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Being thrown into the deep end of a pandemic is likely an extremely chaotic and overwhelming experience, and Director of Medical Services (DMS) A/Prof Kenneth Mak went through just that when he took on the role in February 2020 amid COVID-19. A game changer for the year, COVID-19’s impact on healthcare delivery and services affected many, if not all, in the healthcare industry. In this interview, A/Prof Daniel Fung (DF) speaks with A/Prof Kenneth Mak (KM) to find out more about how things have been since he took over the role of DMS, his insights into the medical landscape, and his visions and hopes for healthcare professionals.
Taking up the challenge
DF: Can you start off by telling us a little bit about yourself and how you became DMS?
KM: Well, Daniel, we have been school mates since secondary school; we both went into medicine with visions of wanting to help others, and I would like to think that each of us has done that. I did not think I was going to be DMS. I graduated from medical school thinking that I wanted to do something with my hands, because I thought I was a little bit more surgically inclined, and housemanship affirmed that in my mind. In the beginning, I was wavering between doing general surgery and paediatric surgery, but as luck would have it, I ended up in a general surgical posting, liked it quite a lot and managed to get into a traineeship and moved on from there.
I started out as a trainee in the National University Hospital and spent a better part of 13 years there before being asked to move across to Alexandra Hospital to head the Department of Surgery. With an understanding that the department would eventually be moving from Alexandra to Yishun, I grew the department so that it could stand on its own two feet by the time we moved. I headed the Department of Surgery at Khoo Teck Puat Hospital (KTPH) for a short while before becoming Chairman of the Medical Board for the next four years. At that time, then DMS, my predecessor A/Prof Benjamin Ong, said that he needed someone to help him and asked me to join the Ministry of Health (MOH). He had realised that it was difficult for a single person to hold all of those responsibilities. I agreed and spent four years in MOH as the Deputy DMS for the Health Services Group. The Health Services Group at that time included the Hospital Services Division and the Primary and Continuing Care Division where they dealt with primary care, so all matters from hospitals to primary care were my ambit and responsibility. We were also looking after mental health, and that's where there were many chances to meet up with you [A/Prof Daniel Fung] and your colleagues in the Institute of Mental Health, debating on how we could improve mental health care in hospitals as well as in the community.
My area of responsibility also extended to Traditional and Complementary Medicine (TCM) – that was perhaps the one area in my work at the MOH that threw me out of my comfort zone. My medical school training and career as a western trained doctor didn't prepare me for this. I went into it with an open mind and realised that there were many committed professionals within the TCM community who wanted to serve the people; many of them were doing it like a charity, depending on donations to work. This was a genuine commitment and I learnt a lot from them in trying to transform care, which was the mandate that Ben gave me.
Ben was also quite mindful of the evolving care needs of our community in Singapore especially with the ageing population. In the next 20 years, when both Daniel and I will also join the senior subgroup of the population, there will be additional health burdens. That will include conditions such as dementia and an increasing vulnerability to other problems because of the increasing frailty.
During my time in MOH, we also had to deal with the war on diabetes, which helped us develop a wholistic strategy to manage chronic diseases. Overall, I found the work in MOH meaningful but it required some balancing between the work in MOH as well as the patients I still had to care for as a senior consultant in the Department of Surgery at KTPH.
Things changed towards the middle of last year, when both Permanent Secretary (then Mr Chan Heng Kee) and Ben asked whether I would be willing to take over as DMS. I had gotten a better understanding of the job, had worked closely with Ben and had the chance to observe what he was doing, so I agreed. But nothing prepared me for what was to come when I took over that role in February this year. I was plunged into the deep end with the rapidly changing COVID-19 outbreak, realising that I had to take things step by step. There was no prescribed playbook to guide me in making decisions, but I had to rely on the moral compass within me to decide what the appropriate decision was. I had to be open to expert opinions from others, and to be humble enough to appreciate that one didn’t hold the monopoly on intellectual thought. As a surgeon, I did not expect to manage a major infectious disease outbreak and public health crisis. It's been a busy and hectic nine months since I started as DMS; I wouldn't want to relive those early moments but I don't think I regret the work that I've done.
