Wednesday, January 31, 2007

Foreign Doctors- Should we err on side of caution?

1.More foreign docs, but 'no lowering of standards'
By K. C. Vijayan Jan 29, 2007 The Straits Times

SINGAPORE needs more doctors, and the Government will let in those from the top two to five overseas medical schools from Asian countries like India.

But Health Minister Khaw Boon Wan made it clear there would be 'absolutely no'' lowering of standards in the move to get more foreign doctors to make up the numbers.

Singapore's goal is to have enough doctors in the public sector, which will translate into a ratio of one doctor per patient in public hospitals, up from the current ratio of 1:2.

Speaking on the sidelines of an Emergency Preparedness Day event at Sembawang yesterday, Mr Khaw said between 250 and 300 doctors are trained locally every year but this is not enough.

There is a need for 400 to 'even 600'' doctors per year, he said.

It was unrealistic and undesirable to produce such numbers locally, as it would mean bright students who wanted to go into areas like engineering and economics switching to medicine.

Yet, the pressure for more doctors would grow as patient numbers increased.

The Health Minister had spoken about this issue when he addressed undergraduates at the Singapore Management University on Friday.

He mentioned increasing the list of medical schools from which foreign doctors will be recognised, with a shortened probation period for such doctors, accompanied by a good supervision and assessment system.

Since 2003, the number of foreign medical schools on the list has gone up from 20 to 120.

Two years ago, there were 130 foreign doctors but last year it rose to 160. Mr Khaw said yesterday he was 'reasonably happy'' with this. 'If the ground feedback is positive, it would give us reason to open up even more,'' he added.

Even if the numbers trained locally were increased, it would still be not enough, given the country's population growth of about 40,000 babies a year, Mr Khaw said yesterday.

One answer: increase the numbers trained here but at the same time accept doctors from foreign medical schools, without lowering standards.

The Government is already looking to broaden the recruitment base to include European countries like Sweden, Germany and France. To this end, it sought doctors from the top medical schools there.

He said the experience has been that other countries will have at least one or two top medical schools, followed by a bunching of others that would be harder to differentiate.

'If you pick the top one or two, usually you will not be too far wrong,'' he noted.

But while identifying the top two in European countries was easy, the problem was different for schools in Asian countries like India and China, which the Government was looking at.

'In India, there must be hundreds of medical schools, if not thousands, and you can't say that we accept everyone and then come in and let's see if they mess themselves up,' he said, stressing that patients' health care was of foremost importance.

'So we start with the top two and very soon we'll get the top five,'' he said, adding that recognition of more medical schools can then 'progress step by step''.

He said it would take time to monitor this. If the foreign doctors did good work, that would generate confidence but if the opposite happened, then the authorities would have to 'tighten up''.

'My key point is: don't lower standards.''

A Straits Times check found, from the annual surveys in India, that it might be difficult to keep track of the top 10 medical schools there.

An Indian media report last year said that while the All India Institute of Medical Sciences topped the survey of India's top medical schools for four consecutive years, the number two spot varied. In different years, the Christian Medical College (CMC) from Vellore and the Armed Forces Medical College, Pune, took second spot.

But the CMC ranked sixth in 2005.

2.A comment from a Singaporean doctor now practising in the USA (travailingdoc)

Hi allI too read about the flood gates being opened and doctors with 5 years following their specialist's qualifications are allowed straight access into the private sector.

With the added recognition of 150 medical schools, Singapore is practically letting in sundry and all.

They have obviously forgotten about the renegrade neurosurgeon of German training who was performing unethical procedures with very questionable skills.We know of many others with very unscrupulous practices and dubious backgrounds.

These doctors are very easy to let in but difficult to eliminate, like a Trojan virus.

As a foreign graduate, to practice in the USA requires many more tough years in training programs and testy examinations before one can even begin the arduous task of getting a license.

This ease of getting into Singapore to practice Medicine will remove safeguards and any supervisory opportunities to vet these doctors before they are allowed to treat Singapore patients.

