I am not one for making New Year's resolutions usually, but I did make some in recent years – when I realised that my body was getting a little out of order and I had more time on my hands now that my children are older and more independent. For instance, I cut down on my intake of soft drinks, including my beloved Coca-Cola. I started drinking water – mainly soda water – and a little red wine, for my heart. Otherwise, I am a wine philistine, the opposite of some local lokun wine connoisseurs who have among the sharpest noses in the world. I once thought "Penfolds Grange" was a breed of Australian chicken.
Doctors' nemesis
Speaking of spirits; when I was a medical student in the 1980s, doctors in the UK then had the highest reported alcoholism and suicide rate among all professions. Turning to the bottle was one way to forget the high pressure, and emotional and physical fatigue of an often underappreciated job. Thankfully, things have improved since, although burnout in junior doctors is still of concern both locally and elsewhere. In the old pager days of brutal clinical work conditions, including one call in every two to three days, tracing results by running to the laboratories and professors shouting down junior staff like terrifying army generals, it was a rougher kind of tough. Today, juggling clinical service loads with more education and research requirements, tests, drugs, interventions and algorithms in a more legalistic, expectant, demanding and high cost-of-living society presents a different challenge for young doctors. A loss in purpose and direction, and a fear of diminishing future prospects, can add to burnout. Burnout is also seen in other professions like law; opportunities in the major law firms are now extremely competitive – unreachable to most – and over half of all lawyers are no longer in practice by their 30s. In 2003, the US Accreditation Council for Graduate Medical Education officially reduced doctors' work hours to no more than 80 hours per week. In 2011, further restrictions were also added to improve work conditions. I spoke to several oncologists in US academic hospitals. They say that while residents work 80-hour weeks on paper, it is a lot more, unofficially, under the radar screen of auditors. In the past 40 years, the pay of US medical residents has not increased when adjusted for inflation. Yet medicine remains the most prestigious profession in America. Over a sushi dinner with Prof Norihiro Kokudo, President of Japan's National Center for Global Health and Medicine, I asked him what the most sought-after university degree and profession in Japan today was and he answered that it was medicine. I asked, "Not working for big companies like Sony or Toyota? Or finance, or in the civil service?" Prof Kokudo replied that lifetime employment was no longer a given in such institutions and there were also some reputational setting suns.
Watching the scale
I have started to eat more greens, fruits and nuts but remain largely a carnivore. I am eating less dessert, but it is hard because I have had a major sweet tooth since childhood. As a middle-aged doctor who no longer does night calls and fear-inducing exams, I began to exercise more and even got myself a Fitbit. I also revived my university passion for rowing. On the misty waters of England, I understood grit – and team-based learning – before it entered the lexicon of progressive medical education. With renewed flab-fighting exercise, I did begin losing weight and also feeling better.
We all have wilful blindness. Diet-wise, mine is durians. As soon as I made a resolution to reduce my durian binges – helped by a poor mid-year season – the year-end season produced amazing fruits and my resolution disappeared like a durian-loathing ang moh confronting the King of Fruit. My father, the ever razor sharp clinician, who is still a practising cardiologist working seven-day weeks at 88 years young, says he knows when the durian season has arrived because his patients' blood glucose levels would all go haywire. I am hoping that the recent globally acclaimed sequencing of the durian genome by Singapore scientists will eventually reveal secrets of medical benefit, since so many fruits such as avocado, apples, berries, citrus fruits and papayas improve our health. Still, one has to be careful with health claims, such as the soursop's miraculous power to treat cancer. No scientific or clinical evidence supports this. However, at a recent dinner at Joo Hing Tze Char restaurant in Joo Chiat, the soursop juice did taste pretty good.
Technology: the best is yet to be
2017 was a good year for coffee shops and coffee lovers like me. In November 2017, the British Medical Journal published a huge review of 201 metaanalyses which concluded that drinking three to four cups of coffee per day can reduce the risk of cancer incidence by 18%, reduce cardiovascular mortality by 19% and reduce stroke mortality by 30%. Coffee consumption also reduces mortality from non-alcoholic fatty liver, liver cirrhosis and diabetes. Earlier in the year, Stanford researchers published in Nature Medicine that coffee consumption could slow down ageing as it is linked to a reduction in the body's inflammation process. Studies also reveal that brainstorming and good ideas ferment optimally in coffee shops not just because of the coffee buzz. Even the ambient roasting, gurgling and steaming sounds of the coffee machine stimulate creative sparks. Every time I order coffee at a local Starbucks, I track how often the service staff get my "no whipped cream please" order correct. Previously, the Starbucks staff got my order wrong over 50% of the time and I unhappily got coffee topped with whipped cream. These days, the rate of this error is less than 10%. Starbucks China, now home to over 3,000 stores with one new store opening in China every 15 hours, just got a huge boost partnering Alibaba. Via Alibaba's Taobao mobile application, Starbucks provides cool high-technology retail and customer service experience where "no whipped cream" really means no whipped cream.