DF: You said that your life was very hectic, what was your typical day like?
KM: I have to say that things are a little better now than they were, say, three months ago. But I'll give you a sense of what it was like then and what it is like now.
Three months ago, we were really in the thick of things – we were seeing extremely high numbers of daily new COVID-19 cases of up to three digits. There were many who expressed concerns that we would be in trouble with our resources and supplies if the outbreak worsened further. We were really managing two different outbreaks all at once – what was happening in the migrant worker dormitories and in the community, and we were trying hard to not let the outbreak in the migrant worker dormitories spill over into the rest of the community in Singapore, because the numbers were much lower in the community at that point. We believed we could ring fence and separate the two groups by locking down the dormitories.
But locking down the dormitories created new problems. While we could detect infection early in a locked-down situation, it meant keeping people quarantined for long periods with little interaction beyond their immediate roommates. It is easy in hindsight to ask whether we could have done better. It is tragic to have to keep people cooped up and isolated for extended periods, and this was a parallel concern we had, while we sought to control the spread of COVID-19 infection among the workers in the dormitories. Right now, a lot of work is being done to improve mental wellness and support for these migrant workers. All the work took up a lot of our time. We had coordination meetings almost on a daily basis, and some were with the other ministries as well, because it was an inter-agency collaboration.
At that time, I was perhaps the most famous doctor in Singapore, giving daily media conferences or doorstop interviews. The journalists and cameramen would give me a lot of encouragement on the sidelines, advising me on how to behave and speak in front of the camera, knowing that I was not trained to do this. At one media conference, I had some dryness and irritation of my throat while wearing a mask and when the Minister turned around and asked me for a response, I responded with a cough. Within a minute, I received a text from a friend with a coffin meme as a creative play on my coughing. It really showed how Singaporeans are tuned in to even minor things happening on camera.
While it was stressful, it was something that I embraced. I had to do many things and I found it difficult to find time because of these multiple commitments coming my way. What I really regretted at that point was the fact that we were meeting so often, even on weekends, that every day seemed like a weekday and I was spending less time with my family. It was very tiring both physically and emotionally.
Things are much better now, simply because the pressures of having to deal with the dormitories have calmed down quite a bit. While we are still focused on trying to make sure we detect infections as early as possible, not just in the community but in the dormitories, a lot of focus is now on how to rebuild our economy, get society back on an even footing and also open our borders safely. That has taken a lot of pressure away from us in the healthcare domain, as we no longer have to be present in every single meeting talking about health-related concerns. I relish the fact that I no longer need to be on camera every single day. It's now on average, maybe once a fortnight . I even get emails from unknown strangers asking when my next media interview will be so that they can tune in!
I am now back into a routine, which still involves coming back to the office and having long work hours, but now I have better control of my time. I am pleased that I can dedicate time for my family.
DF: How about friends?
KM: I think we have managed to resurrect some social activities. We all must obey the same safe distancing rules, making sure that we are not culprits in spreading infection. I think because we have been cooped up so much, just being able to reach out and re-establish friendships, or maybe even having a simple meal, whether on Zoom or in person, brings a certain pleasure. We thrive on human relations and interactions, and I think COVID-19 has helped to impress on me the importance of making sure you keep those relationships alive.
Managing healthcare needs
DF: What would you say is the greatest impact that the COVID-19 pandemic has had on our healthcare system?
KM: Well, COVID-19 has done a lot for us. First, we've been building facilities and in tandem, growing our resources, in order to meet the future healthcare needs of our community. COVID-19 has just disrupted all our timelines, priorities and work plans, and has been taking resources away from these important long-term initiatives. We have not been able to carry out some of the business-as-usual activities that we otherwise would be doing. A positive side to this is that it has made the MOH leaner to carry on our plans while fighting this pandemic. And COVID-19 has forced us to rethink and relook at what is important, in terms of the work we are doing, and the plans we are making.
