You have barely settled into watching Amazon’s Rings of Power before you realise you are now threatened by that one Power that is more all-consuming than even the One Ring. Indeed, there is that One Ring to rule them all, but there is also that One Power that can drive sound-minded people to become teeth-clattering, nerve-wrecked, fingernails-chewing idiots.

No, we are not talking about the crippling effects of high inflation.

Yes, we are talking about PSLE.

But better days await because there is that most important post-PSLE question that needs to be answered very soon, “where are you going for the year-end holidays?” Are Singaporeans going to conquer Japan (or at least Shinjuku) in a tit for tat for what they did to us 80 years ago in 1942? Except that instead of shouting “Banzai”, Singaporeans will scream “Cheap” and then splash the cash from Sapporo to Kagoshima. At current exchange rates, we can have two bowls of ramen with full spread of toppings in Tokyo for the price of that one bowl in Singapore that is accompanied by a sliver of an apology for chashu. In case you haven’t noticed, Singapore is the most expensive place in the world for Japanese cuisine. It’s another world-first for the little Red Dot

IP Premium Freeze

While we are talking about inflation and the rising costs of living, this hobbit has some good news. In the last post, this hobbit noted that on 15 Aug 22, it was reported in the Business Times that “Strong profits for most insurers’ Integrated Shield portfolios, but brace for premium hikes”. In that same report, it was announced that 5 out of 7 will raise Integrated Shield Plans (IP) premiums this coming year. These raises were made in the name of keeping the IP sector “sustainable”, despite making good profits in 2021 and 2020.

Well, well, it appears that in Singapore, pigs can indeed fly. On 2 Sep 22, the Life Insurance Association of Singapore (LIA) announced that IP insurers were freezing IP premiums for about a two-year period – 2 Sep 22 to 31 Aug 24.

Wow, what happened? Did the IP insurers stumble on some Ring of Benevolence or Cloak of Kindness to offer this two-year reprieve? This hobbit is stunned like vegetable.

This hobbit thinks it’s probably some ogre-sized fella sat on these soulless and faceless IP people and forced them to regurgitate some of the profits from 2020 and 2021. Its either that or some fire-breathing dragon finally woke up and breathed on these IP folks.

Whoever you are, Mr Ogre-size Fella(s) or Fire-breathing Dragon(s), this hobbit thanks you.

Widespread IT system outage x 2

Unless you are completely delinked from public sector healthcare, you would have experienced the deleterious effects, or at least heard, of the IT system outages that occurred recently. This happened not just once, but twice, on 25 Aug and 5 Sep 22. These two events were attributed to “node failures”, which in turn were caused by bugs in the firmware of devices supplied by a company called Cisco (not the local security services company). It was reported in the Straits Times on 12 Sep 22 that these “devices have been patched”. This information was revealed in response to parliamentary questions.

It was also reported in the answer given to these questions that in the IT arm of MOH Holdings, called Integrated Health Information Systems (IHIS), which supports the IT needs and operations of public sector healthcare institutions, has a headcount of ~3500. I must say, this is quite a staggering number and this hobbit is stunned like vegetable, again. Some smaller general hospitals may not even have a headcount of 3500. This hobbit wonders how many headcounts does GovTech, the agency that supports the rest of government, has? More or less than 3500?

Anyway, beyond headcounts, what is important is that IT availability nowadays is almost as important as utility-availability in the traditional sense. If there was a power outage or if the water taps ran dry for just a few hours on almost a nationwide scale, you can be sure that the authorities will be tasked to investigate thoroughly what happened and to make recommendations as to what steps can be taken to prevent the recurrence of such events. With our heavy reliance on IT to deliver healthcare today, IT availability is no less important than power or water availability.

For example, life-sustaining critical equipment such as ventilators are plugged into Uninterrupted Power System (UPS) power sockets. The batteries for these UPS systems are maintained and replaced fastidiously and they will kick in when there is a power outage.

As a second line defence, backup power generators are tested regularly in hospitals to ensure they are always ready in case of a power blackout. Even water supply grids have redundancy built-in for some general hospitals.

So do we have the same level of resilience built into our IT systems supporting our public healthcare institutions?