Hospital information technology is less evolved. While American and local doctors appreciate the potential of electronic health records (EHR), especially data sharing for more seamless team-based care, many complain about how user-unfriendly, unintuitive and time-consuming it can be – a frontline disabler rather than enabler especially in crazy busy clinics. Over ayam panngang mertua, nasi goreng belacan and Shanghainese bakchoy at Meradelima restaurant in Jakarta, two world-leading oncologists from two of America's top academic medical institutions complained how their respective hospitals were using the Epic EHR system, which they felt was an epic fail and not patient-centric. They both toasted over Bintang Beer at their imminent retirement from patient care than face the Epic system again in their clinics. In 2015, the American Medical Association published a list entitled "How EHRs tied up physician time in 2015". The Association of American Physicians and Surgeons (AAPS) also put out a strong public complaint, warning that EHRs could "crash" the US healthcare system. An AAPS survey revealed that 80% of American physicians surveyed felt EHR impeded patient care and nearly half believed that patient care was at risk. Even the prototype IBM Watson is more hype than master of the clinical management universe. Still, the 20th century saw the first manned flight by the Wright brothers to the landing of the first man on the moon. And today's mobile phones have more computing power than that of the Apollo spacecraft. There will surely be a better technological tomorrow for healthcare.
Lessons from the dabbawalas
The medical profession is drilled towards zero tolerance for error. Rigorous training and mentoring, military-style discipline, strict standard operating procedures and robust systems have ensured that Singapore healthcare commands the highest reputation not just in the region but also globally. According to the 2017 Bloomberg Global Health Index, Singapore is the fourth healthiest country in the world. However, rare errors can still happen in a chaotic day filled with black swan events that demand complex thinking, fast decision-making, frenetic multitasking and swift action. I have the deepest admiration for the dabbawalas of Mumbai. These remarkable low-cost, low-wage tiffin (dabba) lunch delivery road warriors, identified by their white Gandhi hats, make over 200,000 just-on-time deliveries of hot freshly cooked lunch deliveries daily from home to workers in offices and then provide a timely return service – and make only one mistake out of over six million deliveries. The dabbawala service still thrives as most Mumbai residents prefer lovingly prepared home-cooked food that is healthier than fast food or restaurant food. Dabbawalas use only bicycles and Mumbai's intricate rail network, and are always punctual even during Mumbai's notorious traffic jams, floods and storms. It's not just the faultless supply chain delivery system that is the envy of companies like Federal Express; it's the unique dabbawala organisational culture. Many dabbawalas have the educational level of 12 year olds – most of them are illiterate and their complex delivery system uses no technology (not even mobile phones) except a colour and number coding system. They selflessly live by the creed: "Customer is God, work is worship." The dabbawalas are empowered to make pricing decisions and share profits equally. Their organisation is pretty flat, and they have a self-organising democracy. Health professionals and health systems can learn much from them. I thought about the dabbawalas at the Joo Hing makan (Malay for eat) with kawans (Malay for friends) where a couple complained about the over ten-hour wait time they faced in a public healthcare emergency room to seek treatment for their son who had a Salter-Harris fracture, only to be told by the orthopaedic senior resident that they could not treat their 15-year old as it was an adult general hospital. The father of the patient, who is a medical doctor, expressed more disappointment and bewilderment than anger at such inefficient frontline service. The good news is that this is more the anomaly where wait times are overall improving in public healthcare institutions.
A more affordable healthcare
In December, at the wedding dinner of one of my oncology senior residents, I sat with Dr Jeremy Lim and discussed the newly proposed fee benchmarks in a new Ministry of Health incarnation. When I was Editor of SMA News, and Jeremy a prolific Editorial Board member writing expertly on health policy, there were many emotive articles on the Guideline of Fees (GOF) by then SMA President, Jeremy, the Hobbit and many others. The arguments put forth by SMA was that healthcare came with information asymmetry, even in the age of digital information, and sometimes controlled limited distorted competition, the need for public goods, Government interventions, and externalities. Falling sick and needing treatment, often very quickly, is nothing like choosing a new car. It all contributes to market failure. Ten years ago, the SMA was "stunned like vegetable" when the GOF was deemed anti-competitive and removed. Since then, private sector bill sizes have increased over twofold instead of the reverse. Bringing a speed limit guideline back onto the healthcare highway is more likely to change behaviour and reduce "speeding" overall than rely on the invisible hand of cars regulating themselves on the road. Richard Thaler, one of the founding fathers of behaviour economics and winner of the 2017 Nobel Prize for Economics, warns of "bad incentives" that may financially nudge doctors to possibly do more tests, administer more treatments and perform more procedures. He advocates guidelines and evidence-based medicine.
We live in hope that 2018 will be an even better and healthier year. Happy New Year!