This is not to say that foreign graduates are not good doctors. On the contrary, I have met many from very diverse countries and schools with excellent clinical skills and knowledge, and impeccable morals.But they have mostly come through a very tough and stringent screening process in the USA.

I just read from the American Medical Association newsletter that J1 doctors ( those with a temporary visa to train in the US) and who must return back to their home countries on completion of their training, are now less likely to remain to apply for US PR status because the pay is better in Europe, India and Singapore.....yes Singapore was specically mentioned. So even AMA had caught on to MOH's sell in America.

The Singapore medical scene will change certainly but significantly the character of it will be drastically different from what it is now. There will be enclaves of foreign doctors from similar origins who will monopolize certain geographic localities or specialty leading to in group referrals and controlThe Singaporean doctors with their rather go it alone mentality will be pushed out of the competition.

After visiting Toronto and London after a good 2 decades I have appreciated a change of character in these two cities. I used to love these cities for their charm, history and culture. But my recent visits were marred by rude and haughty residents of foreign extraction and " FTs" who had a ubiquitous presence in the cities.

People were not as warm and hospitable, and it does not feel the same.Many visitors travelling with us shared the same sentiments.

I reckon that when I visit Singapore in year 2009, I will not be able to identify with the citizens anymore.

Looking at Lucky Plaza and its weekend residents will give an idea of what I mean..10 years down the line when all the damage had been inflicted, no decision maker will be held accountable.By then, Singaporeans had again paid the price for another disastrous half baked concoction.

ViVa Singapore

3.My comments:

Hi friends,

After Minister Khaw's pronouncement-which is not new, as he had been hinting on this for many months now, I was expecting some response from the Singapore Medical Association or senior members of the fraternity.

However, it looks like there will be none.

Hence I wrote a letter to the forum page to voice my concerns.

Bewarned that it is very subtle ( too subtle for most "ranter" I think), but the forum editors are unlikely to print "rants".

As the letter has not appeared after 2 days, I am posting it here for your perusal.

Letter to the Editor of The Straits Times

January 29, 2007

Increased supply of doctors- Let us err on side of caution

Dear Editor,

I understand Minster Khaw’s concern that in view of the impending increased demand for healthcare due to the ageing and increased population, increasing the supply of doctors would avert inflation of healthcare cost as per the classic supply/demand equilibrium that any Economics student would be familiar with.

The Minister is also aware of concerns that increasing the inflow might compromise the standards of medical practice as he had taken pains to reassure the public recently that measures would be in place to ensure that this indeed would not happen.

The good reputation of Singapore’s medical practice had taken decades to build. Patients from the region and even from very developed countries usually have nothing but accolades for us. I personally vouch for this.

I hope that the Ministry of Health would err on the side of caution and do its utmost to ensure that only the most qualified doctors are allowed in and only after close scrutiny and vetting.

Most advanced countries require tough and stringent screening process and examinations before alien doctors are allowed access to their patients. This ensures safeguards and ample supervisory opportunities for vetting out unsuitable applicants.

To allow easy entry –almost “carte blanche”, may seem like a good short-term solution but may instead turn out to be a longer term complication.

Singapore Medicine’s reputation, if damaged, may not be restored as easily.

I look forward to learning from these new colleagues.

Dr.Huang Shoou Chyuan


Aaron said...

I know nuts about the medical scene, so I would like to ask someone who's in there for an opinion to a question that I have.

Now that we are recognising more degrees and that we have a postgraduate medical school, could there be a possibility of oversupply? I remember reading some news reports some time back about how GPs are struggling to survive. Is it an issue of not enough doctors, or not enough specialists in some fields?

Anonymous said...

HI all . I'm a GP in pte practice in a HDB estate. Over the years I have witnessed how policies have affected the medical profession.

