Doctors leaving the public sector for private practice


  • More senior docs quit public sector  (09 Mar 04)
  • Public sector told to shed up to 8,100 jobs   (02 Sep 04)
  • More specialists leaving public sector   (04 Sep 04)
  • Minister 'relaxed' about doc's exodus   (05 Sep 04)
  • Stop losing docs to private practice, says Khaw   (25 Feb 05)
  • Loss of top doctors troubles minister  (26 Feb 05)
  • Health Ministry may allow senior doctors to run private practice in public hospitals   (25 Feb 05)
  • Why some senior doctors quit public hospitals   (26 Feb 05)
  • Hello, is the doctor in?  (2 Mar 05)
  • Number of public sector doctors leaving goes down  (14 Sep 06)
  • Keeping in step with private sector  (14 Mar 07)
  • Concern over senior docs going into private practice  (12-14 Jul 07)
  • Private practitioners have made outstanding contributions too  (16 Jul 07)

  • 'National service' for private doctors  (12 Jun 04)

    Questions for discussion Return to Main Medical Index

  • More senior docs quit public sector

       THE exodus of doctors from the public to the private sector seems to be picking up this year, after two years of relatively little movement.

      And this time, an unusual number of senior people are leaving. There were 43 specialists among the 177 doctors who quit last year in spite of Sars causing massive disruption in the health-care system for almost half a year. Twenty-one were from the SingHealth cluster, which in just two months this year has already seen 11 more go. The other major player, the National Healthcare Group, admitted that it, too, has lost specialists this year, but would only say they represented 1 per cent of all its doctors. Both groups said that the departures are inevitable since the public sector's role has traditionally been to train young doctors.

      Still, several recent resignations have raised eyebrows because of the calibre of the people involved. They include at least four heads of department. Last month, Singapore General Hospital lost its top colorectal surgeon, Dr Francis Seow-Choen, and ear, nose and throat specialist Goh Yau Hong. Associate Professor Patrick Tan, SGH's head of haematology, will leave shortly. He is best known for pioneering efforts in using cord blood to cure blood and bone marrow cancers. The National University Hospital has seen six obstetricians and gynaecologists go since last December. They include a former department head, Professor Ng Soon Chye, and fertility expert Jothi Kumar. Its chief of hand and reconstructive microsurgery, Associate Professor Lim Beng Hai, is now serving his notice. The National Cancer Centre has lost radiation oncologist Lee Kim Shang to the Parkway Group. Changi General Hospital will be saying farewell soon to its head of surgery, Dr Michael Ho. He is going into private practice as he wants to spend more time with his four young children.

      Most of the doctors The Straits Times spoke to cited more time for themselves and their families, plus the better service they believe they can give patients in the private sector, as the main reasons for leaving. Ear, nose and throat specialist Dr Goh said he could see as many as 100 patients a day at SGH, reducing the time he would have liked to have for treating patients. His former SGH colleague, Dr Seow-Choen, who was with the hospital for 22 years and is known internationally, said he wanted to leave while he was still at his peak. 'My leaving will also make way for younger doctors to move up,' he said.

      However, there are not as many of these left from the 100 or so specialist trainee posts available each year. Last year, 45 from this pool resigned; the year before that, 35 did. Before 2000, fewer than 20 would leave each year. The last major exodus of all doctors was in 2000 when 243 left. In the two years after that, their numbers dropped drastically to 124 and 135, as the economy slumped. As a result, the number of doctors in the public sector crossed the 3,000 mark last year, surpassing that in private practice for the first time in a decade.

    The Straits Times
    09 Mar 2004
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    Public sector told to shed up to 8,100 jobs

      OVER the next three years, Government agencies must cut their staff by 3 per cent annually - or cough up $10,000 a year for each extra officer. The measure, just announced by the Finance Ministry, applies to a pool of about 90,000 public sector officers. It excludes teachers and the Defence Ministry.

      Meant to help ministries and statutory boards use their manpower better, the new framework took effect from July 8 and may lead to the vanishing of some 8,100 jobs, the Business Times (BT) reported yesterday.

      Though not an 'exercise in blindly reducing headcount', the ministry told BT, it will require agencies that do not cut back sufficiently to pay a 'headcount surcharge' of $10,000 a year for each officer above the 3-per-cent limit. According to the Finance Ministry, the surcharge would add up to less than 2 per cent of ministries' current expenditure on manpower, even if staff numbers are unchanged after three years. Also, the 3-per-cent figure 'is less than the annual average attrition rate - resignations, retirements and other separations - of ministries and statutory boards,' it said.

      In his Budget Debate roundup speech in March, then Deputy Prime Minister Lee Hsien Loong had said the government was considering a 'headcount tax', to counteract 'some slackening' since a headcount freeze ended in 1996. Under the new plan, 'ministry groups - ministry headquarters, their departments and statutory boards assessed as a group' should seek to cut total headcount by 3 per cent each year in Fiscal Years 2004, 2005 and 2006.

    Abridged version
    The Straits Times
    02 Sep 2004
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    More specialists leaving public sector

      THE public health sector is possibly seeing the biggest exodus of specialists in a decade, including six heads of department among the more than 50 who have left for private practice this year. The average number of specialists leaving the public sector has been just over 40 a year since 1995.

      In the past decade, the only time when more than 50 consultants quit in a year was in 2000, when 61 specialists moved to the private sector. That year, a record 243 doctors - or more than 20 a month - left the public service. The rationale then was that the Asian economic meltdown that began in mid-1997 had discouraged many doctors from venturing out in 1998 and 1999.

      Last year, 177 doctors - 43 of them specialists - quit, which works out to nearly 15 a month. This was despite the Sars outbreak making conditions in private practice more difficult, because many foreign patients were put off coming here for treatment. The number of doctors leaving this year looks set to exceed that, as 131 doctors have left in just the first six months. This is an average of nearly 22 a month.

      It was paperwork that drove Dr Tan Chee Eng out of the Singapore General Hospital (SGH). Dr Tan, the former head of endocrinology, said he was spending half his time on administrative work, and the needs of running a department curtailed both his patient care and research. 'That took away my reason for staying in the public sector,' he said. At 44, he was a senior consultant and both his salary and title had reached a peak. 'Salary was not the major factor. If it was, I would have left long ago,' he said. Since he set up his clinic at Gleneagles Medical Centre last month, he not only sees more patients but is able to spend more time with them. He reserves Wednesday afternoons for research and retains his position as adjunct senior research fellow at the Centre for Molecular Epidemiology.