COVID-19 has also disrupted the way we deliver services and the way we interact with each other. I recognise from your background that you are home now. I think the default is working from home unless you are seeing a patient. But even if you are seeing a patient, it does not have to be a physical interaction; as you know, there are many of us now doing tele-health and tele-consultations. I think COVID-19 has really shaken us, moving us away from the comfort of doing things in the old ways, and forcing us to think about how we can do things in a different way. I'm quite confident that some of the new practices and technological innovations we've made – even though they're positioned as pilots and trials – will prevail. I think the way we work in healthcare has changed permanently. We must now carefully curate and ask ourselves what we want to retain of the new and what of the old is still important that we should continue. Our relationships with our patients have changed from face-to-face to remote tele-consultations. We need to work differently to establish a trust relationship with our patients, which is not easy to do. It is harder for patients to recognise our willingness to listen and be attentive through verbal and visual cues by just looking through a screen. Holding the hand of patients to comfort them and build trust is now frowned upon because of the risk of infection spread through touch. I think it does take away a bit of the heart of being a doctor when we have to make these compromises. So COVID-19 is re- defining what the doctor-patient relationship will become as a result of these changes.
DF: Doctors are often associated with diagnosis and drugs but what do you think about a holistic approach to health? Is it important, particularly for chronic illnesses where patients and their lifestyles are also important?
KM: Yes, I think it does make a difference. When I started out as a doctor, through housemanship and as a medical officer, I was quite determined that I would go beyond the superficiality of being a doctor – come into ward, see a patient, check vital signs, issue an order and step out, and never see the patient again until the next day. I thought, in order to make a difference, one of the most important skill sets I should learn and master, if I could, was really just being able to sit down and listen to people. This principle has stood me in good stead. Whether it is in an outpatient clinic, or in the wards, just talking to someone who has fears or concerns makes a difference. You may be dealing with someone who’s got an incurable disease, whose life expectancy might be in the order of weeks and months. If you go beyond just simply asking how they are, to talking to them about their fears, about the things that they wish they could have done, still want to do and wish you could help them do in their remaining time, then you go beyond just simply understanding an illness, you start understanding the person. I felt very strongly that to make a difference in the lives of my patients, it is important to know them better. I have never really shied away from wanting to know my patients, though there are some doctors who are afraid. We fear the pain of close engagement with patients, that as we listen to them, we open up a little bit of ourselves. It is common for many of us to build a subconscious wall within ourselves to separate us from feeling too emotionally attached to the patients that we have. I have always resisted that, thinking that it's good to know your patients beyond their illness and be more closely attached. This demands that you give a little bit of yourself as well. I always thought that this step was important for a doctor.
It has gotten harder over the years to always do that and it needs mental discipline rather than just a desire, but I've never regretted taking that first step to asking a little bit more about what my patients are going through. I feel that by making the time, patients trust you a little bit more. This trust relationship, through deep and meaningful conversations, will build up over time. I know that sometimes people joke and call me an “atypical surgeon” or physician-surgeon, but I've never regretted getting close to my patients like that.
DF: Can you tell us a little bit, in terms of your understanding at least, what are the main challenges you see in the healthcare system going forward, apart from COVID-19?
KM: Well, there is this one big piece about the “three beyonds” that we have been socialising. The first is “beyond healthcare to health” – shifting away from a focus of just treating an illness to now talking in terms of how we want to preserve the health of people. We want to work upstream to manage a disease as it manifests and, as early as is possible, stave off progression to complications and late stage disease. There is a lot of work we can do in this space, and as time goes on, there'll be progressively greater emphasis on preventive health and focus on preserving health. I think this will occur across the life span.
We are looking at Child Health and how we want to improve developmental assessments, to make sure children are growing properly and that those who need help can get help early, because if they don't, there are so many adverse outcomes that can occur. We want to make sure that they get the best start they can have, irrespective of the background that they're in. We also want to support their health in the schools, the communities, and their homes. There are different challenges as one passes through adolescence and young adulthood, but a lot of attention is also being placed on the more senior years. We want to make sure that everyone can age gracefully and maintain as much quality of life as possible. We are less concerned about quantity of life, but we want to make sure that whatever increase in life years we can give a person, also continues to be meaningful and purpose-filled.
