken with a Martin Yan accent when he played his blind Rogue One character. (“Yan can cook, but Yen cannot look”).

Puns aside, Rogue One was a good Star Wars movie because

  • For once, everybody died, including the smart-ass robot
  • There were no crass efforts to merchandise everything
  • There are plot loopholes as big as Sarlacc’s mouth, like in all other Star Wars movies

2016 was a good year for Donald Trump, Kim Jong Un and Boris Johnson, because bad-hair days are now de rigueur among the elite and the establishment.

Going forward, what does 2017 hold? This Hobbit is no fortune-teller, but he will hazard a few predictions. It’s the year of the Rooster in the Chinese Almanac and yes, this is the year many of our chickens come home to roost.

2017 will be the year that many residents will exit as specialists. And the picture is not good. We hear horror stories of many newly-minted specialists unable to secure jobs in the restructured hospitals (RHs). And we are not just talking about certain specialties only; it is across the board. Popular and “lucrative” disciplines such as ENT and Eye are grappling with this problem too. Apparently, there is an instance of 4 ENT residents exiting in 2017 from one institution and only one was offered an Associate Consultant (AC) contract. There are dozens of ENT and Eye residents exiting over the next two to three years that probably will have no AC jobs. And if you extrapolate to other disciplines, the number must be in the hundreds.

These newly-minted specialists who will not get AC contracts have 3 options:

  • They stay on and remain hired as Service Registrars while bearing the professional responsibility of specialists.
  • They leave for the private sector, either working for more experienced specialists or open up practice in an already-saturated market and without sufficient experience to run a practice independently
  • They can do something else, like open a bakery or café, like what quite a few lawyers have done. But unlike lawyers, they have spent four to five years undergoing postgraduate training for something that they now have to ditch.

This Hobbit once wrote about the Residency Turkey quite a few years ago. Well, the Turkey has been eaten and now it’s time to manage the Residency Chickens that are coming home to roost.

Current leadership is not responsible for this mess for sure. The guys who are have flown the coop long ago.

The legal profession and the Law Minister were quick to react when they sensed too many people were going into law. But there is no such apparent deftness in MOH or SMC and things are going on business as usual. People are still rushing to medical school overseas if they cannot get a place in a local one and the local schools are still churning out about 500 medical graduates annually and of course when you have so many graduates, you have to offer more specialist training positions.

MOHH and the RHs are also still actively recruiting specialists from overseas to exacerbate the problem of a glut in junior specialists.

The crux of the problem is that unlike in the past, the people who fund training are NOT the folks that hire specialists. MOHH is the funder and the employer of residents and they can create and hire residency positions that RHs welcome (“free or cheap labour”). But once that is done, the newly-minted specialists have to be funded from the operating budget of a RH and they become “expensive and inexperienced labour”. Instead of hiring an AC and training them to “full” consultant, some RHs prefer to hire full-fledged consultants from overseas.

It is true that no one owes anyone a living. Residents cannot all expect to get AC contracts as a fait accompli from the RHs. RHs should not be under compunction to offer AC contracts to all exiting residents. But when the number of residents who do not get an AC job outnumber those that do, it means more than that. This is a systemic problem that requires a comprehensive solution, not superficial band-aid solutions that the residency system represented, which in turn has created so many problems of its own now downstream.

Another bad idea that was hatched by some feather brain was in the area of medical indemnity. Some wise guys in MPS (Medical Protection Society) thought that they could pick and choose what they offer Singapore doctors. About a year ago, MPS unilaterally changed what they offered obstetricians from an incidence-occurrence product to a claims-made one. This led to a big uproar in the community and some senior OGs giving up obstetrics altogether. These bean counters probably thought they were the smartest folks under the sun, and that they could cherry-pick what they want to offer us natives here – they could minimise the losses or preserve the margins for the OG sector using a claims-made product while still offering incidence-occurrence plans to the rest of the medical profession here. Someone made decisions based on counting their spreadsheet chickens even before the eggs hatched.

Guess what, they obviously haven’t seen The Empire Strikes Back (In this Hobbit’s opinion, still the best movie in the Star Wars franchise) or understood that seemingly clever decisions have what we call “negative externality effects”. And the externality effects this fateful decision has triggered are both great and negative for these bean counters. Starting this year, the RHs have decided to buy medical indemnity insurance for all their doctors. The already did so for the junior doctors, but now it has been extended to all doctors, including specialists. MPS will probably lose tens of millions of premiums annually arising from this, beginning in 2017. It’s actually a good thing in the long run because it sends a clear message to any medical indemnity provider that The Empire will strike back if need be.

There are lessons to be learnt from this episode. First, gone are the days when you can just sail in and out of our little island deciding at a whim what we primitive natives have to take from you.

Secondly, if you are a mutual or sort-of cooperative, behave like one. Don’t behave if you just another commercially-run, bean counter-dominated organisation. As anyone will tell you, doctors generally dislike bean counters.

Thirdly, while public sector employees almost never look for more work, sometimes their hand can be forced. In this case, the sudden realisation that indemnity product coverage in Singapore can be changed overnight by a foreign indemnity provider (which is not even subjected to regulation as an insurance provider in Singapore by the relevant authorities since they do not even have an insurance license here) have forced them to at least for now ring-fence the public sector from such vagaries with their own in-house plans. The public sector has the will, scale and resources to do so when their feathers are sufficiently ruffled.

The next big question is- will this new arrangement be extended to the private sector as well? Or will there be new entrants into this market?

We will talk about more chickens that are coming home to roost next month. And yes, this Hobbit promises more chicken-related bad puns. Cluck, cluck….







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