      Dr Khoo Kei Siong, the National Cancer Centre's former head of medical oncology, gave the same reason for leaving - too much administrative work. 'When I cannot spend enough time with patients, I find the work less satisfying.' He used to see 40 to 50 patients a day. Diagnosis and treatment can be quite fast, he said, but cancer is a major disease and he wanted to spend more time explaining to patients what they can expect and the alternative treatments available. Private patients can also afford more expensive medicine that has been shown to have better results, he said. 'We are less likely to see the treatment fail. It is always more satisfying when patients do well,' he said.

      The push to make Singapore a regional medical hub makes the transition easier. Foreigners now account for almost half the patients he sees.

      Other prominent doctors who have gone into private practice this year include SGH's former head of haematology, Dr Patrick Tan; and its former head of colorectal surgery, Dr Francis Seow-Choen. Changi General Hospital lost its head of surgery, Dr Michael Ho, while the National University Hospital (NUH) lost its chief of hand and reconstructive microsurgery, Dr Lim Beng Hai. Next year, NUH may lose its head of medical oncology, Dr Lim Hong Liang. He has told the hospital of his intentions, but has not tendered his resignation yet.

    The Straits Times
    04 Sept 2004
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    Minister 'relaxed' about doc's exodus

      THE exodus of more than 50 specialists from the public health sector to private practice this year is a natural sign of an improving economy, said Health Minister Khaw Boon Wan.

      He said he was 'relaxed' about it, although a Straits Times report yesterday said the number of specialists leaving the public sector this year might be the biggest in a decade. The average number of specialists leaving the public sector has been just over 40 a year since 1995.

      But Mr Khaw said that a worse scenario would have been if only 'five left, and I've got no one left' holding the fort. 'We should look at the total population of specialists,' he said. 'I'm happy with the current arrangement. We're a public institution; we will always have to teach and train. In the meantime, we will continue to open up and let foreign-trained specialists come and join us.'

    The Straits Times
    05 Sept 2004
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    Stop losing docs to private practice, says Khaw

      Health Minister Khaw Boon Wan wants to put a stop to the exodus of doctors to the private sector that has depleted public hospitals of 'good doctors and dedicated teachers'.

      Hit by a record 247 doctors leaving public institutions last year, Mr Khaw slammed his ministry's attitude that 'loss of doctors to the private sector is not a loss, for as long as they continue their practice in Singapore'.

      This is wrong, he said on Friday night.

      When a senior doctor leaves for private practice, the country suffers a big loss.

      This, he said, is because younger doctors lose the opportunity of being taught and mentored by him; his skill and experience is lost to subsidised patients who can't afford private rates; and he can no longer help the nation advance medically.

      He suggested easing their administrative load, giving them more say in the running of the hospital and even allowing them to see private patients in public hospitals as ways to keep them.

      Speaking at the launch of a book to commemorate 100 years of medical education in Singapore at the College of Medicine Building, Mr Khaw spoke of the need to 'go all out to retain doctors with sound institutional values'.

    The Straits Times
    25 Feb 2005
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    Loss of top doctors troubles minister
    Straits Times

       A record 247 doctors quit public hospitals for private practice last year, and Health Minister Khaw Boon Wan is not at all happy. He wants experienced doctors to stay. He wants his ministry to stop thinking it is all right if they go so long as they remain in Singapore. And he wants to fix the problems that make senior doctors so fed up they quit after decades in public hospitals.

      It is a big loss each time a senior doctor goes, he said yesterday. Poorer patients lose, because they cannot afford private treatment. Young doctors lose, because they miss out on the teaching and mentoring of senior doctors who act as role models. Singapore loses too, as its target to be the region's medical hub and ' Mayo Clinic of the East but without the costly price tag' depends on having strong medical institutions with top talent. Faced with increasing competition from the region, Singapore's aspirations depend on its ability to produce top clinicians and retain the best.

      Mr Khaw was speaking at the launch of a book to mark 100 years of medical education in Singapore, at the College of Medicine Building. The event was attended by more than 100 members of the medical fraternity. Mr Khaw said he was troubled when he returned to the Health Ministry in 2003 as minister to find that so many senior doctors he had known from his days as a hospital administrator had quit. He named surgeons Abu Rauff and Walter Tan, children's cancer specialist June Lou, obstetricians and gynaecologists Ng Soon Chye and Noel Leong, and orthopaedic surgeon S. Krishnamoorthy. 'These are doctors who have devoted many years of their lives to public service; good doctors and dedicated teachers,' he said. 'I had expected them to retire in the public sector. Why are they now in private practice?'

      He disagreed with ministry officials who felt 'loss of doctors to the private sector is not a loss, as long as they continue to practise in Singapore'. The ministry's view has been that the departure of 100 to 150 doctors a year is only to be expected, and it is the way the public sector trains doctors for the private sector. But Mr Khaw is taking a different tack, after speaking to doctors - young and old, those still in public service and those who have quit - to ask what makes them go, and what would make them stay.

      He is convinced it is not about money, and senior doctors who resigned told The Straits Times he is right. Mr Khaw found some doctors fed up with administrative duties that have piled up. He wants to cut the 'unproductive paperwork'. Some seek better recognition, others want more say in how hospitals are run, or are keen to do research and pioneering work. All this can and should be looked into, he said.

      Dr Leong, a senior specialist who quit in 2001, told The Straits Times it is frustrating when hospital administrators call the shots. 'Senior doctors want a say about the direction the hospital is going. But when there are differences, the administrator's view prevails.' Younger people in top hospital positions did not always appreciate senior doctors' views either. 'We are passe, and they are glad to get rid of the fossils,' said Dr Lou, who went private last year.

      Change is likely, as Mr Khaw did not like what younger doctors told him either. Many aim to become specialists, build a reputation, and then join the private sector. Younger specialists who had already left told him they had seen how senior doctors were treated and decided to go sooner. Mr Khaw said it was necessary to 'reset the career progression of our young doctors' so they will stay.

