Letters to the Editor
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"One thing for certain that i can share with you is that learning new things, and learnig them quickly, is something you cannot avoid, as you progress in the future" - Mr Koh Yong Guan
SPEECH BY MR KOH YONG GUAN, PERMANENT SECRETARY (HEALTH) AT THE NUS CONVOCATION CEREMONY ON 17 SEPT 98
Mr Pro-Chancellor, Parents, Graduates, Ladies and Gentlemen, today is a very important event and milestone for the parents and all of you who are graduating. I congratulate the parents on the achievements of your sons and daughters, and I congratulate the graduates on your success.
I completed my university education in engineering towards the end of 1972. Today I am here in my capacity as Permanent Secretary in the Ministry of Health. It is therefore a particular pleasure for me to be addressing graduates from the NUS Dental, Medical and Engineering faculties as well as those who have attained postgraduate degrees in Dentistry and Medicine.
I trained as an engineer. Today I work in the Ministry of Health as the Permanent Secretary and in the Monetary Authority of Singapore as the Managing Director. I am neither engineer, doctor nor banker. I am what the Civil Service calls an Administrative Officer. I have, however, since graduating from the university worked in hospitals, and in the finance, education, taxation and defence areas in our Civil Service. I have, therefore, had the opportunity to work closely with engineers, doctors and dental surgeons. With this as background, I would like to take this opportunity to share with you my observations about engineers and engineering, medicine and doctoring, and finally relate some of these observations to the real-life issues in the Ministry of Health that I have to grapple with.
Practice patterns of engineers and doctors
Let me start off with some statistics on engineers and doctors. I will take doctors and dental surgeons collectively as one group. In Singapore we have about 5,500 graduates in medicine, both locally and from overseas. Almost all of them are registered with the Singapore Medical Council to practise professionally as doctors, and almost all of them do, except for about 5%, comprising mainly the lady doctors, who dont. The picture is very much similar for the dental surgeons.
On the other hand, we have about 25,000 graduates in engineering, including those who graduated from overseas and local universities. Of these, only about 10% are registered with the Professional Engineers Board to practise professionally as engineers. It is also probably true that many of the engineers who are registered with the PE Board do not engage in professional engineering work, probably more than the 5% which I mentioned for the doctors. These are very interesting statistics. What do they tell us about engineers and doctors? More significantly what do they tell us about the engineering and medical disciplines?
These statistics are indirectly supported by the observation that there are engineering graduates working in almost all spheres of economic activity. You see engineers in management, finance, business, sales and marketing. I certainly see many engineers in the financial sector: as bankers, fund managers and forex traders, and they are very successful. By contrast, you dont find many doctors in any of these areas, or in any area outside of medicine. Although I have not compared the situation with other countries, I am quite certain that the picture is very much the same. Let me hasten to add that I am not advocating for doctors to move out of medicine and go into these other areas.
So what leads to this diversity of career choices for engineers? Clearly, we train far more engineering students than we have need for professional engineers. The market cannot absorb all engineers to practise professionally. And some, whether by choice or default, pursue alternative careers. By contrast, for medicine, we limit the number of students which the medical faculty takes in every year. The numbers we admit are derived directly from projections of how many doctors we need in future, and there is little slack. This is because medical studies are more costly, both to the state and to the student, and it is undesirable to produce an excess supply of doctors because the supply and demand of health services do not lend themselves to normal market forces. In addition, because a significant portion of the cost of medical training is borne by the government, a bond is also imposed.
Thus, the difference in practice patterns between engineers and doctors can partly be attributed to these supply issues. But alone, they cannot fully account for the variance. In fact, I believe that a more fundamental determinant is the difference in the way doctors and engineers are trained.
Differences between engineers and doctors
Broadly, engineers are trained to look at systems and structures, and how the pieces fit together. They analyse the purpose and function of component parts or sub-systems of a larger system. They also build components and sub-systems and integrate them to form larger and more complex practical workable systems. Often the sub-systems are built by different people. By virtue of this systems-centred training, and the need to integrate each others work, engineers are well-equipped to take on generalist jobs such as management positions.
Doctors on the other hand, are trained to be specialists in one particular system, that is the human body. Certainly a very complex system, but nevertheless one distinct entity. Their starting point is what their patients tell them and what symptoms they can observe. They then do tests to verify or confirm a diagnosis. Their work is thus patient-centred.
Furthermore, because their work can often be a matter of life and death, or more generally the preservation of good health and life, the focus is far more intense and intensive. Healing the sick or alleviating their suffering brings great personal satisfaction and fulfillment to the doctor. Doctors also spend many long years in training _ at least 6 years before they can start as a general practitioner, and as long as 13 years to be a specialist. Whereas you would seldom hear anyone speak of a calling to be an engineer, you would frequently hear doctors speak of their vocation as a calling.
