Singapore: Pragmatism, Noah’s Ark and the Relentless Search for Best Practices

From Tokyo, I flew on to Singapore, where I had the honor of being visiting professor at the massive (1500-bed) Singapore General Hospital, a guest of Dr. Kheng Hock Lee. Kheng Hock, one of Singapore’s leading family physicians, has been charged with developing Singapore’s hospitalist program.

Having last been to Singapore 20 years ago, many people gave me the clichéd tourist warning that “you won’t recognize the place.” This, it turns out, is an understatement. The city is sprawling and dense, but its growth has been both planned and generally sensible. In fact, in its devotion to planning, Singapore reminded me of Las Vegas, minus the jewelry, the porn, and the absurdity. Everything is just so, driven by a government that – though a mildly authoritarian, one-party system – seems to be remarkably well trusted by the governed. What a refreshing change from Tea Parties and “Keep the government away from my Medicare!”

Yes, the well-known tales of caning for certain crimes are true, as is the proscription on public gum chewing. On the other hand, locals told me, time and again, that “the government is really smart,” “they manage the country like a well-run business,” and “they are so pragmatic!” Have the ministers brainwashed the populace into euphoria? I don’t think so. Shockingly, I think the explanation is (are you sitting down?) government competence.

Being a Singapore bureaucrat is actually a respected position: many senior officials have advanced degrees from top U.S. and U.K. institutions, and the health minister is said to be an avid reader of Harvard business guru Michael Porter. And government officials are well paid – many times more than their U.S. counterparts. “This takes away their incentive to steal,” one Singaporean told me, “ and ensures that the best people go into government.” What a concept.

I was particularly struck by two examples of this pragmatism. The first was what I’ll call the Noah’s Ark approach; the second, the perpetual search for best practices.

In this tiny city-state of 5 million inhabitants, you’d think there would only be one transport system, one public utility, and one major hospital system. And, if they set out to build Asia’s biggest and best casino, they’d build one doozy. Right?

Wrong. In Singapore, the government frets about the inevitable calcification of monopolies, and tries to relentlessly nurture innovation and continuous improvement. To get there, they have a core belief that competition is critical, and so they engineer it into all they do. The result: there are two competing transport systems, energy systems, and hospital systems.

And that spectacular, multi-billion dollar casino complex they’re building on Marina Bay, across from the sparkling new skyscrapers (in slightly tongue-in-cheek Singaporean Catch-22-speak, it is known as an “Integrated Resort”)? You guessed it: they’re also building a second one, on Sentosa Island, just a couple of miles away.

Singapore is a relatively “new” country – it became independent during the LBJ Administration. As a tiny island sandwiched between the southern end of Malaysia and the Indonesian archipelago, it is ethnically diverse – lots of Chinese and some Muslims and Catholics, with oodles of ex-pats from everywhere. It has no natural resources. Given this deck of cards, Singapore’s founding fathers appreciated that its survival depended on economic advancement and the creation of an enviable quality of life for the people. This need, coupled with the government’s pragmatic mindset, led to a perpetual search for best practices.

On the day I arrived in Singapore, two delegations from SGH had just returned from visits to U.S. hospitals that had implemented the clinical IT system they were thinking of buying. While we Americans might fly a couple of hours to kick the tires on a new computer system, Singaporeans think nothing of flying 14 hours to do so.

In fact, that’s how I first met Kheng Hock, who emailed me about 3 years ago when SGH began considering the value of hospitalists. I was amazed – before he contacted me, he and his colleagues had read everything I had written (until then, only my mother had done that) and had already visited a hospitalist program in Canada, because they heard that the Canadian solution – building a hospitalist model using mostly family physicians – was closest to their own.

What is so impressive about their site visits – other than the fact that they are delightful people who soak up knowledge – is that they are agnostic about where to go to learn. I think some of this owes to their location and history – the country is on the Equator, it’s a former British colony, the people have strong ties to America, there is a large Chinese population: a set of circumstances that have made Singaporeans remarkably open to looking anywhere for good ideas. How to set up a strong primary care infrastructure? Road trip to England. Multispecialty groups? The Mayo Clinic. Hospitalists? UCSF. If only we were that open to learning from others.