      He tossed up the idea of letting senior doctors who want the independence of private practice to run their own clinics in public hospitals, seeing their own patients, in return for continuing to coach young doctors and students. He hopes to retain the top 20 per cent to 25 per cent of each year's batch of doctors in public hospitals until retirement.

    The Straits Times
    25 Feb 2005

    Doc brain drain not OK

      THERE are some in his ministry who think that the migration of doctors from the public to the private sector is "not a loss", as long as they continue to practise here.

      But Health Minister Khaw Boon Wan disagrees.

      With a record exit of 247 doctors 87 of them specialists from public healthcare last year, those who lose out are not just subsidised patients, but also young doctors who would miss out on the teaching and mentoring of senior doctors, said Mr Khaw. The loss is also Singapore's. Teaching hospitals or academic medical centres not solo practice is where progress is more likely to be made in acquiring "new capabilities" for competing globally. So, to ensure a "critical mass" of talent in the public sector, Mr Khaw is targetting is to retain the top 20 to 25 per cent of each cohort of 300 doctors in the sector until they retire. At this "steady rate", they would eventually form a pool of 3,000 doctors. But achieving this will be a challenge, given the many reasons doctors leave the public sector for the private. Said a troubled Mr Khaw: "Several doctors whom I worked with during my previous term (at the Health Ministry) are now in private practice. These are doctors who have devoted many years of their lives to public service and are good teachers and dedicated teachers."

      Speaking at Friday's launch of To Sail Uncharted Seas, a book commemorating the centenary of medical education here, Mr Khaw urged public healthcare institutions to look into staunching the drain. "It's not just about money," he conceded. For example, Mr Khaw noted that "some doctors are fed up with administrative duties" when they just want to focus on their clinical and teaching duties.

      Indeed, Dr Tan Chee Eng, the former head of endocrinology at Singapore General Hospital (SGH), told Today he left the hospital last year because he was "overly-burdened" with administrative work. He had to handle the bulk of the department's paperwork and meetings, on top of his clinical work, teaching and research. The busy hospital environment also took its toll on 45-year-old gastroenterologist Dr Yap Chin Kong after 20 years in public service. The senior consultant started suffering stress-related stomach pains. "Maybe age was catching up, but I felt I was not able to take that pace anymore," he told Today. He now sees six patients a day minimum in private practice, down from 50 a day previously.

      Some doctors felt that senior doctors moving out of the public sector could be good for junior doctors, who could take on more responsibilities and promotions. Said Mr Khaw: "Many young consultants who have left told me they would actually like to remain in public hospitals, but felt uncertain about their continuing employment." He asked hospitals to lay down a viable career path for senior doctors, who are often put on contractual terms after their retirement age. As for doctors who find "the independence of private practice and the freedom of being self-employed hard to resist", they could be offered to the option to stay on while running their own clinics. They could get admission rights for their patients in the private wards of public hospitals, in return for which, they could teach and coach young doctors. The scheme could be restricted to doctors who have served 25 to 30 years in public hospitals, Dr Khaw added. He also announced that the second medical school at the SGH campus would have an initial intake of 25 in 2007, set to double in subsequent years.

    26 Feb 2006

    Crucial to keep senior public docs rooted
    (Speech by Health Minister Khaw Boon Wan)

      When doctors move out of the public sector, it is a loss to the country, argued Health Minister Khaw Boon Wan yesterday at a celebration to mark the centenary of medical education in Singapore

      The commemorative book mentions the many excellent contributors to our health-care sector: Professors Ransome, Sheares, Shanmugaratnam, Seah Cheng Siang, Wong Hock Boon, S. S. Ratnam and several others.

      Singapore is blessed to have these excellent doctors who are not only great clinicians, but inspiring teachers and mentors to their disciples. They could have made more money in the private sector servicing the rich, and could have had more time for themselves and their families. But they chose to be with their students and their patients, many of whom are from the lower income group. These are dedicated individuals who understood the meaning of public service. They found satisfaction in seeing a needy patient treated, and a young doctor properly tutored, beyond what material compensation could provide.

    Regional medical hub at risk

      THROUGH their dedication, we have produced several generations of top clinicians who keep SingaporeMedicine head and shoulders above our neighbours. Until 15 years ago, our status as a regional medical hub was unchallenged.

      In recent years, however, our neighbours have closed the gap. Moreover, they enjoy a cost advantage. While we still enjoy a premium, it is not unlimited. If we are not careful, we will lose the regional medical hub status.

      This is not unlike the competition between PSA Corp and Pelepas, or between Singapore Airlines (SIA) and the low-cost carriers. PSA and SIA have shown we can face the competition and still hold our ground. But we must be prepared to restructure and forge new strategies. In the competition to be the regional medical hub, the key is our ability to produce clinicians head and shoulders above our competitors.

    Loss of teachers

      FOR this reason, when I returned to the Health Ministry in 2003, I was a bit troubled by what I saw. Several doctors with whom I had worked during my previous term were now in private practice: Abu Rauff, Walter Tan, June Lou, Ng Soon Chye, Krishnamoorthy, Noel Leong. These are doctors who have devoted many years of their lives to public service; good doctors and dedicated teachers. I had expected them to retire in the public sector. Why are they now in private practice?

      Within the ministry, there seems to be the view that the 'loss of doctors to the private sector is not a loss, as long as they continue to practise in Singapore'. I do not agree. The loss of good teachers and clinicians from the public sector is a big loss to Singapore.

      First, it is a big loss for our subsidised patients who cannot afford treatment in the private hospitals.

      Second, it is a big loss for our young doctors who will miss out on the teaching and mentoring by these senior teachers. Forging the right values for public service is critical for our medical service to remain what it is - highly competent and at the cutting edge.

      After all, what is the difference to Singapore between the likes of Feng Pao Hsii and Foong Weng Cheong doing private practice in private hospitals or in public hospitals? To their patients, it may be trivial.

      But to the young doctors and junior consultants, it is a big difference: the interactions with their teachers and trainers, in the wards, in the doctors' lounge, in the corridor, are an inspiration and a daily reminder of what public medical service is all about. This is how good institutional values are forged and reinforced.

      All strong institutions have a critical mass of role models, who coach and mentor the young. They provide the deep roots from which we get the new shoots, branches, flowers and fruit. After a century of medical education, we have sunk some roots, but not quite deep enough.

