Thursday, July 23, 2015

Why we must have foreign patients

Jul 22, 2015,

Doctors need more patients to hone their skills, and Singapore patients benefit when a large pool of patients fuels biomedical innovation.

Jeremy Lim 
For The Straits Times

Medical tourism has been characterised as being about economic benefits and about attracting rich foreigners. Not any more - it's not about them, it's about us.

In 2003, then Acting Health Minister Khaw Boon Wan launched SingaporeMedicine, a national initiative to establish and enhance Singapore's position as the medical hub of Asia. The ambitions were bold: one million foreign patients a year by 2012, the creation of 13,000 jobs and a contribution of $3 billion to the economy, or roughly 1 per cent of gross domestic product (GDP).

Since then, SingaporeMedicine has disappeared from policy discussions, becoming an agenda policymakers appear ready to excise from the collective memory. The SingaporeMedicine website has even been taken down, and once bold signage in at least one public hospital proclaiming "International Medical Services" has now quietly shortened to an ambiguous "IMS".

What happened?

In launching SingaporeMedicine, Mr Khaw took pains to assert that "the dream of becoming a regional medical hub and containing healthcare costs are not mutually exclusive", to allay fears that such moves would raise healthcare costs for all Singaporeans. He also pre-emptively explained using the analogy of Toyota Corollas, Lexus cars and Formula 1 racing that Singapore had to offer different types of healthcare to different target segments - Corolla-type care for the "bulk of our patients" with "maximum reliability, zero defects and lowest possible cost", Lexus-type healthcare for those who can afford and want more, and Formula-1 cases to "show the world that we can hold our own against the best in the world and win".

Fellow parliamentarians were not easily persuaded though. For example, Madam Halimah Yacob voiced concerns about distracting or diluting the public hospital core mission of serving Singaporeans. She said: "Foreign patients who come here do so because they want better and faster treatment and will have to be given priority... if we want to establish a reputation and continue attracting them. As it is, we are already suffering from a shortage of doctors, nurses and other allied professionals."

By 2009, the Health Ministry's tone had subtly shifted to arguing that SingaporeMedicine was only a secondary objective and that "our primary objective is to serve Singaporean patients, rendering good medical care at competitive prices".

Despite the public concerns, Singapore has to soldier on. Foreign patients are vital to our healthcare system's continued ability to provide quality healthcare for Singaporeans. In healthcare, high volumes deepen clinical acumen, sharpen surgical skills and enable higher quality for all patients, foreign and local.

I fear attracting foreign patients is no longer a "nice-to-have" but a "must-have".

We may not have enough patient volumes in some specialities to even maintain competence and safety. Malaysia's Institut Jantung Negara (National Heart Institute) aggressively markets itself internationally and performs almost 3,000 open-heart operations annually.

The National Heart Centre in Singapore? Fewer than 300 bypass operations in the last 12 months. What about the National University Hospital? Only 75 operations.
"We have excellent outcomes despite the small numbers," you might say. "How long more?" would be my response. Many of our heart surgeons cut their teeth in an era of plentiful patients and we continue reaping the fruits now.

Do we have enough patients today to train and build up the next generation of cardiac surgeons? Singapore has 43 cardiac surgeons island-wide: The latest numbers work out to only about a dozen operations per year per surgeon.

Is this enough?

The American Board of Thoracic Surgery stipulates that for surgeons in training, "operative experience requirements include an annual average of 125 major operations".
Let's be unequivocal - we need more patients.

The second reason we need more foreign patients is for biomedical innovation. For our biomedical research and innovation ambitions to be realised, Singapore needs medical scientists and clinicians to sub-specialise and focus on specific diseases or even sub-types of specific diseases.

And for this, we need patients, far more patients with certain selected diseases than Singapore's modest domestic population could ever provide.

When I trained in Johns Hopkins Hospital, my supervisor was Dr Patrick Walsh, a world-renowned expert in prostate cancer. He had performed personally thousands of prostate cancer operations and this intimate knowledge of the disease had enabled him to pioneer innovative surgical techniques and contribute immensely to the foundational understanding of prostate diseases. His patients come from all over the world, not just America.

This call to reignite SingaporeMedicine is not a blunderbuss, clumsy and unbridled pursuit of all manner of foreign patients. Similar to labour policy, SingaporeMedicine needs a scalpel-like precision:
  • Where are Singapore's strategic priorities in healthcare and where are the gaps? 
  • Which types of foreign patients with diseases of interest and value to Singapore do we need to help plug these gaps? 
  •  How do we encourage, for our own interests, foreign patients with these conditions to choose Singapore and help us maintain our pole position as a regional medical hub and as an increasingly successful biomedical powerhouse? Better coordination between public and private healthcare sectors? Special visa arrangements? Subsidies for expensive technologies? 
I don't have the answers, but I do know we need to have that conversation.

Forget the one about foreign patients crowding out locals; it's a red herring and hurts Singaporeans.

Let's discuss how some types of foreign patients can benefit from the excellent care Singapore is able to offer today, and help us to help ourselves. 

The writer is a partner in the Health & Life Sciences practice of Oliver Wyman, a management consulting firm.

[A well-argued position on the need for Singapore to widen our market for healthcare. Unfortunately, most people are mono-factorial decision makers who are unable to see beyond their personal interests and concerns. 

There is a quote (erroneously attributed to Edison) that 5% of people think, 10% think they think, and 85% would rather die than think.

Actual percentages aside, and whether these are immutable qualities or situation-specific qualities, in most cases, people tend to react viscerally, from the gut. Thinking takes energy and resources (time) and time-stressed people, will take shortcuts (heuristics). 

From an interview, Edison showed a sign he had printed:
"There is no expedient to which a man will not resort to avoid the real labor of thinking."
- Sir Joshua Reynolds 
“That is true. There is hardly a day that I do not discover how painfully true it is,” went on Mr. Edison. “What progress individuals could make, and what progress the world would make, if thinking were given proper consideration! It seems to me that not one man in a thousand appreciates what can be accomplished by training the mind to think.
Heuristics are expedients that most (if not all) will resort to, to avoid having to think.

The comments section of the online paper is rife with illustrations of such "expedience".

The point is, the argument is sound, it is logical, and it is even persuasive. If one is persuaded by facts and logic. 

The problem is that the vast majority of people do not use logic, are rationalising creatures, not rational creatures, and are selective audience for information that support their pre-conceived notions. 

Hence, MOH had to climb down from their well-thought out policy to frame the policy in politically digestible morsels. 

There is nothing wrong with this. Call this Behavioural Economics or Political Economics or Behavioural Politics or chopped liver. Understand that good policy must be translated into good politics or it will not fly.]

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