When I came to the Ministry of Health one observation that quickly struck me was that it was rather difficult to get specialist doctors to work together. I asked a very senior medical consultant why it is so difficult for the Ministry of Health to persuade two groups of specialists in the same area of specialisation to come together and work together. His answer to me was, "It is impossible to get doctors to work together." And this is from a very senior member of the medical fraternity who has spent many years working with specialists in and outside of his own area of specialisation. The difficulty in getting doctors to work together may have become more pronounced now that we have sub-specialisations within a specialisation. So within what was one specialist area, like cardiology or neurology we now have several groups of sub-specialists.
I ascribe this particular trait of doctors to the fact that entry into medicine, like everywhere else in the world, is highly competitive and some of the brightest of each student cohort go into medicine each year. The result is we have doctors who are highly intelligent and who, by training become highly individualistic.
Also, the nature of clinical practice is such that doctors are generally in a position of authority. The patient and doctor establish a very close relation. Even though patients are becoming more and more educated, the doctor-patient relation still remains an unequal one. The patient may seek a second or third opinion, but he is ultimately not likely to question the doctor over what the doctors conclusions about his conditions are, and the doctors solutions for his problems.
Professional teams vs individuals
One of the main impacts of this individualism is on the building-up of our national specialty centres. Singapore has 5 specialty centres in the area of eye, skin, heart, cancer and neuroscience. The latter three are new and we have been putting a good deal of effort into ensuring that they can become centres of medical excellence, delivering high-quality care with good outcomes.
One key factor which the Ministry has to grapple with in the development of these centres is the difficulty we face in getting doctors within the same specialty area to work together. Because Singapore is a small country, we need to centralize certain more complex methods and procedures at these centres. This is to ensure optimal usage of sophisticated and expensive equipment, and that the skills of our specialist doctors are maintained. But if the doctors are unwilling or unable to work together in such a setting, the whole of the healthcare system in Singapore will be weakened, and we will find it hard to maintain our position as a centre of medical excellence.
Individual doctors alone cannot put Singapore on the map, no matter how renowned they are. But together they can, and in the process bring many opportunities for others too, both patient and professionals alike. This is why a key emphasis of the Ministry in building up these centres, is their inclusiveness. We will allow for qualified doctors from any hospital whether public, university or private, to practise in these centres. Those who want to contribute but would like to remain in their current institution will also be offered dual appointments. We also want the university to regard these centres as an integral part of its academic system. We urge doctors to look beyond their institutional and sectoral walls and see themselves as part of the larger health care system of Singapore. With such a broad-based approach, we will then be well-positioned to deliver good care to Singaporeans, and to achieve excellence by any standard.
Professional leadership and health administration
Another practical consequence that the Ministry of Health has to grapple with _ again related to the distinctive training and worldview of doctors _ is the difficulty in finding doctors who are willing to leave clinical practice to take up professional leadership and health administration positions in the Ministry. This is especially so now that the hospitals have been restructured and function as separate entities from the Ministry of Health. Hence the vast majority of specialist doctors are no longer employed by the Civil Service. In addition to their specialist skills, doctors would also have over time built up a pool of patients and a strong reputation, which once lost, are hard to regain. They may also be concerned about a potential loss in remuneration. It is thus understandable why doctors are hard-pressed to put aside clinical work to pursue administrative careers.
At the Ministry of Health, one of our priorities is to enhance Singapores position as a regional medical centre. With medicine and technology advancing so quickly, the Ministrys regulatory role will also need to be further strengthened, to ensure that the standards of professionalism and safety and standards of health care in Singapore are not compromised. This is why we need to continually develop and nurture a pool of doctors who can take on senior professional leadership appointments in health administration. These are the people who will guide and steer the development and practice of health and health care in Singapore. They will also be responsible for setting the tone and standards of professionalism and practice in Singapore
The Ministry has tackled the problem, to some extent, by creating health administration as a distinct specialty. Health administration doctors undergo traineeship, which comprises the Master of Medicine in Public Health, and specific postings in the Ministry or at the public sector hospitals aimed at honing their skills in health administration. This group of people form the core of the Ministrys health administration expertise.
But we cannot afford to restrict our talent pool only to this group for two reasons. Firstly, the number of doctors in the Civil Service is very small compared with the number in the restructured hospitals, the university and in the private sector. Secondly, with medicine, specialisation and technology developing so quickly, it is impossible for this group of health administrators, or indeed any one category of doctor, to have developed sufficient knowledge to effectively regulate health care at a national level, or to act as professional leaders in all aspects. We in the Ministry are thus shifting our paradigm and considering medical professionals on a national basis, as one large national talent pool.