      Look at the Mayo Clinic, it has deep roots and strong branches. You can cut off several branches and the institution will continue to flourish. Against tsunamis, it will not be uprooted. Can our public medical service survive a tsunami?

      Third, it is a big loss even for SingaporeMedicine as private practice here tends to be solo or, at most, limited groups. While there are notable exceptions, this model offers few opportunities for medical advancement.

      SingaporeMedicine must have deep roots to compete globally. Our regional medical hub can no longer just compete with our neighbours. India has emerged as a competitor and soon it will be China. They have the talent, the ambition and the large base of clinical material for their doctors to sharpen their skills.

      Competing globally requires us to continually acquire new capabilities. This means sub-specialisation, research and perfecting new skills. Progress is more likely to be made in teaching hospitals and academic medical centres, with departmental structure and rigorous peer review processes.

      As the region and the world raise their medical standards, we must work even harder to remain leader. Solo practice with its attendant limitations will not give us this edge.

    A perennial problem

      TO BE sure, retention of medical talent is a perennial issue. I have spent many years in the health sector. During this period, public hospitals have always had to grapple with the problem of retaining their share of talent. Some years, like in the 1980s, we bled badly; in recent years, we are coping better. There are now more specialists in the public sector than in the private sector.

      But talent retention is a continual challenge. It is not just about money. Medical service in the public sector is a noble career choice, a calling. While we should pay our doctors well, we must not chase the market. Whatever we decide to pay in the public sector sets the floor for the industry. It is fruitless to think we can close the gap.

      The right approach is to concentrate on the basics: focus on medical service as a noble profession, build strong institutions and go all out to retain doctors with sound institutional values. The more we have such doctors, the stronger the institutional culture. The more such role models, the greater will be their influence on young doctors. As they interact with the likes of Balachandran, Tan Cheng Lim and K. T. Foo, correct values will be reinforced and a new generation nurtured.

    Deepening our roots

      I ASKED some young doctors how they saw their career progression. Some were candid: train hard, become a specialist, acquire sub-specialty skills, build reputation, then leave for the private sector in their prime. If this is representative of their generation, then I worry both for the public medical service as well as for SingaporeMedicine.

      I worry because, while we take in 300 doctors every year, to sink deep roots, we must have the top 20-25 per cent of each cohort remaining in public institutions until they retire from medical service. At a steady state, these 3,000 doctors, spanning all age cohorts, will form the critical mass of our medical talent pool. If we succeed in this, SingaporeMedicine will be able to compete internationally, while safeguarding the high medical standard all Singaporeans, rich or poor, deserve.

      We must try to achieve this. There is no single silver bullet which can solve all the issues.

      Some doctors are fed up with administrative duties. They want to focus on their clinical and teaching duties. We should not unduly load them with unproductive paperwork.

      Some want better recognition of their contribution. We should find a way to acknowledge their status and their achievements.

      Some want to have a better say in the way their hospital is run. We should engage them and give them a productive role to play.

      Some are keen on research and enjoy the opportunity to pioneer or train in new procedures. We should try to support them.

      More fundamentally, many young consultants who have left told me they would actually like to remain in public hospitals but felt uncertain about their continuing employment in later years. They saw public hospitals not being able to accommodate senior doctors like Foong Weng Cheong and K. L. Tan, despite their having put 30 years of their career in public institutions. Given such uncertainty, they decided they had better start their private practice earlier, while in their prime.

      We must remove such uncertainties and reset the career progression of our young doctors. They must see that we have a viable model of allowing dedicated doctors who have invested 25, 30 years of their lives in public service to remain productive in the public hospitals and retire gracefully.

      Many such senior doctors, like Y. Y. Ong, Tan Ser Kiat and Low Cheng Hock, are happy to do 40 years of public service and retire in public hospitals. We should assure them there is an important role for them to play in public hospitals. We can vary the nature of their role as they enter different phases of their public service. For example, as they reduce their clinical duties, they can take on more of a teaching and mentoring role.

      But some doctors find the independence of private practice and the freedom of being self-employed hard to resist. Perhaps, it is possible for these doctors to have a second career in private practice but within public hospitals, after they have served their years in public service.

      Why can't we offer these senior consultants the privilege to migrate, say at age 50, from public service to private practice, without leaving the public hospitals?

      They can run their private practice as they would if they were in the private sector, running their own clinics, with admission rights for their patients in our private wards. They would remain as members of our clinical departments with departmental support for their inpatients in return for the continued teaching and coaching of young doctors and trainees.

      Private practice in public hospitals is not a new idea. It has been done elsewhere. We have talked about it but have worried about its impact. Will there be abuses? Will public patients be neglected?

      If we restrict the privilege to the senior consultants who have put in 25, 30 years of their time in public service, of what is there to be fearful? If we start small and expand gradually as our staffing levels improve, there is no reason why existing public services will be neglected. In time, as we gain experience and confidence, we can extend such privilege to senior consultants from a younger age of 45. But I think we must never go below this age threshold.

    Building strong institutions

      BUILDING institutions and retaining talent are the responsibilities of hospital managements and their boards of directors. In fact, these are their most important responsibilities.

      Let me challenge them to work towards the vision of what our public institutions can become. We should aim to match the best in the world in patient care, teaching and research. In Asia, we should be the best and be recognised as such by our peers, head and shoulders above all the others.

      Being the best, however, does not mean tall shining buildings or the most fanciful and expensive pieces of equipment. Being the best means we have the best clinical outcomes, we invent new devices, new techniques and new processes. We do everything better, faster and cheaper than others, and patients from the region want to come here for their treatment.

      In short, let us become the Mayo of the East, but without the costly price tag. Not all our clinical specialties can succeed, but hopefully a few will produce dramatic results within a few years, to encourage the rest to keep faith.

      Can it be done? Some of our best students take up medicine every year; some of our best brains are in the health sector. Moreover, we are not starting from ground zero. After a century of medical education, we already have some of the assets in place. But we have to be clearer in our goal and bolder in our approach towards this goal.

      Building strong institutions is a long-term endeavour, beyond bricks and mortar. It requires leadership, dedication, discipline and patience. Take a long-term view but have a clear road map so progress can be measured and, if need be, refine the strategy.

      The ability to retain good teachers and good role models is the key. The ability to enlarge the pool of such medical talent year by year will track our progress.