And, like any good business, they are willing re-boot when they feel they’ve made the wrong choice. As a former British colony, their medical training model was patterned after the U.K.’s system of house doctors and registrars, a system that, in my judgment, does not work as well as U.S.-style residency and fellowship training. (There is no core curriculum for the residents, who wander from one clinical apprenticeship to another, with a relatively high service-to-education ratio; there is no residency program accreditor to set and enforce standards; and, believe it or not, there are no real residency directors – someone to organize the residents’ experience and advocate for them.)

Singapore’s solution: to switch over to U.S.-style residency training. They have even gone so far as to bring in the ACGME – the U.S. residency accreditor – to help guide them through this transition. During my visit, we had some preliminary discussions about a possible role for the American Board of Internal Medicine (which I serve on), since they also feel the U.S. system of board certification is better than their current one. It wouldn’t surprise me to see Singapore docs participating in ABIM-style Maintenance of Certification programs within 5-7 years.

You’ll be comforted to know that they don’t just adopt American healthcare models willy-nilly. Residency training, fine. Board certification, terrific. Hospitalists, lovely. Our American fee-for-service system, or our employer-based private insurance system, or our inability to say ‘no’ to any new technology, or our malpractice system… no way.

Perhaps the most impressive example of their willingness to learn from others is the new Duke-National University of Singapore (NUS) Graduate Medical School. Their traditional medical school system is also modeled on England’s, a six-year program that enrolls kids straight out of high school, with a strong emphasis on clinical skill-building but a less scientific base than one finds in the best schools in the U.S. And then there was the Noah’s Ark issue: before the Duke program, Singapore had only one medical school, and it was not known for innovation.

By now, you’ll find the course they took predictable: they launched a new medical school in partnership with Duke University. To their great credit, they plucked Dr. Bob Kamei, the long-time pediatrics residency director at UCSF and an old friend, to be their Dean for Education. I had the chance to spend a day with Bob at Duke-NUS, and it was remarkable.

The school recently moved into a glistening new, state-of-the-art education and research building. They have chosen to focus on a limited number of research areas: areas in which Singapore has a selected advantage or interest (such as emerging infections and certain high prevalence cancers). For the educational component, rather than adopting their traditional right-out-of-high-school model, they went with the U.S. practice of enrolling university graduates for a four-year med school experience. They have managed to recruit superb students from Singapore (mostly folks who didn’t know they wanted to go to med school when they entered college) and elsewhere. They offer heavily subsidized tuition in exchange for a commitment by the Duke-NUS graduates to remain in Singapore for several years after graduation.

Unlike Cornell’s med school in Qatar, which relies to a considerable degree on Manhattan-based professors parachuting in for visiting professor gigs, Kamei chose to build a larger Singapore-based faculty – recruiting some terrific folks from the U.S. and elsewhere for multi-year stints, joined by a strong cadre of Singaporean natives. Most of the students’ lectures are given by Duke faculty in North Carolina (the students watch them on streaming video), but the bulk of the education involves small-group “team-based learning,” in which students, supported by faculty facilitators and a robust IT infrastructure (including world class simulation) work through interesting sets of clinical and scientific problems. It is highly innovative – and, in typical Singaporean style – marries the local needs and culture of Singapore with the best of breed from the rest of the world.

It’s true, Singapore is not a Jacksonian democracy, and there are faint hints of repression in the air (I noticed that some folks seemed a bit cautious before criticizing the government or saying anything that might be construed as disparaging any ethnic group; the latter is illegal). But after watching the U.S. healthcare debate deteriorate into Death Panels and gun-slinging Town Halls, one has to wonder whether ours is truly the better system. As Bob Kamei told me, “Yes, you give up the freedom to carry guns here. But, in exchange you gain the freedom of being able to walk down the street of a large city at night with absolutely no fear of violent crime.”

There’s something to be said for that.