Introduction
Drs Marcus Tan, Thong Jiunn Yew and Seng Kok Han run a community-based psychiatric practice, operating out of two clinics. The three of them got to know each other during their National Service days more than a decade ago, where they served in succession at the Singapore Armed Forces Ward, Alexandra Hospital. There, they ran both the inpatient psychiatric ward and day centre for distressed servicemen. We are glad to speak with Dr Marcus Tan to find out more about their vision of bringing psychiatric care to the heartlands.
Could you tell us more about your psychiatric practice?
Jiunn Yew and I started the practice in 2010, while Kok Han joined us in our fifth year of practice. Each of us brings to our practice some 18 to 20 years of clinical experience.
Despite us having rather different personalities, we became close friends and discovered that we share the same vision and passion for the work we do. Understanding each other on a personal level has been really helpful in allowing us to anticipate each other's practice requirements, needs and goals. I think this understanding is essential to form the stable foundation necessary for a working partnership that endures, much as we are still a relatively young practice compared to our seniors in more established practices.
Our flagship clinic is situated at Ang Mo Kio Avenue 10, nestled in an aged neighbourhood precinct populated by a mix of old- and new-school hair salons, hardware stores, itinerant fortune tellers on makeshift tables, mom and pop Chinese grocery shops, a wet market and food centre, a Taoist shrine, traditional Chinese medicine physicians and several GP clinics.
This location holds personal meaning to me. I grew up in Ang Mo Kio and this was one of those places my friends and I hung out at in our teens. The neighbourhood has changed a lot, obviously, but this remains a place that most locally born Singaporeans can relate to. We wanted our practice to be situated in the community, in a place where we live and work, and I could not think of a more ideal spot. With the occasional wafts of fried salted fish mixed with the buttery aroma of kopitiam coffee, and strains of Hokkien songs playing from the HDB flats above our shophouse clinic, it does not get more heartland-like than this.
Our other clinic operates out of Novena Medical Centre, which is more centrally located to serve our patients working near or in town. They visit us on their way to or from work, and sometimes during their lunch hours.
What motivated you to go into the heartlands?
The phenomenon of hidden morbidity is well recognised in psychiatry. Through the course of our work in public institutions, we came to know of the need for greater accessibility to psychiatric services. Apart from the unfortunate stigma attached to being diagnosed with a psychiatric illness and seeing a psychiatrist, persons afflicted with psychiatric conditions can be apprehensive to seeking treatment due to the perceived costs involved in the private sector.
I recall that in the year 2007 or 2008, I had the opportunity to see a pair of parents who were in acute grief after losing their child to suicide. Part of their anguish was that while they knew that their child needed help, they were unsure of how to go about doing so. They had not been keen to approach public institutions as they feared that their child would be left with having "an official record" that would affect his future. While this fear is really quite unfounded given strict guidelines on medical confidentiality, this is a worry that is real and continues to be present for many. Over the course of my work with them, it became apparent that we can do more to provide timely access to psychiatric services for those in the community who are in need.
Instead of waiting for patients to show up at the doorsteps of psychiatric departments of general hospitals and the Institute of Mental Health (IMH), we decided that the way forward in combatting mental illness is to bring our services to the heartlands, where most of us live and work. In addition, a presence in the community will likely go some way to help our efforts in de-stigmatisation. Doing so also avails us opportunities to link up with GP clinics, as well as community mental health and social resources – all of which are important components of a comprehensive mental wellness service.
The concept of establishing a psychiatric service in the heartlands is not new; some of our seniors have also done so, mostly on an ad-hoc basis, before we did. IMH has also established outpatient clinics in polyclinics, but waiting times for appointments can be long.
The opportunity came along when we were approached to join private practice. At that time, we were offered several locations in private hospitals to choose from for our clinic. We managed to state our case for a community-based, heartland practice to serve the needs of the local population.
And here we have been, for the last eight years.
Could you share with us the working model of your practice?
Our practice is focused on providing affordable, financially sustainable and accessible psychiatric care at a one-stop location. To do so, we try to keep consultation rates as low as possible. We also take care to practise judicious prescribing and avoid polypharmacy as far as we can. The latter helps contain treatment cost.
The main challenge we face, like any other private clinic in Singapore, is that the cost of medications are significantly higher than what public institutions obtain them for. The other challenge is rental which, I believe for other clinics too, is an escalating cost over time.
We do what we can to minimise the cost of goods and overheads. We source for the most affordable alternatives for medications, order in bulk to leverage on the economics of scale and constantly review our work processes to reduce wastage. Office products are "recycled" and at times "repurposed". Savings are then passed on to patients.