      But this must be done in a sustainable way. First, it must not clog up the medical leadership with limited career opportunities for the upcoming young consultants. Second, it must also be financially viable for the public institutions.

    Adapting to the new world

      AS WE look back at the last 100 years, we can be nostalgic about the good old days of the old masters like Cohen and Seah Cheng Siang. Their grand rounds were legendary, attended by all staff from housemen to consultants. That period was sacrosanct and everyone enjoyed the teaching and the camaraderie that went with it. The junior doctors who were ill-prepared would tremble in fear as they would have to present their cases to the grand master.

      But as Dr June Lou lamented to me: That world is, sadly, gone. These days, when a round is conducted, half the staff are absent. I suppose we now live in a new world and we have to adapt. If we do not, we will be more disappointed, and worse, become ineffective in our mission.

      I am optimistic because I still see many in the public institutions with strong institutional values: Satku, Tan Chorh Chuan, John Wong, Tan Ser Kiat, Y. Y. Ong, Chee Yam Cheng, Low Cheng Hock, Soo Khee Chee, K. T. Foo, Rajasoorya, Lim Yean Teng, Philip Eng and so many others. There are enough people around who still believe in the higher calling of public service.

      But we need to ensure they have worthy successors in the pipeline. To do so, we must convince our young doctors to reset their career progression. It should be to train hard, become world class, serve the rich and the poor, teach the young, build the next generation of doctors, retire in public institutions.

      Not all doctors will share this career path. But for those with good institutional instincts, we must do our best to support them along this career path.

    Abridged version
    The Straits Times
    26 Feb 2005

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    Health Ministry may allow senior doctors to run private practice in public hospitals

      The Health Ministry is considering allowing private practice within public hospitals.The move is to stem the brain drain in public hospitals, where the number of top doctors leaving for the private sector hit a record high of over eight per cent in 2004.

       Health Minister Khaw Boon Wan said there had been few examples of this in recent years, as many top doctors leave public hospitals at their prime to start their own private practice. He said they left not only because they want to be self-employed, but also because they are not sure public hospitals can accomodate senior doctors like themselves. Mr Khaw said: "Why can't we offer these senior consultants the privilege to migrate, say at the age of 50, from public service to private practice, without leaving the public hospitals? "They can run their private practice as they would if they were in the private sector, running their own clinics, with admission rights for their patients in our private wards. "They would remain as members of our Clinical Departments with departmental support for their inpatients in return for continuing teaching and coaching of young doctors and trainees."

      Dr P.C. Wong, Head of Department of Obstetrics & Gynaecology at the National University Hospital, said: "Instead of losing the public doctors to the private sector, this way at least we retain the very senior good doctors. "And they do public work as well as a little bit of private work within the institution. So they get the best of both ways, and I think this is a good way to retain the good doctors within the public institution."

       Mr Khaw suggests restricting the privilege to senior doctors who have served more than 25 years in public hospitals. This is to prevent abuse which may leave subsidised patients neglected.

       Dr Lim Suet Wun, CEO of National Healthcare Group, said: "The scheme that the Minister is putting up now is unique in that it places an emphasis on the value of the people, and that is the key difference. "I agree with him that if you want people of value, it does take time to evaluate and to make sure that the person has those values which are very strong and for the institution. "And from that perspective, I think that age is one proxy we can see that these people have served in the institution for a long time and people who over time, we know they have proven that these people are people we can trust, people who won't try to raise charges unnecessarily and therefore this is a fairly neat scheme."

    Abridged version
    Channel Newsasia
    25 Feb 2005

    Private and public sectors cannot mix
    Letter from Lim Boon Hee

       I am puzzled that Health Minister Khaw Boon Wan says he does not share his ministry officials' views that the migration of experienced doctors to the private sector is okay (Feb 26-27). It reminds me of Japan, where ministers come and go, but it is really the senior bureaucrats who wield the power in their ministry's workings.

       It is idealistic to think that senior consultants can be enticed to stay in public hospitals and run their private practices as if they were in the private sector, running their own clinics, with admission rights for their patients in our private wards. It is just plain impossible with the inflexibility, rules and regulations in our public hospitals. The mentality is different. In the private sector, you can have everything done short and sharp, whatever scans or the tests you need in one day. Can an overloaded public hospital have the spare capacity to do so, unless it is at the expense of subsidised patients? All too soon, the frustrations and limitations imposed by the public hospital administrators will force these senior consultants to flee!

       The public hospital administrators are not equipped with the right market-oriented savvy and nimbleness. They are used to bureaucracy and gain security from generating tonnes of unnecessary paperwork. In private practice, the single most critical question is: How can I make it most convenient, hassle-free, flexible and comfortable for my patients? Our public hospitals can never measure up to this benchmark, because they can barely cope with their present workload. So, to attempt to transplant a private sector within the domains of the public hospital is akin to doing organ transplants when the donor and the recipient are incompatible rejection is inevitable. It is either a clean break from the public sector into the private, or not at all. Hybrids will not work.

    Letter to Forum
    28 Feb 2005

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    Why some senior doctors quit public hospitals
    They didn't leave for money - many retain links with public sector

       HE WAS at the birth of Singapore's first 'test-tube' baby, and spent decades treating patients and helping to train younger doctors while staying true to his passion for research.

      When Dr Ng Soon Chye looks back on his long career at the National University Hospital, he says he was 'very happy at NUH and never thought of leaving for the private sector'. Yet he resigned in December 2003, one of six obstetricians and gynaecologists who left the NUH within months of each other. 'For me, it was all push factors,' said Dr Ng, 55, of his decision to quit to enter private practice. Like other senior doctors who quit the public sector, he did not leave for more money. Nor was it because he was no longer head of department, a change made some years earlier. Pressed to name the push factors that made him leave finally, he said: 'There were a lot of policy changes within the institution - at multiple levels but particularly affecting O&G - that I felt were not quite right. I left as a matter of principle.' He felt that it was no longer meaningful to stay on. He had worked alongside the late Professor S.S. Ratnam to bring Singapore's first in-vitro fertilisation baby into the world on May 21, 1983. Despite leaving the public sector, he has not given up his first love: research. He remains an adjunct professor with laboratories at both the National University of Singapore and the Nanyang Technological University, and his current subject is cloning.