To encourage more doctors to come forward and contribute their expertise in professional leadership and administrative positions, we are prepared to offer such senior positions in the Ministry HQ to doctors on term appointments. We will also be prepared to let senior doctors holding such appointments in the Ministry to concurrently hold clinical appointments in the hospitals. The length of the term will also be negotiated with the Ministry. This will give doctors the flexibility of returning back to clinical practice once the term is completed, or keeping one foot in clinical practice at the same time.
On our part, we will ensure that they are remunerated fairly, and that the scope of these administrative positions is broad and challenging, and thus a boon to their careers. Hopefully, the doctors themselves will then see such appointments as enhancing rather than taking away from their clinical repute! We are prepared to consider doctors not just from the Civil Service, but from the restructured hospitals, the university, the private sector, and even overseas for such appointments. From the Ministrys perspective, we will now be able to select the best person for the job, from a bigger pool of talent.
One recent example is the Singapore Blood Transfusion Service, which is a government department. With the impending retirement of SBTS Director, the Ministry needed to find a suitable replacement with relevant expertise, and who was willing to take on the position. The Ministry felt that the best person for the job would be A/Prof Patrick Tan, Senior Consultant and Head of the Department of Haematology in the Singapore General Hospital. A/Prof Tan is not a civil servant. In April this year, the Ministry appointed A/Prof Tan as the Director of the Singapore Blood Transfusion Service. A/Prof Tan also continues to be Head of SGHs Haematology Department.
As for key senior medical appointments in the public sector, in keeping with our policy of recruiting the best person for the job, we will not hesitate to bring in qualified doctors from the private sector or from overseas. For the Director of the National Heart Centre our search went as far as Australia, and we finally appointed Prof Lim Yean Leng who was then practising in Australia, as the Director. He is a highly-respected cardiologist and has the qualities we felt were necessary to pull the heart specialists in Singapore together in order to establish the National Heart Centre as a centre of excellence.
I hope that with such employment arrangements, more doctors will look beyond the horizons of their clinical vocations - demanding as these may already be _ and take on the wider challenges of health administration and professional leadership at the national level. Their contributions in these areas, I believe, will be crucial in determining how far we can go in raising the standards of medical excellence in Singapore. I also believe that our ability, in the Ministry of Health, to motivate our specialists to come together and work together in the specialist centres will determine how well we will succeed in enhancing our position as a leading regional medical centre _ a centre that Singaporeans and regional patients will see as the centre of first choice when they need specialist medical services. I hope that my long exposition today will be remembered by some of the medical graduates, and you will consider the challenge of taking up senior medical leadership positions later on in your career.
Let me conclude with a few words to all of you who are graduating today. You are graduating and going into the job market at a time when the region is going through the most serious economic downturn in thirty years. We will not escape unscathed because of our close linkage to the region in terms of trade and investments. The impact is already being felt - in the slowing down of our economic growth, in the prices of COEs, the falling property prices and perhaps felt most directly and increasingly, the ease or difficulty of finding employment quickly or the number of job choices available. In this climate of downturn it is important to realise that however gloomy things may look at this moment, things will turn around. The jobs you may get may not be the ones you desire most. Do not despair. You can learn from whatever job you may get. At this stage it is important to seize the learning opportunities that present themselves in any job and develop the experience that will be most invaluable later on in your career.
Whether you are graduating from the engineering, dental or medical faculties, the university education you have received from the NUS during your undergraduate years is comparable with and as good as what you can get in the best universities in the world. You are well equipped, and you are well grounded. Whether you choose to pursue your professional career and pursue professional depth and excellence or to move into other areas not so directly related to professional practice in your field, you will find that your university education has provided you with the strong fundamentals to learn, and to learn quickly. One thing for certain that I can share with you is that learning new things, and learning them quickly, is something you cannot avoid, as you progress in your career in the future. In my own case, I have had to learn about taxation, health administration, central banking and macroeconomics when I moved into new areas of responsibilities within the public sector.
What a university education does not equip you equally well with, however, is the ability and skills to work with other people, and later on to be able to get other people to work for you. This is what Daniel Goleman calls EQ, or Emotional Intelligence. This you will have to learn, and how well you are able to do it will to a large extent determine how far you can go.
In this regard, I would like to end my speech today by referring to the saying that "No Man is an Island". This is nowhere more relevant than in working career. As you embark on your working career, you will find that besides professional skills and knowledge, you will also need the skills to relate to your colleagues, your superiors and your subordinates. Such skills will be critical, particularly for those of you who move into management later on. You will learn that the full power of an organisation can only be brought to bear if you are able to motivate the people in the organisation to achieve its common goal. This is true whether you are an engineer or dentist or doctor, and this ability will stand you in good stead no matter how the economic winds blow or whatever direction your future careers may take.
Finally, to each of you, whenever you pursue your career from here as a doctor, an engineer or in whatever area you may choose, you are standing on a very important threshold of your life: To go forth, build a career and a family and to make a difference to Singapore as we move into the next millennium. I wish you the very best.