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READING AND WRITING CHEE YAM CHENG - WELCOMING THE MASTER BACK TO SMA NEWS
BY THE HOBBIT
After a long drought from the Master himself, am I glad to read in these two months’ SMA News that he is back. He had been quiet for quite a while, too long a while, and I had been entrusted to continue the SMA News tradition of contributing to “Personally Speaking” whilst the Master was away. But a charlatan am I. As the Master writes again, I would and am most happy to pale into the pallor of the paper I wrote on.
The new Editor of the SMA News, Cheong Pak Yean had invited me to write about what I felt about an article that was written in 1987 by the Master himself. The year I received a place in medicine in NUS, and 2 years before I actually matriculated, thanks to the profound policies of the day. I cannot resist such an invitation. To look back, and comment on what was written some 13 years ago. Reading Chee Yam Cheng is difficult and writing Chee Yam Cheng is even more difficult. The Master writes as a galloping horse, across issues and time, from a panoply of perspectives.
I detect a sense of abandon and relief in his writings today. As I have the benefit of reading the draft of his article which is published this month, I am warmed by the directness of his rhetoric. Surely, it is words of purpose from both the ground and the peak of high office. And it can only be so by someone who has been at both places.
I should do no less in being direct. Let me simply quote from the Master 13 years ago and comment on these 10 memorable quotes. They are taken from an article by Chee Yam Cheng called:”Vision 1999” published in the SMA News(letter) in 1987. 1999 came and went. Let us see where we are from a 2000 perspective.
Memorable Quotes from the Master & Response from the Hobbit
Quote
1
Master: “The acute hospitals are bearing the burden of housing
these poor folks in their last days and it is, to my mind, not cost effective
at all”.
Hobbit: Nothing much has changed. Except for a lone hospice that
had to be relocated due to the antagonism of a bunch of insensitive residents,
acute hospitals are still the place of choice for dying, with the exception
of our Malay brothers, who still know the value of a home to the dying.
Quote
2
Master: “Some residual animosity on the part of the outgoing doctor
on the doctors left behind in service makes trust and cooperation very
difficult”.
Hobbit: I don’t know about the animosity. But certainly, the chasm
between the private and public sectors remain just as wide for some specialties.
Quote
3
Master: “The specialist register would be a reality and so too would
continuing medical education be part of every doctor’s life”.
Hobbit: The specialist register is indeed a reality, but to what extent
do doctors participate regularly and adequately in CME? Some estimates
put this figure as low as 5% or as high as 20% for those obtaining the
25 points to be given a CME certificate. There are many reasons for these
statistics. Certainly more work needs to be done on CME.
Quote
4
Master: “Those specialists within government institutions should strive
to attain a level of knowledge and skill that is the best available world-wide
before embarking into private practice. There should be no obstacle to
going into private practice. The only self-made obstacle is for the intending
doctor to question and examine himself – is he of an acceptable standard,
can he last the 10 – 15 years in private practice doing good work before
he calls it a day…..remember then that the public cannot be fooled anymore,
not that they were fooled before. But they will be better educated and
more aware of improperly trained doctors…”
Hobbit: 2 pluses and a minus here. Certainly, there is no obstacle
about going into private practice now. The public are also certainly more
aware and less tolerant of medical errors, as given by the recent publicity
over this. The minus is the number of 10 – 15 years of private practice.
Specialists are finding it less rewarding than ever to stay in the public
sector. A 10 – 15 year period implies that specialists go into private
practice when they are between 45 – 50 years old. Nowadays, most specialists
go into private practice in their late thirties or early forties. They
will remain in private practice for about 20 years. In fact, talk to a
young registrar or senior registrar and you will find that none of these
colleagues of ours have any plans about retiring in the public sector.
Could public service be made more attractive and a lifelong service in
public sector a desirable career option?
Quote
5
Master: “Our local graduates deserve more than what they are getting
today: I believe we are not equipping them to face the harsh realities
of life… Worse still if they feel that long hours, hard work and years
of experience are unnecessary relics of the past”.
Hobbit: I was a houseman not so long ago. We had no call allowance,
we gave IVs, did 120 second hypocounts and even injected potassium into
saline bottles. Now I understand that housemen don’t do such menial tasks
anymore. Good for them. Thanks to some of our colleagues in SMA and MOH,
they even get a $70 call allowance! But has this translated into better
care for patients? I hear of housemen quitting housemanship recently because
they cannot take the hardship (no IVs and no hypocounts!). This was simply
quite incredible to us ‘older’ folks. Maybe its because people are getting
generally softer, or is it because L$13,000 university fees attract a
different breed of people than from my time (they can afford to pay up
hefty bonds), I don’t know.
Quote
6
Master: “How can we remunerate doctors for humanistic qualities that
are difficult to quantify?….Society cannot keep rewarding richly only
services that can be quantified easily”.