      Dr Ng was one of 43 specialists who left the public sector in 2003. Last year, the number jumped to 87, the highest for any single year. He was one of several specialists named yesterday by Health Minister Khaw Boon Wan as people whose resignations were a loss to the public hospitals because they had been 'good doctors and dedicated teachers'. The others included Dr Abu Rauff, Dr Walter Tan, Dr June Lou and Dr S. Krishnamoorthy, all of whom had held positions as heads of department.

      Dr June Lou, former associate dean of paediatrics at KK Women's and Children's Hospital, left in June last year after more than 30 years in the public sector. While the minister said it is important to retain doctors like her, Dr Lou felt that younger people now in charge of hospitals might not agree. 'They may not want our input. We are passe, and they are glad to get rid of the fossils,' said Dr Lou, who is in her late 50s and specialises in children's cancers and blood problems. Like Dr Ng, she had expected to stay until retirement, but decided to go because she did not want to fight the move to have older doctors make way for younger colleagues. 'I was old enough for them to say, 'It's time to move on'. So I decided to bow out gracefully,' she said. But she felt the exit of older doctors sends the wrong signal to young doctors. Young doctors who see 'the way they are treating the older guys, pushing them around like that' will wonder if they will end up in the same boat eventually. So they may decide to leave while at their peak, in their 40s. To keep senior doctors, Dr Lou suggests mapping out an area for them. 'The hospital should say we would like to keep you here, to do the following, then let the doctor decide,' she said.

      The minister recalled meeting Dr Lou, who lamented that hospital rounds, where a senior doctor went through a ward with younger colleagues, were no longer what they used to be: sacrosanct, with the emphasis on teaching and establishing camaraderie. 'That world is sadly gone. These days, when a round is conducted, half the staff are absent,' Mr Khaw quoted her as saying. Dr Lou said she still spends half a day each week running a clinic at KKH and conducts tutorials for some former students who want them.

      Dr Noel Leong, 58, who used to head KKH's in-vitro fertilisation centre, said he would have stayed if he had a say in the direction the hospital was going. 'If we can't influence things, we might as well leave,' he said. In the past, he said, doctors were kings. But, increasingly, administrators had taken over the lead.

      'Senior doctors want a say about the direction the hospital is going. But when there are differences, the administrator's view prevails,' he said. There should be a greater sharing of power, he feels. Like the others interviewed, Dr Leong preferred not to describe specific instances of frustrating experiences that made him decide to go in 2001. 'We doctors don't like our underwear to be seen,' he said. But he agreed with the minister that losing so many senior doctors leaves a gaping hole in the public sector. 'There is such a thing as vintage doctors with vast experience, teaching and clinical network, with a voice in the regional and international arena,' he said. Now in private practice, he still helps out at both KKH and NUH and remains an examiner for post-graduate medical students.

      Orthopaedic surgeon S. Krishnamoorthy left for private practice in 1997 at the age of 57. Things are more efficient in the private sector, where a patient can come in the morning, have all investigations done and a treatment recommended later - all in a day. In a public hospital, unless it is urgent, a patient may have to wait a week to get an MRI scan. He has found the level of job satisfaction in the private sector much higher too. 'Patients have heard about you, want to see you and appreciate you. A relationship is established right from the start,' he said. 'In the public sector, you are loaded with lots of cases. You are always rushing with a huge list to clear.' Like the others, he also retains a link to the public sector. He is a visiting consultant at the Singapore General Hospital, where he treats mainly subsidised patients and is a mentor to younger doctors.

    The Straits Times
    26 Feb 2005

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    Hello, is the doctor in?

       SCALE matters. The private sector can never offer talented doctors the opportunities for sub-specialisation and research that public hospitals do. First-rate doctors know this, and realise that they can achieve more in teaching hospitals and academic medical centres, than by going solo or joining small groups in private practice. Yet, a record 247 doctors quit public hospitals for private practice last year. In being troubled by this loss, Health Minister Khaw Boon Wan has focused on an important issue. The outflow of doctors would not have been a problem had patients, too, been able to follow them. But subsidised patients cannot afford treatment in private hospitals. Then, the haemorrhage deprives young doctors of the opportunity, not only to learn medical skills but also to imbibe the invaluable values of public service that lie at the heart of a caring profession. Having diagnosed the problem, the minister has suggested a course of treatment as well: Focus on medical service as a noble profession, create strong institutions and do your best to retain doctors who have sound institutional values.

      The last part of his call is critical. Doctors who leave for the private sector because of money - which, admittedly, is there to be made - cannot be held back. But doctors who leave because they feel unwanted in bureaucratic structures that do not value their experience and input are in a different category. Several doctors who spoke to this newspaper gave touching - and alarming - accounts of what one veteran said was a sense of being treated as passe, as 'fossils' that were best gone. The kind of attitude that produces such sentiments in senior doctors is nothing less than diseased. The sooner it responds to ministerial treatment, the better. Of course, there are other reasons for doctors leaving. One way to address these reasons, of which there is a range, is to encourage private practice in public hospitals. That way, senior doctors can continue to share their experiences with junior colleagues and mentor them while pursuing their career interests. Keeping doctors in public hospitals should not be seen only as an issue for older doctors. If young professionals setting out on their careers think that what is happening to the veterans will happen to them one day, they will plan their exit better than public hospitals can plan their career paths. That would be a terrible loss.

    The Straits Times
    02 Mar 2005

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    Number of public sector doctors leaving for the private sector goes down
    Doctors say more medical students needed to ensure enough staff for future needs

      SINGAPORE: The number of public sector doctors leaving for the private sector has gone down according to figures from the two health clusters here. The numbers peaked around 2004 when some seven percent left the public sector. Doctors say Singapore could still face a shortage of medical staff in future.

      Dr Heah Sieu Min is one of almost 90 specialists who quit the public sector in 2004 to go private. Now running his own clinic in Paragon, he stresses he didn't leave Singapore General Hospital after 10 years for more money.

      "If you are a head of department or you are a consultant, you will need to actually fulfil a certain administrative role which sometimes can be bog you down rather than allow us to do what we were trained to do, which is doctoring and looking after patients. I think most colleagues and myself find that this is one of the main reasons why we would leave the public sector, not just so much for the salary part because they do pay relatively well in the restructured hospital," said Dr Heah Sieu Min, Consultant Colorectal Surgeon, Pacific Colorectal Centre. Dr Heah says, he can now focus more on his patients, instead of packing 30 appointments into 3 hours like he used to in the public sector.