From HMOs promoted by the GOv ( resulting reduced pay for Drs ( mine went down by 30% after I am forced to accept S$10-12 NETT payment per patient that I see instead of the recommended $20-30 per patient suggested by SMA - even a barber or elctrician earns more per case), to empty clinics bec there is a glut of GPs, to ridiculous cutthroat prices offered by some Drs ( S$12 for consult and medication ) , to unfair situations like a patient being told that if u r a subsidised pt u had to wait a month for ur operation but if u a paying patient u could have it the next day bec the surgeon's list is full for subsidised cases but free for paying cases.
To suggest that there be 1 Dr to 1 patient in the hospital boggles the mind.Does that mean we r going to have more Drs than nurses in hospitals? The cost for medical treatment can only rise , not kept at bay.
If there is a lack of Drs, it must be in the hospitals and that requires a specific type of Dr.Letting in all and sundry is not going to solve the problem.Better training and incentives to stay in the hospitals is the key.So many people I know leave the system because there is no incentive to stay.they cite heavy workload , short contract based employment even for specialists- how can u blame anyone for leaving when there is no job security.
Those joining the profession now should think twice- the landscape is likely to get very ugly over the next few years.
just my 2 cents worth.

nofearSingapore said...

Aaron: Whether we have too many or too few doctors is a mystery to me!
On the one hand we have GP's struggling to make a decent living and on the other we hear that we are short of doctors?
Just look what happened to lawyers.
They say there was too many, so some quit and less attended law schools and now they say there is a dearth of lawyers!
If there is a need to address shortage ( assuming there is), changes should be incremental and not drastic like this. Evoluation, not revolution!

Anon: Thanks for visiting. We specialists in private practice really empathise with the plights of the GP's. You guys had to fight the polyclinics who opened night clinics next to your own. ( I think they have stopped now).
Doc, my 2 kids are not doing medicine and I do not want them to be just cogs in our system to be manipulated by the powers that be ( unless they have real passion for medicine).
Voice out to your GP college reps about your concerns. The authorities should know that we have real concerns and not just being territorial.


Gerald said...

From what I have been told, the dearth of doctors is in the public hospitals and polyclinics, rather than in private practice, no?

I think something is seriously wrong with the system when people who practice a noble profession discourage their kids from taking after them. My parents are both docs and they too discouraged me from doing medicine (not that I was interested or even capable enough in the first place).

travailingdoc said...

Hi all,

Sorry its me again.
Having been in the Govt service for too many years and then in private practice, one cannot but feel the "they ( the private doctors) and us ( the establishment)" is still prevailing.
It has always been the case of the MOH to have a hands off policy when dealing with the doctors in the private sector.
There is no connectedness between the MOH and the private sector, except only when it comes to matters of administration and licensing.
The welfare and concerns of the private doctors are not top on their list of priority.
Right from the Health Minister to the upper echelons of the Ministry, they are judged on their performance in the public sector.
The private sectors are competitors and if kept at bay will be more feathers in their caps if this will further enchance their status.
All their efforts had been to gartner all the health business away from the private sector to the public. This had resulted in the starving of doctors in the private sectors who are facing difficulties in maintaining sustainable and financially viable practices.Many had raised fees and even been unscrupulous , finally slaughtering the golden goose with the perennial source of Indonesians filtering to Penang and now Bangkok.The SARs really brought out this dependancy on foreign patients by the private specialists.
Ministry's projections of health needs do not take into account the doctor population in the private sector.
For obvious reason this is a blind spot in their calculations.
So, over supplied GPs in the hinterlands are not their concerns.
The doctors in private practice are to fend for themselves, come what may. If you suffer , you are just a statistic.
So, yes, they need foot-soldiers to do the scut for the hospitals , but these doctors have no pathway for progression in the pyramid of hierachy.So, there is an abundant number of senior MOs with many years in the Ministry who eventually after all the consternations and aggravations leave to set up shop in the HDB with high rentals and overheads but only allowed to charge pittance for their services.These departures are replenished from the local medical school, but now bringing in foreign doctors will be a cheaper source.

This is a calculated wastage in my opinion, like a disposable razor, you throw it away after you have no need for it anymore.
This is how I see the direction of the MOH all these years and it has not changed its spots.

I will be relocating to a warmer climate and am going through the many calls from prospective practices this period. The USA has a projected physician shortage this coming years and for my specialty, my one advertisement brought in 200 viewings and 5 definite offers.I turned a dozen away.