Pre-employment Grants for Singaporeans Studying Medicine Overseas

Currently, Singaporeans studying Medicine overseas in recognised universities can apply for a MOH Pre-Employment Grant (PEG) to partially fund their studies. In return, they are bonded to serve the government for up to 4 years, depending on the number of years the grant was given to the student. The grant is given on merit. But it is not known publicly as to what are the exact meritocratic criteria involved here. This grant is very popular and has brought back many a Singaporean doctor to our shores over the years to work as a house or medical officer. This hobbit may be wrong, but anecdotal evidence suggests that slightly less than half of Singaporean medical students are successful in getting this grant.

It is said that folks who don’t get this grant often end up seeking employment and training overseas and there is a higher risk that they will never come back.

On the other hand, recently, on the MOH Holding website, there was an announcement that it was conducting a Request for Proposal (RFP) for the Appointment of a Recruitment Agency to Provide Services for the Recruitment of Doctors in India (announced 6 Sep). This was followed up by another RFP 10 days later for Request for Proposal (RFP) for the appointment of recruitment agencies to provide overseas recruitment services to MOHH and its Affiliate(s) for a period of two years with an option to extend for another one year.(https://www.mohh.com.sg/programmes-partnerships/tenders)

The earlier RFP was for the recruitment of 60 Medical Officers from India from 2022 to 2024 with an option also to extend for another year, while the later RFP was for recruitment of nurses, enrolled nurses, nursing aides and healthcare assistants

Let’s just focus on the doctors bit for a while. If we are so short of medical officers and we have to appoint agencies to help us recruit them from overseas, wouldn’t it be easier if we just awarded more PEGs? It is estimated that annually we produce about 500 doctors locally and another 200 Singaporeans go abroad to study medicine. Wouldn’t this shortage of 60 medical officers be easily plugged by giving out more PEGs? It would be nice if we knew, excluding those that don’t bother to apply for the PEG, how many unsuccessful PEG applicants there are roughly in a year so that stakeholders can take this discussion further. It would be very useful if stakeholders also knew, of the unsuccessful PEG applicants, how many indeed remained overseas for their HO and MO employment and training.

This is a difficult post to write. Simply because it attempts to address issues that are raw and painful to a segment of the medical profession – the junior doctors, i.e. the house and medical officers, residents etc.

There have been many instances of reporting of junior doctors finding life unbearable now in the public institutions. Many have purportedly quit or are in the process of quitting. Apparently, dissatisfaction is at an all-time high and about to get worse.

This Hobbit has provided links to articles on this topic found in the mainstream media at the end of this post. But these are only from the mainstream media. If you go beyond this, there are much more stuff found in blogs, memes etc.

What is the profession’s response to this? At the risk of stereotyping, the profession’s response can be divided into two groups. One group of doctors are those that share the view that things are really bad. Another group just thinks that well, today’s younger doctors are soft and just can’t hack it and things were far worse last time.

This hobbit will not go into whether things are better or worse now. For one thing, the Covid-19 pandemic has upended many things in the practice of medicine. PPEs cannot be that comfortable, especially with global warming. Taking consent now is a labourious affair. Unlike my time, you can’t just find a houseman to stuff a consent form into a patient’s face and instruct him gruffly in Hokkien or Cantonese, “Uncle, we have to operate on you, sign this form”.

Things are also better now, because you don’t have to give IVs and contend with performing 120-second hypocounts. And of course everyone gets paid decent money for doing calls.

So there are pluses and minuses between the past and present. It is pointless to debate ad nauseam whether things are better or worse between the present and the past from a material point of view. Of course if money is the solution, it would be simple for MOH to pump more money and pay junior doctors more. After all, MOH has the largest budget allocated this year by the Government, at some S18B, even larger than MINDEF. So paying the junior doctors say a bit more won’t really put a big dent in the budget. But life is more complicated than that. Of course, more money also helps, but money is not the cure-all or be-all.

It may be fruitful to look at abstract issues that drive morale. What is clear to this hobbit is that life in the past was bad too. But we had one thing that perhaps young doctors today don’t have very much – hope.

We knew that life will get better when we became specialists or when we serve out our 5-year local undergraduate bond. We knew there was an end to all this and things will get better. I am not so sure if young doctors have this optimism today.

Let’s take the example of being a specialty “trainee” (the old term for “resident”). We knew that when we completed specialty trainee, we will be appointed Senior Registrar or Associate Consultant. Senior Registrar was the term used when the Specialist Accreditation Board (SAB) and Specialist Register had not come into being yet. There will always be a job in a public hospital for you after exit. And on top of that, you know you are well-trained, having seen and managed many, many patients. That black name-tag (signifying you were a ‘senior’ doctor with at least a master’s degree or fellowship, i.e. at least Registrar) that was hanging off your chest or stethoscope gave you hope, satisfaction and a spring in your step.