       Almost two years on, he doesn't regret leaving and says measures which allow doctors to do part time private practice didn't entice him to stay although he still maintains his ties with restructured hospitals. "Sometimes it's neither here nor there, although it's a very interesting plan in the right direction, but I don't think it addresses the issue fully. So most doctors would think either you are in the public sector or you are out in the private sector looking after your patients," said Dr Heah.

       Although fewer doctors have left the public sector in recent years, some senior ones who've stayed still feel the pinch. "At the general level, that really impedes development of sub-specialty. At the institutional level, we are putting in a lot of resources into training, and it can be disheartening to the senior doctors to continuously train and the end the doctors leave for private practice. It doesn't help that there are a few regulatory restrictions in place that decide the number of specialists we can have," said Dr Chay Oh Moh, Chairman, Division of Paediatric Medicine, KK Women's and Children's Hospital.

       Dr Chay says she sees a 50 percent attrition rate of the only six specialist paediatricians she trains in each cohort and an increased supply of doctors she feels would mean better work life balance for them and less incentive to leave.

       While the problem isn't as dire for eye specialists - the Eye Institute wants younger doctors to feel more of an obligation towards their patients. "Once we take up medicine, many of us have a certain set of things we want to do for our patients, especially those who can't afford private sector care, and that typically is the bottom 20 to 30 percent of the social strata. I think as doctors we have the responsibility of rolling out quality care for them. We have to plan out and roll out many plans and healthcare activities to serve this population well, to do that is very challenging and there are many things we still need to do and I would be very happy to spend many years of my life doing that," said Dr Lim Tock Han, Director, The Eye Institute National Healthcare Group.

       Dr Lim believes that more informed patients will also begin needing longer consultation times which would mean the need for more doctors.

       Currently NUS only admits 230 medical students each year. Some doctors say, to make up for the numbers leaving the public sector it may be necessary to let the market dictate how many medical students to admit each year and how many to assign to each speciality.

       With Singapore's push to become a regional healthcare hub and its ageing population, one thing's for certain, it's going to need more doctors.

    14 September 2006

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    Keeping in step with private sector

       I refer to the letter, "What are the civil servants' real gripes?" by Mr Joseph Khoo (March 7).

       Mr Khoo asked whether insufficient pay was the key reason for resignations in the Civil Service, and whether there were other more cost-effective ways to reduce turnover apart from raising the salaries of civil servants.

       We agree with Mr Khoo that salaries are not the sole factor to attract and retain talent. There are other equally important considerations such as job challenge, career progression, development opportunities and effective leadership. The Civil Service has been working continually to strengthen and enhance these areas. We will continue to look at ways to provide challenging and fulfiling careers for all civil servants, including increasing opportunities for officers to be rotated among different jobs.

       According to a study released lsat year by Hewitt Associates titled Taking Your Talent Pulse, pay ranks second on the list of motivators for high potential employees as this sends a clear signal that they are valued and rewarded for their contributions. The top motivator is job challenge. Nonetheless, as private sector wages rise, the wages of civil servants cannot remain stagnant. While the Civil Service does not aim to lead private sector salaries, we need to keep pace. Otherwise, we will lose our ability to recruit and keep good officers.

       The resignation rate in the Civil Service has increased, from an average of 4.8 per cent in 2005 to 5.7 per cent last year. Some parts of the civil service are facing much higher attrition. For example, in the Management Executive scheme, meant for graduate officers, the resignation rate rose from 7.4 per cent in 2005 to 10.6 per cent last year. The resignation rate is highest at the entry-level grade, at 25 per cent. Some segments of the Service are feeling the competition more than others. For example, 42 per cent of accountants who left during the past year cited better pay and prospects in the private sector. About 46 per cent of Legal Service officers who resigned over the same period were either paid or expected to be paid higher remuneration packages upon joining the private sector, with some getting more than a 30-per-cent pay increase.

       I wish to reassure Mr Khoo that the Government is mindful of its responsibility to be prudent in its use of resources. There will not be a uniform, across-the-board large revision in Civil Service salaries. Services lagging significantly behind the market are likely to receive the larger adjustments.

    Ong Toon Hui
    Director, Leadership Development
    Public Service Division, Prime Minister's Office

    Note by Gerald:
      Contrary to popular belief, the majority of doctors in the 'government' hospitals are NOT civil servants. This is because the hospitals have been 'restructured' and come under two not-for-profit companies, namely Singapore Health Services (Singhealth) and National Healthcare Group (NHG). Even the polyclinics are no longer run by the government directly.
      The few medical services provided directly by the government include the school health serivces and the blood bank. Even then, most of the doctors running these are seconded from Singhealth/NHG and are not civil servants.
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    Concern over senior docs going into private practice

       I AM deeply concerned by the increasing number of doctors leaving the restructured hospitals for private practice. Being in the medical industry for the last six years, I have seen numerous highly experienced specialist doctors leaving for greener pastures. They bring with them tonnes of experience accumulated over many years.

       I cannot help but worry: What is going to happen to our health-care system if this goes on?

       Their departure also means that they are unable to impart their knowledge to junior doctors. This can have serious repercussions in the long run. How many average Singaporeans are able to afford private treatment of more serious illnesses like cancer and heart disease?

       Though some of these doctors do return as visiting consultants, it is non-subsidised (i.e., full-paying) patients that they see. Their leaving for the private sector is a great loss to society. What is being done to retain our doctors so that they continue to serve the community? Is it the fault of the health-care system or have our doctors become more mercenary?

       Allow me to quote from an interesting article by S.Y. Tan, MD, JD Professor of Medicine & Adjunct Professor of Law, University of Hawaii. It says: 'The policeman wears a badge that warns the criminal he's there to protect society; the doctor wears one that pledges to society the protection of its health. The doctor's badge is his white coat, his stethoscope. What message is my badge sending these days? Does it still proudly proclaim that the health and dignity of patients will be my first concerns? Or does it say that I will treat your medical ills for a fee?'

       In striving to be a medical hub, let us not do so at the expense of those Singaporeans who can afford only subsidised health services.

    Annie Koh Seok Kien (Ms)
    The Straits Times Forum
    12 Jul 2007

    Why single out doctors as being mercenary?