What I am saying is , there will be a general shortage of doctors worldwide as many in the advanced countries are shying away from medical schools.

So, doors may still remain open.


Aaron said...

Assuming what everyone said here is true, the situation sounds really bad. Does the Singapore Medical Council not know of this issue? If they do, should they help voice out the concerns, especially the plight of GPs? Then again, they might not think that it's worth the trouble to attempt an indirect slap at something that is said by the health minister.

Sigh. I have a couple of friends who are doing their houseman now. I wonder if they will eventually kick themselves for choosing this path. It would be sad if a profession that requires so much investment in terms of time and money end up earning, as in the words of the GP in private practice, less than a barber or electrician. :(

Dr Oz bloke said...

Doctors are generally very conscious of their profession's status as being "noble"

It is an obsession.

Just say straight to the face of doctors that they are earning too much money. That they charge too much. Remind them that they made an oath. Etc etc....and what will they do? They will back down.

After all we doctors entered this profession not for the money. But in really healing the sick. Seeing our patients recover well...that's priceless! Who wants money when you can have that?

So having more doctors will not raise fees. MOH thought that healthcare was different from other fields. They thought the economics was different. Well it's no different. In fact competition works even better to drive healthcare costs lower!

History has proved this. The fierce competition in the GP market has shown that GPs start undercutting each other to try to win more patients over. Prices have actually come down a lot if you consider inflation. And I'm talking about the consultation fees here.

Of course the medicine costs keep going up. Well nobody is going to begrudge Pfizer, Roche, GSK and gang from making the profits. We need them to do well to drive our economy man.

So when you see your GP next time, just find out how much that consultation fee is and how much the medicine fees are.

More foreign doctors (regardless of whether they are good or not) will be good for healthcare costs. It will lower it, or at worse keep it flat with 0% growth.

MOH has been getting feedback from doctors. And they have responded. Very smart. Knowing more allows you to formulate strategies to you advantage.

As for the "dearth" of MOs in the hospitals? Well MOH made a smart move a few years back and has been tweaking it since.

In the past, if you got traineeship in a specialty that meant your future was sealed. You train, pass the exams, then become registrar, then SR or AC and then consultancy. Isn't that right Dr Huang?

So those MOs that don't get the traineeship realise that's it for them. Might as well buy out their bonds and go out and be GPs ASAP. There is after all no hope for them anymore in being specialists.

Well MOH got smart.

So they changed the system. Now they give just about EVERY doctor a traineeship in the specialty they want. But the way it works is that there are no guarantees anymore. You can have 10 traineeships given out, they all pass their exams, they all become registrars, but later on....well some may not become consultants. So it's a very brilliant solution. Increase the competition. Give everyone hope from day one. Then at the end of the journey you sacrifice those that you cannot accomodate. Too bad chumps.

This has worked so successfully that in some specialties eg Orthopaedics the trainees get a PAY CUT (cos they effectively have to pay the hospital for training them) when they get their traineeship. MOH says ok we give X number of positions. But I have X + 10 applicants and we want to give them all a traineeship (who doesn't want more manpower right?). So they suggest to the applicants, if we take you in you gotta to PAY $Y a month. Ok with you guys? And these trainees say OK!

Amazing isn't it?

As for ENT. They have increased the number of trainees per year and the real culling stage would be at the exit exams. This was recently introduced much to the despair of my good friends. To make matters worse they shortened the training time so that this year's trainees would compete with last year's trainees.

Brilliant. Giving feedback to the authorities certainly helps them make better decisions for the public.

But rejoice cos for the people in Singapore, seeing doctors would be a cheaper, faster and more efficient experience in the future!

Dr Oz bloke said...

Hi Aaron,

just to put things in perspective...

I think the GP was referring to the consultation charge you pay to the GP being less than what you pay to a barber or electrician for his "labour"

But the GP market in Singapore has always also included profits from the dispensing (sale) of medicines.

So it's not exactly the same as equating the barber and the GP. Some hairdressers charge a couple of hundred dollars for a perm (ceramic perm anyone?)