Now associate consultants, let alone residents or senior residents, do not have this aura of positiveness around them. In fact, residents do not have any assurance of any job security when they exit. All this came about because a few geniuses in MOH decided to Americanize our specialty training system more than 10 years ago with ACGME-I Residency. The idea was that being a more structured system, the residency can produce more specialists faster. A good summary of this is that some geniuses thought they can produce more specialists like how the Clone Army was produced on the planet Kamino (Star Wars Episode 2), vis a vis the old system of apprenticeship, like Jedi (or Sith) training.

To this old coot, residency is a term used by Celine Dion when she is contracted to sing at a casino in Las Vegas for 2 years after Titanic. But like the Titanic, our young doctors are sinking in residency.

It starts with this ill-informed idea that training can be delinked from employment. This can be acceptable in a large country like the USA, where you can train in a Los Angeles hospital and after that the LA hospital may not offer you a job but you can get a job in a hospital in the state of Montana. America is a big country and life goes on. This cannot be so in a small place like Singapore. If you exit training in NUHS and don’t get a job offer from NUHS, the chances are you can’t get a job in the other two clusters as well. It is simply unwise to delink training from employment in Singapore. MOH should disabuse public healthcare clusters and hospitals of the idea that they can recruit many residents (i.e. cheap labour) and then hope someone else will hire them later on when they exit.

This is especially so because most residencies are confined to the same cluster and other clusters’ clinical leadership do not know the resident. This is different from the past when MOH controlled the postings centrally. Trainees rotated between different hospitals across the country and he has a chance of being hired by different hospitals after exit.

We then move on to what happens after one exits and cannot get a job in where he trained.

If nobody hires them as associate consultants then legally speaking, they can still set up shop in the private sector and practise as specialists in private hospitals, albeit somewhat lacking in experience and exposure.

But as of recently and in a practical sense, they cannot.

There are only a few private hospital operators in Singapore. Recently the largest private hospital group issued a policy stating that they will only accredit new specialists if they have been registered specialists for at least 5 years, of which at least 3 years must be of consultant grade (note: consultant, not associate consultant) in a public hospital. If you were promoted to consultant from associate consultant after 3 years and not 2, effectively you have to hold a specialist position in a public hospital for at least 6 years and not 5. Another private hospital has also followed suit with this policy.

Now back to these new specialists who cannot get a job in a public hospital. What are they going to do? Theoretically,  they can practise as specialists in the private sector with no practising and admission rights in at least 5 (some of the largest) private hospitals in Singapore. What kind of prospect is that? This may be OK if you are a dermatologist or psychiatrist but definitely not OK if you are in almost all other specialties that require a hospital setting.

In other words, from the start of residency to the time a specialist is able to gain practising rights in most private hospitals in Singapore, he needs to be employed for at least 10 years (5 years of residency + 5 years as AC and Consultant) if not more in the same public hospital that trained the resident. Yet, the young doctors are not getting any assurance it will be so from some public healthcare clusters and hospitals. Of course there are good residents and not so good residents, and nobody owes anyone a living for 10 years, especially if the resident doesn’t perform. Nonetheless, this kind of uncertainty is very unsettling for young doctors today, and a source of unhappiness that in our time many years ago, under the old traineeship system, simply did not exist. In the past, if a trainee was very bad, the hospital simply did not sign him up for exit. This is unlike today when we over-recruited, under-trained our residents and under-employed them after exit.

In the past, once you are a trainee in a certain department in a hospital, you are practically family. Of course, every family had its problems, but you are still part of the family.

The powers that are have recently addressed this by drastically decreasing the number of training positions offered in some specialties. This in turn has created another source of unhappiness. Newer batches of medical graduates now wonder why there are so few residency positions available when compared to their seniors. This is the typical sort of deep unhappiness and frustration that accompanies boom and bust, feast and famine cycles. And in this case, they are man-made, avoidable cycles.

Perhaps the only bright area for young doctors is in family medicine and this explains why its popularity as a training program is rising. Once you exit you are not at the mercy of private hospitals’ accreditation requirements. And with the emphasis on prevention, everyone having a regular family physician and Healthier SG, the future of family medicine looks reasonably bright.