       IN THE letter, 'Concern over senior docs going into private practice' (ST, July 12), Ms Annie Koh Seok Kien laments the increasing numbers of doctors leaving restructured hospitals for private practice.

      The past two years have seen an increasing number of foreign patients, driving up the income of specialists in private practice, while the remuneration of doctors in the public sector has remained largely unchanged. The income gap between medical specialists in the private and public sectors is now blatantly obvious to the entire medical fraternity.

       Students apply to medical school for a variety of reasons. Whatever the initial reasons, when they graduate and subsequently set up families, even those who remain extremely altruistic have to start planning to accumulate wealth as any responsible parent would. Even if their initial aspirations were to send their children to a local university, as the potential for earning more arises, their aspirations may now be to send their children to top universities overseas.

       These are natural instincts which ensured survival of homo sapiens over milleniums. Even politicians and civil servants whose ambition is to serve the nation harbour these same aspirations. Why single out doctors as being mercenary? Indeed, there are some doctors who are unscrupulous. This is possible in private practice where there is no regulation to prevent overcharging. These are not the doctors we would want to retain in the public sector.

       Speaking for the doctors at the National Neuroscience Institute, a restructured hospital, as long as the difference in income is not too great, the working conditions reasonable and fair, and there is a sense that we are providing the best patient care we can, we are happy to stay on in the public sector to serve all patients who need us.

       But if the gap gets greater as it is threatening to, I would not hold it against any of my colleagues with families who leave for the private sector. I only hope that in private practice, they will still be guided by their conscience when dealing with patients. The price of medical care does not follow the rules of supply and demand because the consumer (the patient) can never be fully informed and usually goes to the doctor with total trust, submits to various procedures recommended and seldom questions the fees that are eventually charged. That is the reason why private practice can be so lucrative.

    Associate Professor
    Lee Wei Ling
    National Neuroscience Institute
    The Straits Times Forum
    14 Jul 2007

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    Private practitioners have made outstanding contributions too

      I REFER to the article, 'Mayo formula? Best cross-disciplinary care for patients' (ST, July 12). Let me begin by congratulating the doctors of Singapore for the high standard of medical practice. Doctors, both in the public sector or private sector, have maintained excellent standards.

      It is unfortunate that Prof Tan Ser Kiat implied that practitioners in private practice lag behind because of lack of resources to keep up with the latest and best in medical technology.

      Let me say that this is not true. Some of the best and latest equipment are in the private sector. Furthermore, private practitioners have made outstanding contributions.

      Some of us from the private sector, including myself, have been honoured to serve Singapore. I was appointed as Medical Director of the Singapore National Eye Centre (SNEC) on Feb 23, 1989. Let me quote what others have said of me: According to Professor Ian Constable of the University of Western Australia: 'Arthur has done as much or more than any living ophthalmologist for the teaching of clinical skills and for surgical intervention programmes in the Asia-Pacific region.' Professor Wallace Foulds of the University of Glasgow said: 'Almost single-handedly he raised the practice of ophthalmology in Singapore to world-class and the SNEC is a lasting tribute to his far-sightedness, his energy, and his political skill.' In addition, a world award was given to me in 2005 by the International Council of Ophthalmology. A year later, the American Academy of Ophthalmology gave me an award 'in recognition of your numerous contributions'. In March 2007, I received the Naumann Award for 'Leadership in Global Eye Care'. This month in Singapore, the World Glaucoma Award 'in recognition of your major contributions in glaucoma' will be presented to me on July 18 by the The International Glaucoma Societies.

      Let me conclude by saying that I am grateful to the team of excellent doctors and to Health Minister Khaw Boon Wan, Dr Kwa Soon Bee and Prof Lim Pin for they have enabled Singapore to move forward. We must work together so that the objectives of Mr Khaw to attract a million medical tourists to Singapore every year can be achieved.

      I hope that the private sector can work closely with the leading public sector leaders, like Prof Tan Ser Kiat, and also hope that disparaging remarks on private practitioners would be avoided.

    Prof Arthur Lim
    Medical Alumni Association
    16 Jul 2007
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    'National service' for private doctors
    Kuala Lumpur

      Malaysia is introducing a new form of national service to ease the shortage of doctors in the public sector.

       It will soon be compulsory for the country's 8,000 private doctors and specialists to serve for a certain number of hours in government hospitals every year.

       Health Minister Chua Soi Lek said their services would reduce the heavy workload of doctors and specialists in those hospitals and help them to gain more experience. 'Government doctors and specialists, also numbering about 8,000, are looking after 48 million out-patients and 1.7 million in-patients nationwide a year,' he said on Thursday. Speaking after a dialogue with leaders of the Association of Private Hospitals Malaysia (APHM), he noted that there was a shortage of 3,300 doctors in the government health sector. His ministry will consider making the compulsory service a condition for the renewal of annual practising certificates.

       A joint committee with representatives from the ministry and the private health care sector, including the APHM, will be set up to work out the details of the new scheme. 'These include the stipulated number of hours, which hospitals they will serve and how much they will be paid,' he said. 'But I don't think they want to be paid as it is a form of social contribution.' Datuk Dr Chua said the proposed public service idea was well-received at the dialogue.

       APHM president Ridzwan Bakar told reporters that many private specialists who had lectured at public universities in the past were willing to work part-time in government hospitals. He also stressed that the logistics had to be worked out before the compulsory service could be implemented.

       Labour leader N. Marimuthu urged the government to provide tax incentives to compensate private doctors and specialists for their services. He agreed that they could help ease the workload in government hospitals and cut waiting time for patients. 'But making it a condition for them to be able to renew their annual practising certificate is tantamount to a kind of underhand tactic,' he said.

       A senior medical specialist said the ministry had previously paid about RM25 (S$11) an hour to private doctors to work as government medical officers but the response was not good. 'The ministry should instead send patients to be treated by general practitioners to ease the burden on its out-patient clinics.'

    The Star/Asia News Network
    12 Jun 2004

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    Questions for discussion

    1. Describe the Singapore Government's policy towards doctors leaving the public sector.
    2. Name the push and pull factors that result in consultants going into private practice.
    3. What advantages/disadvantages for Singapore as a whole do you see as a result of this?
    4. List possible incentives/disincentives that may encourage public practice.
          Email your answers/opinions here.

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