The second is “beyond hospital to community” which focuses on access to care. We want to make sure that care doesn't occur just in hospitals and clinics. We want people who are in the community to get access to the proper care they require, without needing to get into a hospital. From that point of view, all the work that our social service agencies are doing to reach out to people at home, to try and make sure that they're looked after and have proper access to care, becomes an important consideration.
Finally, we have “beyond quality to value”. This is particularly relevant now when we are talking about the economy under threat because of COVID-19 stifling economic activity. We want to make sure that the care we provide is not just of high quality but is value-based. We want to make sure that when care is provided, it is appropriate and the cost of delivering that care is not inflated and creating a burden to the individual and the population.
The “three beyonds” provide key tenets of what we need to do. As we move along, we also need to consider the care model we want to embrace. What is the healthcare model that makes sense for the people in Singapore? Is it one that is hospital-based? We can now reach out to and allow people to enjoy access to healthcare services in their homes and communities. Telehealth becomes an important challenge – the pilots we've put in place during COVID-19 will likely last, but what we need to understand is whether we could do more. Is it just a substitution of the activities? The current telemedicine interactions work like a substitute – through a communication or a screen, but it's effectively the same type of clinical interaction albeit virtualised. Are we able to go a step beyond that to redefine some of the care encounters and think of different ways of doing things? COVID-19 has created the opportunity for these conversations to start even if they had been just brewing in the background previously, and it's important for us to rethink what our care model is all about. In the last eight months, we have been generating data of our clinical interactions with patients as we try to grasp how the pandemic is evolving. If we use this data to improve our understanding of disease patterns and predict behaviours, we can change disease trajectories and intervene positively with the help of technology and data analysis. Increasingly, I see doctors having to gain new competencies that we don't teach in medical school. We were taught about medicine, conditions, treatments, tests and investigations for diagnosis. In clinical practice, we realise that we need to go beyond that, to communicate better with our patients, to think about how we want to nudge behaviours in the right direction to promote health-seeking behaviours. The next step now is to make use of the data that we have, to analyse and find trends, and use that positively to impact the outcomes for patients. How would we want to use the data we have to identify what is important, to strategise and to prioritise? Perhaps the greatest challenge is that we're being asked to step up, to relearn, to gain new competencies, and hopefully these competencies contribute to making a difference for our patients.
Serving as a doctor-soldier
DF: Just a little change of direction here, you have a lot of experience as a doctor, but also as a soldier, because you have been serving National Service much longer than many of us.
KM: It is a bit of serendipity, I really couldn't have imagined I would be serving in the Singapore Armed Forces (SAF) for as long as I have, but I'll tell you that I'm not alone. I started out as a medical officer, no different from anyone else, and went through Medical Officer Cadet Course. Very early on, I moved out into dealing with other things, such as doctrine development, and spent a lot of time in the units doing non-doctor-related activities, so much so that most people would not have believed I was a medical officer given my involvement in different things. I did spend some time in a battalion casualty station (BCS), but as an operationally ready national serviceman, I went into other matters such as logistics combat service support areas. I have never actually worked within a combat support hospital. While most people think I'm very active in the SAF because I'm a doctor, the reality is my contributions are actually in non-medical related roles.
DF: Does that help you in your work, I mean, in the war against disease?
KM: I think it helps me look at things with a less traditional eye, and see things differently compared to others because of the different responsibilities and positions I held in the SAF. I tend to look at system issues and intent rather than processes and protocols. I became more outcome-focused compared to being task-focused. I think that that has contributed to the way I am in terms of my working style as well. I am less dogmatic about process and protocol but give importance to understanding the big picture and basic principles in order to do the right thing. That sense of a moral compass is especially important for me and stands me in good stead thus far. My service has also helped me when it came to COVID-19 and we had to have very close working relationships with the SAF, who stood up to help us quite a bit. A lot of people who are now contributing are close friends that I knew from the SAF, and it is much easier to work when you're working with friends compared to working with strangers.
Aside from work
DF: That is quite a lot of challenges. Perhaps you could share some light-hearted insights. Tell us a little bit about your favourite food or a book you would recommend?
