There has been some concern over a spate for ophthalmologist resignations from the public sector in the last 12 months or so.

But first, some statistics to put things in context. In the latest SMC Annual Report (2022), it was recorded that there are 314 ophthalmologists in Singapore, of which 122 worked in the private sector and the rest (192) worked in the clusters. Therefore, about 39% of all ophthalmologists are from the private sector.

From 2018 to 2022, a period of 4 years, the number of ophthalmologists increased by 42, from 272 to 314. That’s about an increase of 10.5 per year in this period. I.e. we are increasing the number of ophthalmologists by about 10 a year, nett of the ophthalmologists who retire in the same year.

If we assume that the country produces nett 10 ophthalmologists a year, and to maintain the market share between private sector and public sector at around the current 40%/60% split, then roughly 4 ophthalmologists should leave in a 12-month period for the private sector.

However, In the last 12 months, a total of 15 ophthalmologists have left the public sector or have tendered their resignations and are now serving notice, give or take a few. And interestingly, the vast majority of these 15 are senior consultants, or on the verge of becoming one, since the most junior ophthalmologist of these 15 was already registered with the SAB (Specialist Accreditation Board) in 2016, i.e. with at least 7 years of experience as a specialist before resigning. Three of them are very senior, having graduated in the 90s and collectively have chalked up some 60 years of specialist experience between them.

To better understand why so many ophthalmologists have left or are leaving in the last 12 months, we need to first acknowledge that there are several peculiarities of ophthalmology:

1. The practice of ophthalmology is not as dependent on hospitals as many other disciplines, not unlike dermatology. Hence there is a less pressing need for one’s practice to be located in a clinic suite that is co-located with a private hospital. Hence, an ophthalmologist doesn’t have to pay sky-high rents.

• Secondly the epidemiological trends of eye diseases are firmly on the ophthalmologist’s side. At least 80% of Singaporeans become myopic by the time they reach adulthood, and this translates into a great pool of patients that can benefit from refractive surgical procedures e.g. Lasik. 80% of the elderly will develop cataracts, which again serves as a very large source of patients.

• Due to the perceived criticality of sight, patients in this day and age do not wish to be treated by family doctors for eye conditions except for the least complex of conditions that can be treated with just eyedrops and ointments prescribed by the family doctor. Gone are the days when a family physician will routinely attempt to lance a stye or excise a chalazion. Some still do, of course, but they are few and far in between, especially among the younger family physicians. Most GPs are not trained to perform indirect ophthalmoscopy or tonometry and do not have the equipment anyway. All this means that, in comparison to most other disciplines, ophthalmologists take up an inordinately large share of the disease burden.

A secondary factor that needs to be discussed is the role of insurance in private sector ophthalmology. While many other specialties are very dependent on insurance-funded work, ophthalmology is less so. This is because non-insurance work are a plenty in ophthalmology in the form of Lasik procedures and even aesthetic blepharoplasty. That is why despite insurance players resisting recruiting new doctors onto panels and cutting down on reimbursement rates, ophthalmologists have no problem earning a decent living in the private sector sans insurance.

The above can be considered as unmodifiable factors that are particular of ophthalmology that makes going into private practice less daunting when compared to other disciplines.

But it doesn’t quite explain why the sudden exodus has happened. Your friendly neighbourhood hobbit actually went to talk to a few of them. When folks in their fifties and late forties leave, you can be sure that there are significant push factors behind the move. This is in contrast to someone leaving for private practice when they are in their thirties and early forties, when pull factors play a more important role in the decision-making process.

Some of the push factors expressed include:

1. A relentlessly and sharply increasing workload and punishing work schedule that gets harder and harder to keep up with as one gets older. As one ophthalmologist put it, “At the rate this is going, I can’t see myself growing old and retiring in Institution X, because I don’t think I can keep working at this rate. Might as well go out and work at a less punishing pace now and lengthen my working life”.

• Changing of remuneration policies. Each institution has a different work and pay culture. Some are more ‘capitalist’ and some are more ‘socialist’. Not a few said that a particular institution was getting more and more socialist in remuneration policy and yet workload kept increasing. Another ophthalmologist said, “You cannot have your cake and eat it too. If you want to make me work harder and see more patients, then pay me more. The pay structure has to incentivise me to chase after more patients. Communist countries failed economically because socialist-style remuneration did not lead to more productivity”. (Oops. This one really hit home for me)

• There is a need to strike a better balance between research, teaching and clinical service. “Some of us are bearing the brunt of the massive workload and bringing home the bacon for the institution but we are getting paid less than folks who see fewer patients and spend most of their time doing research”.  This is nothing new, the tension between service needs and academic medicine. But somehow the already-delicate equilibrium between the two has apparently deteriorated lately, probably brought on by the rapidly increasing service workload. The tension is more manageable when the workload is likewise manageable. But when the workload becomes unreasonable, then old wounds concealed by a thin scab may just dehisce again.

The obvious solution of course is to train more ophthalmologists to meet the demands of workload. But it takes a long time to train an ophthalmologist. So, in the meantime, the fastest way to beef up supply in the public sector is to recruit ophthalmologists from overseas. Singapore public sector pays relatively well compared to some other countries and it would not be too difficult to recruit ophthalmologists from e.g. UK. But in the long run, this may not solve the problem either. There have been examples of foreign-trained specialists who likewise leave for private practice once they obtain full SMC registration. For foreign-trained specialists with a basic medical degree that is registrable with SMC, the time taken to convert from conditional to full SMC registration can be as short as 2 to 3 years. Unless we plug this hole and mandate a longer period of service before a foreign-trained specialist can obtain full registration and can therefore leave for private practice, recruiting more foreign-trained specialists may be a just a short-sighted or stop-gap measure at best.

In addition to addressing directly some of the push factors stated above, perhaps a better approach is to better distribute the workload between the private and public sector ophthalmologists. But this would require the cooperation of insurers, especially the Integrated Shield Plan (IP) insurers. Not just particular to ophthalmology, IP insurers have  instituted a suite of measures to restrict and reduce IP work in the private sector while pushing more and more work back to the public sector, thereby exacerbating the demand-supply imbalance there. These measures include not just disincentives to seek care in the private sector even though the IP policy provides adequate private sector coverage, but also incentives for the policyholder to go back to the public sector.

There are no easy solutions here but obviously something needs to be done quickly to turn the tide. If not, the dark triumvirate of poor morale, worsening working conditions and more resignations may spill over to the public domain in the form of ballooning waiting times for appointments and surgeries.