To further help defray the cost of running the clinics, we also take on teaching assignments and involve ourselves in employee assistance programmes and external contracts for on-site consultation.
We are proud to note that the average cost of care at the practice is contained below $10 per day – around the price of a meal from the food court – for the majority of our clients. This also gives us some bandwidth for pro bono work with selected cases.
To ensure that quality of care is not compromised by the patient volume we manage, we cap the maximum number of patients seen per session to ensure that sufficient time is allocated for each consultation. To enhance accessibility, we also have to ensure that our clinics open long enough to minimise first appointment waiting time. To accommodate patients who prefer to see us after work or during weekends, we run evening clinics on most weekday evenings till late and back-to-back sessions on Saturdays into the afternoon. This in turn has translated to rather long working hours. Apart from ward rounds which are done before and/or after clinic hours, we run as many as 13 sessions per week. Weekends are seldom protected time off and it is not uncommon for us to work some 70 hours per week.
One feature of our practice is that we work alongside our GP partners to co-manage stable patients on maintenance treatment. Once the patients are stable, they are returned to their GPs who continue care, until the time when they are well enough for treatment to be discontinued or when unwell. For the latter, we will take over management until the patients are stable enough to be returned to the GP or be discharged. Anytime an opinion or sounding board is needed, we are just a phone call away from our GP colleagues.
Apart from attending to our patients from referral and walk-in sources, we also offer what we term "transitional care" for patients who already have appointments from the outpatient departments to public hospitals, but are unable to wait. For this group, we provide earlier assessments and initiation of treatment where we manage the patients until they see our public sector counterparts. This helps to moderate the cost of care for them too. I believe that this initiative to promote early intervention has made a difference, especially for those who are in crises.
Administratively, we look after different aspects of the practice. Jiunn Yew takes charge of the day-to-day operational and logistical issues, Kok Han manages the staffing, while I look into our liaison with the community and professional partners. I also work on charting the practice's focus and overall direction. Having said so, most issues that arise are discussed, with a consensus reached before decisions are made.
What keeps you going when dealt with challenges/difficulties?
Being in the community, we do not have the benefit of support from a multi-disciplinary team that can help to share the workload. Some cases can be rather difficult – not just from a biological point of view, but a psychosocial one as well. When faced with challenging cases, we confer mini "grand ward rounds", or peer review learning as it is called now, to discuss the case and bounce ideas for treatment off one another. I am glad to note that the staunch peer support that we have cultivated in the practice over the years has helped sustain us. While we may differ in opinions at times over operational and clinical decisions, we have always managed to resolve our differences.
On a personal level, we are also good friends who play well together. Despite our schedule, we make it a point to meet regularly for dinner to catch up. When possible, we also travel together for conferences and leisure.
I have to admit that the engaging nature of the practice and the often hectic day-to-day routine takes a toll in more ways than one, at a cost to our personal lives. The people around us may not always understand why we do what we do. This is also when we turn to each other for support.
At this point, I am glad to say that we are blessed to have understanding families and supportive partners who appreciate the nature of our work.
Are there any memorable patients/incidents in your years of practice?
The accessibility of our location, to some extent, avails us to patients from all walks of life. Over the past eight years, we have had some really interesting cases. We have diagnosed clusters of folie à deux or delusional disorder by proxy, treated cases of psychosis initially attributed to paranormal causes, and exposed doctor-hopping benzodiazepine abusers – in one case, a patient tried to impersonate her twin!
Being in the heartlands also allows us to leverage on our surroundings for therapy. I recall how I used to take buses with patients to help them habituate the anxiety they feel. I have also utilised coffee shop toilets for exposure and response prevention therapy for some of my patients with obsessive-compulsive disorder. Some years back, I had a young patient who had a phobia of trees after seeing his family home get demolished by a falling tree during a typhoon. He would get really nauseous and throw up while on his way to school. To overcome his fear, we took to climbing trees at one point. Although that helped his condition, it did not end well for me.
Of course, it is not always all rosy. We have had to contend with threats and even some rather "colourful" letters from anti-psychiatry individuals. It's all in a day's work. What matters is that we do our best so we can go home and sleep easy.
What lessons do you have to impart to our younger colleagues just starting out?
Private practice is not as easy as how it may look from the other side. It comes with its own set of challenges. Contrary to what some may think, the main driver for most of us moving out from the public sector is to have the control to shape the practice we want.
Some do hit the big time, but most of us just get by.
No matter what, don't lose yourself. Work for your passion for the art and be prepared to work very hard. Take time out when you need to. Don't burn out. While it may get lonely at times, you know that support, in the form of colleagues, is always only a call away.
When lost or in doubt, always remember to do right by your patients. The rest will follow.