There are certain things that are beyond our control, such as the demands of infection control and patient load brought on by the pandemic. But many things can be managed. Are we managing public expectations and patient expectations? Or are we content to just accept the inexorable climb in these expectations, and let the young doctors (and nurses) bear the brunt of it? Some expectations are reasonable and should be met but are all expectations reasonable? What are hospital administrators and MOH doing to buffer our frontline healthcare workers from some of these unreasonable expectations?

Another common phenomenon which is seldom addressed is that when every hospital and department attempts to manage their risks (a euphemism for covering backside), then invariably new and more complex policies are written which in turn lead to more work being created downstream for the junior staff like medical officers and staff nurses. Has anyone thought of saying “Hospital management will take this risk so that we don’t pile more work on the medical and house officers”? No. The usual answer is “we will implement a new policy to address this problem/risk”. Which almost always translates into more work for the poor guys at the ward or clinic floor.

The lack of opportunity for career advancement and the lack of certainty in career prospects have a pernicious effect on morale and undermines hope. Aggravating this situation is the junior doctor often has to bear the full brunt of unreasonable public expectations as well as get bogged down by an every-increasing array of administrative and policy requirements that are perceived to increase the survivability of hospital management but not that of the junior doctor.

Is it therefore any surprise that our junior doctors are feel they are running on empty?

Links to writings about junior doctors’ plight in mainstream media:

https://www.straitstimes.com/singapore/health/long-call-hours-teach-time-management-but-not-best-way-to-learn-medicine-say-junior-doctors

https://www.channelnewsasia.com/singapore/review-junior-doctors-work-hours-among-steps-improve-healthcare-workers-well-being-2551376

Drained and Gaslit: Junior Doctors in Singapore Have Nothing Left to Give

Recently there has been some disquiet about the NUS Faculty of Medicine (sorry, this YLLSOM thingy never quite jelled with an old coot like me. My degree is from Faculty of Medicine, not some guy who gave a lot of money to NUS) accepting students from ‘less than the best academic’ records and more varied sources (read: not just RI and HCI).

A certain Anthony C.H. Leong wrote in The Straits Times (23 July 2019), “What is wrong with the meritocratic old ways of judging by the quality of the candidate’s academic results, further refined through an interview? We tell our children to work hard academically to get the relevant results for the course they wish to pursue in university, only for them to be denied a place by some populist policy. Their parents will have to cough up a fortune to send them overseas. I don’t think those who are unfairly rejected, especially those who do not have the means to go overseas to study, would think very kindly about their country and its professed meritocracy”.

There are quite a few points raised in this quote that needs addressing. First, we need to understand what is the purpose of a medical school, especially a state-funded medical school. The purpose of the NUS Faculty of Medicine or YLLSOM (OK lah, he did give a lot of money to get his name on this school) is to produce the better doctor, or the best doctors it could to serve Singapore. This hobbit emphasises “to serve Singapore” because YLLSOM is largely state-funded (i.e. by taxpayers). To serve Singapore may be of secondary importance if it was privately funded, but it is not.

The primary purpose of YLLSOM is not to fulfil someone’s aspiration to be a doctor, although the individual’s aspiration and the YLLSOM’s primary purpose are not in conflict with each other, philosophically speaking. This may sound somewhat brutal, but that’s  the hard truth. They only come into conflict because of the scarcity of resources – the number of places YLLSOM can take, with the limited resources it has (funding, manpower, space etc), versus the number of people who want to become doctors.

Second, a primer on meritocracy. The word meritocracy comes from the word ‘merit’ obviously. Meritocracy is about putting people in power and/or privilege due to the ability they have, and not due to other factors, such as wealth or social position/inherited titles. We seldom say it, but the people rewarded in a meritocracy, by a meritocracy, are actually the “meritorious” (deserving of merit).

The Cambridge Dictionary describes meritocracy as a “social system, society, or organisation in which people get success or power because of abilities, not because of their money or social position”.

The next point about a meritocracy is that there are many forms and notions about meritocracy. What Mr Anthony Leong has described is academic meritocracy. This concept of meritocracy is widely held by large swathes of society, no thanks  to cultural or even governmental norms. But it is not the only form of meritocracy. For example, when we reward athletes for their performance in competitive sports or highlight citizens for acts of kindness, service to community, valour, or moral fortitude, these are, in a way, also forms of meritocracy, but the norms are different. A National Day Award from the government, such as the Public Service Star, is based on non-academic norms of meritocracy. A person who swims the fastest 100m butterfly in an Olympic Game gets the gold medal and is given S1M. The world and Singapore society have decided that he is “meritorious” and hence deserving of the medal and cash award. But it is another form of meritocracy that is not academic meritocracy. Academic meritocracy is simply a form or meritocracy based on academic ability and performance.