KM: Food-wise, I'm partial to Japanese food. It's not always restaurant-level food but it's just something that perhaps gives me a little more comfort. I love anything soupy, so I don't mind ramen. I'm Cantonese, so I guess I have this cultural bias towards wanting to have soup with my meals, and that brings a sense of home especially if you are overseas. Pursuits-wise, I've read a lot of esoteric things, but for the average doctor, I think the book that really made a lot of difference in my early years was The House of God by Samuel Shem. It's a book that I read during my housemanship days, but it was a little bit cynical. It talks a little bit about the different motivations that people have going into healthcare, but it was one of those books that sort of set me off thinking that there's a little more to medicine than just a profession and that left me with a deep impression.
DF: Okay, that's a satirical novel written in 1978, sounds good. How about a movie you would recommend?
KM: Movies – well, I have not seen a lot of movies recently, especially in the last eight months. I guess I will not mind going back into the cinema again if not for the fact that COVID-19 prohibits us from having too much close contact with other people in the cinema. But musicals are something I really love; I loved Les Miserables. There was one musical I was really hoping to watch and that is Dear Evan Hansen. I have not watched it, but the music's great, so maybe one day I'll get a chance to watch it.
Words of wisdom
DF: What would you like to say to the front-line staff, those who are just beginning their careers, medical students and trainees, during this period?
KM: I probably have something different for the medical students and those who are already doctors.
For those who are doctors, I really want to thank them for the work they're doing. If you are in your junior years, it means you were plunged head-on into this war against COVID-19 because you would likely be in the clinics, hospitals and public healthcare institutions, and you would very likely have been deployed into roles and responsibilities that help us to either diagnose, treat or manage COVID-19 patients. If you were in that situation, I really want to thank you for all the hard work you have done. I know it has been a very long-drawn effort from each of you, and many of you might be feeling drained and tired. Many of us thought COVID-19 would blow off by June –that was what even some infectious diseases specialists had predicted and I was quite optimistic that we would bring things under control quickly. But as you know, it is very likely that COVID-19 will be here to stay for a long time, at least until we've got a vaccine introduced and vaccinations going. For many of us who aspire to be non-infectious diseases doctors and surgeons, COVID-19 can be something that is disheartening because it could be seen as derailing our career aspirations to go off on our Health Manpower Development Plan trainings, to travel and learn new things. But I'd like to encourage all of you that this is just one point in time. Many of us felt the same way during SARS, and since then there have been many opportunities for us to do what we wanted in our careers eventually. I want to encourage everyone to press on and to not lose heart – together we can work as one healthcare system to do the best we can for Singapore.
For students, I'll modify that message. You are looking at all this and observing on the side-lines. I'd like you to pay attention to what we're doing – not so much learn about tactics or how we manage patients, but to learn about the attitudes and reasons why we continue to go into the clinics and wards, to wear our personal protective equipment despite our misgivings, to go into a COVID-19 co-opted ward or ICU, and our willingness to look after patients in that regard. And I'd like our students to be able to appreciate that every day, because many of our doctors, nurses and allied health professionals make sacrifices of sorts. The sacrifices may be big – it may be in a setting where the risk of getting infected ourselves are high – but it may also be in settings where the actions we take and the commitment towards our work take us away from loved ones. We do it because we know we're making a difference and we're looking after people; it's part of our mission, our mandate, it's part of who we are as healthcare professionals. I'd like our students to be able to learn that so that when you graduate, you can understand the commitment we have, you can understand the reasons why we're doing this, and you can imbibe that and also contribute in the same way.
DF: Any last words you want to say to the readers of the SMA News?
KM: Well, I'm glad you guys are around, and I have to admit Hobbit writes very well. I continue to enjoy what comes on within the pages of the SMA newsletter and journal. You are doing good work where you are in the Association and I'm sure that we'll be able to find ways to collaborate and bring the whole medical community together in various issues that we find important. SMA has done very well for itself and we look forward to more good years for the Association. Keep strong, keep safe and keep healthy.
DF: Thank you.