But people are willing to pay. If you saw a GP for 40 minutes, and he spoke to you, examined you, advised you, gave you information and then gave you 1 type of medicine would you be happy to pay $40? ($30 for consultation and $10 for medicine) I doubt so.

On the other hand if you saw the doctor for 10 minutes and got a whole bag of medicine inclusive of antibiotics, and he charged $40 ($10 for consult, $30 for the 5 types of medicine). I would think that represents more "value for money".

It's just how the market is like in Singapore.

recruit ong said...

"Does the Singapore Medical Council not know of this issue? If they do, should they help voice out the concerns, especially the plight of GPs? Then again, they might not think that it's worth the trouble to attempt an indirect slap at something that is said by the health minister."

sorry for going off topic. Isn't this the same case for another top profession i.e. the lawyers? And probably the mousey accountants too. it seems that in Sg (save for a handful mavericks) the more one is educated the more he is afraid to speak out against the wrongs.

travailingdoc said...

Hi Dr oz bloke,

An interesting perspective you have presented. Thanks for updating on the present MOH policy ref traineeship.Seems like
MOH really have every doctor, by the know what.
Now I know setting up my daughter in the USA medical school was a good choice.

Anonymous said...

Hi its the Gp bloke again.

I would like to address 3 points that were raised

1.MOre competition = cheaper medical treatment
True , but only to a point.and it comes at a price.
Each practice has fixed overheads- cost of staff(the biggest chunk of your costs), rental , cost of medicines. The first can't be changed unless u want one staff to do jobs meant for 2 persons and get her to quit in the process of saving on costs.Rentals only go up. Cost of medicine can be reduced by choosing cheap generics but can only be done to a point so as not to compromise standards.And cost of medicine rises 5-10%every 2 yrs or so.
MOre clinics mean less patients per clinic.To make ends meet , the Dr has to raise prices to cover his fixed cost .So prices can increase in the face of competition when all the Drs find that with such a small pool of pts to fight over they cant meet their costs and make a living.

Just walk around ur neighbourhood and see how many clinics are empty.

2.Making less per case than a barber or electrician
I make $8-12 per (certain )HMO( health management orgn) patient.It is true.INsurance Cos farm out the contracts to Health Mannagement orgns who then farm out their contracts to GP.The Gp see the cases and bill a certain HMO at a rate fixed by the HMO- ie cost of drugs is fixed by the HMO and is pegged at the nett purchase price of the drug- the Gp gets no profits from the prescription of the drug-and from the total amount of money given to them by the insurance Co, the HMO will deduct their cost, their expected profit margin and after all is deducted, they divide up the remaining sum among the Gps.This amazingly always come out to between $8-12 per patient.THis then is the nett amount that u earn from seeing a single HMO .Other HMOs may tell u "look $10 is all we r paying u per patient take it or leave it" .God help u if the HMO case is a complicated case bec if u have to see him for 20min or 30 min there is no recourse for u to charge more. I do earn less per case than a barber or electrician. The HMOs know that there enuff hungry Drs to accept such low compensation - that is why they are able to force such low compensation with a take it or leave it attitude.If u dont take the contract, some Dr hungry enuff will take it and eat into your patient pool.U have no choice. for Dr Ozbloke comment" After all we doctors entered this profession not for the money. But in really healing the sick. Seeing our patients recover well...that's priceless! Who wants money when you can have that?"
I am sure most Drs enter the profession bec we love what we do.NOthing gives us more satisfaction to see a disease well managed , have the patient recover and the happiness on the face of ur patient.But we have families to feed , bills to pay , staff to take care ofq.You can't live on gratitude.It just doesnt pay the bills.

Strange drOzbloke thinks Gps should be pressured to give in to low remuneration when he thinks drug Cos should be allowed to charge the sky for their drugs and make billions- a tab of simvastatin be4 the patent ran out was about $ it is betw 15-50 cts.So who is the one making big bucks out of patients.Certainly not the lowly Gp- he is at the end of the long queue.

Anonymous said...

Gp Bloke again
Btw the measly $10-12 per patient that is paid to us also includes the task of doing the hundreds of data entry of patient particulars, drugs given out , Mc days every month on the web site of the HMO. I dont think u get much cheaper than that- $ 10 for consultation, examination and data entry too!

travailingdoc said...