Dynastic and feudal China since  the Sui Dynasty in 6^th century AD practised academic meritocracy through the imperial exams. People who excelled in these exams were put in positions of power as officials of the imperial court. Sometimes, the Emperor himself witnessed the final round of these exams himself and marked some of the scripts! Surely this is sponsorship and belief in academic meritocracy of the highest order! Yet one of the main reasons China faded as a superpower in the Qing Dynasty is that it clung to outdated norms of academic meritocracy. People were rewarded and appointed because they excelled in the Classics and Confucian Texts and not on Science and Maths. The world (especially Europe) moved on while China was stuck in backward feudalism. So even as we support and uphold meritocracy, we need to examine and revisit what are the norms of society so that the form and substance of meritocracy remains relevant to the needs of society. Academic meritocracy is no exception.

Back to YLLSOM. As aforesaid, its main aim is to produce the best doctors that it could to serve Singapore. Academic meritocracy is nothing more than an allocative tool to achieve this main aim. Academic meritocracy is not an end in itself.

There are several ways to look at what YLLSOM is trying to achieve by moving slightly away from pure academic criteria for admission into its ranks. First, it is an admission that academic performance is NOT the only meritocratic norm for admission.

Secondly, the correlation between a good doctor and outstanding A level academic performance is not that strong. It is true that you need to have above average academic performance to survive the rigours of medical education. But is a straight As at H2 with three H3 paper distinctions student more likely to make a good doctor than a student with 4As at H2 with no H3 papers? Or will the student with 2A and 1B at H2 necessarily make a worse doctor than a student with straight As at H2 level? The answer is obviously “no” to these questions. Beyond attaining a minimal level of academic achievement necessary to suggest the student has the ability to complete his MBBS, academic performance at A levels does not predict or correlate with his eventual performance as a doctor.

Thirdly, by admitting people from different backgrounds, YLLSOM is perhaps admitting that it is important to have diversity in the medical profession. We need brilliant people to be the next professors of medicine and make scientific breakthroughs. We also need less brilliant (but still intelligent-enough) people to be  the doctors serving patients in the community. Both are equally important, and everyone else in between.

Diversity also prevents groupthink. The risk and downside of groupthink is very real, whether in the medical profession of any organisation. Just look at the Hong Kong government now and the unrest in its society. It is probably a result of groupthink in its highest ranks that prevented them from seeing the grave repercussions that have arisen from trying to push through the now infamous Extradition Bill.

Actually, the policy of choosing people not just based on the best academic performance for Medicine is not new. It is just expressed in a different form. Those of us who entered NUS Medical School in the eighties will remember that the government then had a policy of deliberately trying to shunt the best students to other fields such as Engineering or the Arts because it felt it needed the best academic talent not to be concentrated just in Medicine. There was apparently a PSC officer at the medicine admission interviews (sitting at the extreme left or right of the panel of interviewers) who would offer you “a deal” of sorts – would you want to consider a teaching scholarship? Or a PSC scholarship to Cambridge to read Maths? We never knew whether these offers were real or not, but we were all advised by our seniors to say “no” to show our resolve to become doctors. I know of quite a few people with A level “perfect scores” who did not get into medicine. And while there was no evidence to prove so, people with less than perfect scores seemed to have a better chance of getting into Medicine in the eighties.

In summary, this hobbit thinks:

• The job of YLLSOM is not to give out places as awards or rewards for academic excellence under the framework of academic meritocracy. It’s main job as a publicly funded medical school is to produce the best doctors it could for Singapore.
• Academic meritocracy, which is meritocracy based on academic ability, is not the only form of meritocracy. Academic meritocracy is often used as an allocative tool, but it is not an end in itself.
• The norms of meritocracy are as important as meritocracy itself. The norms determine who is meritorious, and these norms have to be examined and revisited from time to time so that meritocracy remains relevant to the needs of society.
• Beyond attaining a required level of academic performance that suggests the person can withstand the future rigours of a medical education, there is little correlation between actual performance as a doctor and his A level results.
• Diversity in a medical school cohort is important, because each cohort has to fulfil different roles in society. Diversity also prevents groupthink.