Hobbit: Nothing has changed. We still reward those who contribute
to the bottom line. I always wondered as a student how much of my tuition
fees went to people who really taught me medicine, like Robert Pho, Ng
Han Seong, William Chew, Tan Cheng Lim, Low Cheng Hock, my registrars
like Wee Siew Bock, Agasthian, Teo Sek Khee, Low Chee Kwang and the like
and how much of the fees went to paying some glory/money seeking academic
who never gave me a tutorial or even returned my greeting in the corridors?
For all the talk about elderly, we still do not have a geriatrics department
in our tertiary hospitals and our only medical school does not even have
a single geriatrician under its employ on a full-time basis. I understand
that William Chew, Ng Han Seong and company only get a few hundred bucks
a month to teach medical students and frankly, they did more than they
were paid for. We have long talked about recognising good teachers, acknowledging
role models for our young doctors and developing geriatrics. But believe
me, where decisions are made, the bottom-line of a balance sheet seems
paramount. And with DRG-based payment, Chee Yam Cheng’s fear of society
rewarding only quantifiable services is more real than ever. The talk
is never walked. Talk is cheap and socially correct talk is cheaper.
Quote
7
Master: “A GP is not a dropout of the system meant to train specialists…
there should be… a proper register for general practitioners”; “If he
opts to be a family physician, that should also be recognised as a specialist
post”.
Hobbit: Again, a complete failure after 12 long years. GP/Family Medicine
as a specialty is as distant as Siberia. We talk of putting the family
doctor as the centre of healthcare, but let us look at the stark facts:
Hong Kong, Australia etc recognises Family Medicine as a specialty, we
don’t. After 5 – 6 years of having M.Med (Family Medicine) exams in Singapore,
we still don’t have a Consultant-Grade Family Medicine doctor in the polyclinics.
It must be the only MMed degree in Singapore without a consultant. There
is still no department of Family Medicine, although half of each cohort
of undergraduates ends up as GPs. In the meantime, we have bought a Gamma
Knife, some Excimer lasers, expanded our Singapore National Eye Centre;
we are in the midst of building a new National Heart Centre and last I
heard, thinking of buying a PET scan. The MMed (Family Medicine) is possibly
the most economically irrelevant NUS MMed degree today. It is irrelevant
because the government wants Family Medicine to be “affordable”. But what
can Family Medicine in Singapore afford today, I ask?
Quote
8
Master: “Who should government subsidise and who should government
not subsidise?”
Hobbit: The multi-million dollar question is still unanswered after
13 years. It is a question that no one with only a fleeting interest in
healthcare would want to answer. And the sad point is, it will be so if
health is in fact run by fleeting stakeholders. Why risk unpopularity
during my brief watch in health, the street-wise may ask? And so, in the
absence of a means test, or rather the absence of a will to have a means
test, our frontline doctors and nurses in the public health care system
continue to slog through armies of patients in the polyclinics, many who
should not be there, subsidised specialist outpatient clinics, and subsidised
wards. The flesh is unwilling, the will is also weak.
Quote
9
Master: “... come 1999, the Singapore doctor would have benefited
from a planned, rational schedule of training and apprenticeship – from
housemanship days till he becomes a specialist on the specialist register”.
Hobbit: Certainly, we have more exams to take, but do we have a
better training programme? How could it be, when we leave it to altruism
to keep good senior staff? People make the difference. When the last of
the great teachers retire, what good is a programme on a piece of paper?
The last of the Mohicans, like the Master himself, is already in their
fifties. In 10 years time, there will be no such icons left. Because we
reward by the bottom-line, we will perish likewise, by the bottom-line.
How can basic trainees have good training, when we continually expand
our services but depend on the same number of 1200 bonded Housemen and
Medical Officers? This number has not changed for the last 10 years or
more. The population has grown. New and bigger hospitals have been built
and new subspecialties created. Surely the average trainee will now have
less time for training and research, since the number of junior medical
staff has not changed in the past 10 years and this same number must provide
a greater volume of service. Maybe that is why the few Housemen quit in
the last few years. You don’t need a Master in Public Administration to
figure this out.
Quote
10
The Master’s closing remarks then were “That is the challenge
ahead. We have 12 years to achieve. I am optimistic we can”.
Hobbit: Where are we and when are we going? Vision 99 was written
when Chee Yam Cheng was in his late thirties. It is now 2000. I am afraid
he was more wrong than right. I do not share the same optimism about the
next 13 years that he had 13 years ago about the next 12. Perhaps I know
too much. Perhaps I am a product of the cynical late nineties, when I
saw before my eyes the unravelling of the medical profession in positions
of influence and power. Vision 99 remains just a vision even in 2000.