Hey guys,

Please don't ever let Hilary Clinton or our payors in the US know that Singapore doctors charge only US $ 6 - 10 for a consultation with medications too, and in a city ranked worldwide 20th or thereabouts in cost of living.

Dr Oz bloke said...

Hi anonymous who keeps referring to me as GP bloke,

With regards to your comment "Strange drOzbloke thinks Gps should be pressured to give in to low remuneration when he thinks drug Cos should be allowed to charge the sky for their drugs and make billions-"

It's not what I think! It is what is happening!

Look at what you are doing accepting the HMOs terms? That's what's happening.

And yes we do this because we have bills to pay and mouths to feed.

I am just sharing the facts that I see and know. That's all. It's not what I think!

I hope you understand that. Sometimes the truth and reality is unpleasant and not what we want to hear. But nonetheless it is just what is happening out there.

anip garg said...

I am an Indian doctor doing MD(Paedia) currently. I want to work in Singapore. Can you please guide me about the required steps and scenario there?
Thank You

passerby said...

to dr oz bloke:

Er, I think GP bloke is identifying himself as GP bloke for his ID and not referring to you... this is consistent with the second comment on this post.

nofearSingapore said...

Hi all,
I am pasting a comment from Gerald Tan here. He originally posted to another post.

Gerald Tan said...
On the other hand, the Ministry of Health is rapidly expanding it's list of "recognised overseas medical degrees", which has now hit 120 (and counting...), and includes world reknown ones like Universita Degli Studi di Roma La Sapienza (Facolta I and II), Uppsala Universitet, Ruprecht-Karls-Universitaet Heidelberg, Erasmus Universiteit and Universita Degli Studi di Firenze.

Now I'm not saying anything about the quality of these universities, and I'm sure medicine is fairly universal throughout the world, but I just wonder if graduates from these places would be in touch with the local Singapore languages and psycho-social aspects of diseases (e.g. TCM, etc)

So perhaps it isn't wrong to restrict graduates for certain disciplines to local universities, or at least administer some form of proficiency testing or conversion course.

Having said that, I do agree that the ultimate test is seen during actual work rather than a paper qualification.

nofearSingapore said...

Hi Gerald Tan,
( see last pasted comment)
I am not as concerned about the quality of medical schools that are on the list as the fact that there will be a cultural gulf between these new doctors and our general population.
It is not wrong to assume that the top few medical schools of advanced countries ( plus India/China) would probably have adequate standards.
The opportunities for furher training for our local medical students and young doctors will be seriously curtailed.
Gerald ( from your website, you are probably a med student or a young doctor), I am sure your peers are equally worried.
Keep your fingers crossed. We know your plight.


Anonymous said...

To be honest, Sigapore registration suffers from a serious lapse, unlike in many other countries they don't have a qualifying exam. Graduating from a college does not mean anything and focussing on that is inherently wrong.

Secondly by not allowing free competition, the medical market in Singapore quite skewed and open to government control. As we have seen a number of times, getting government to micro-manage leads to unintended consequences without the self correcting mechanism of the markets.

I am not a medical person but from business. I can +vely tell you, the more you try to keep competition out, the weaker the marekt will be

Anonymous said...

Everyone has their favorite way of using the internet. Many of us search to find what we want, click in to a specific website, read what’s available and click out. That’s not necessarily a bad thing because it’s efficient. We learn to tune out things we don’t need and go straight for what’s essential.
This goal-oriented way of surfing the web is largely based on short-term results. For example, finding facts to write a blog post, doing a comparison before making a purchase and reading a news site to find out what’s happening right now.

foreigndoctorinsingapore said...


The decidedly unfriendly mood of these threads against foreign doctors like myself discourages me from seeking permanent residency. I can also feel the undercurrent of racism whenever I meet a local who knows I'm a foreign doctor. So don't be surprised if doctors like myself leave once the need to be here is gone. You only want western doctors but look down on people like me. Better re-examine your national psyche.