Leading Innovation and Change at the Health System Level - Interview with DDMS A/Prof Dan Yock Young

Clive Tan

This is the full version of this article.

SMA News spoke with Deputy Director of Medical Services (DDMS) (Health Services Group) A/Prof Dan Yock Young to hear about his work in leading healthcare transformation, and his thoughts and perspective about some of the ongoing planning work for the healthcare system.

Dr Clive Tan – CT: Hi Prof Dan, thank you for agreeing to this interview with SMA News. To start things off, could you share with us who the role models and mentors you looked up to early in your career were, and what was it about them that inspired you?

A/Prof Dan Yock Young – DYY: This question alone will take the whole afternoon if I start talking about all my mentors. (laughs) I subscribe to the Chinese saying “三人行,必有我师” (idiom from Confucian Analects meaning there is always something to learn from other people). In life, we will meet many potential teachers; the question is whether we take the opportunity to learn from them. One of my professors once told me, “There is no such thing as a bad teacher; even if you learn nothing useful from them, you'll learn not to be like them.” There were many teachers in my journey, and a few true mentors in my training career who left an indelible mark.

When I was a house officer, I was posted to Singapore General Hospital’s Medical Unit III; we called this the “hell posting” at that time. The head of department then was Prof Ong Yong Yau – the great YY Ong. There was one evening at about 6 pm when we were still fervently clerking cases. He came by to do his evening round and saw that many cases were still unclerked. Prof Ong rolled up his sleeves and began clerking the cases, taking blood and setting IV plugs. We all went, “Eh, Prof is clerking cases," and quickly ran over saying, “Prof, we'll do this.” He said to us, “Why? This is a patient here lying in need, I am the doctor whom he needs, so why should I not be doing anything – I'm just doing my job.” Perhaps because I was very young in my career then, it struck me that that was the simplest and most basic form of doctoring, a doctor responding to a patient's needs. And that has always reminded me, even many years on, that the first and most fundamental duty of a doctor is to the patient. Even though we may belong to a system and there are hierarchies and so on, our first responsibility has to be to the patient. That experience left an indelible mark.

Moving to gastroenterology, I've had many teachers and mentors as well. I was very lucky that I had Prof Lim Seng Gee, Prof Yeoh Khay Guan and Prof Lawrence Ho, whom I call my mentors. I always tell the people that you do not need to confine yourself to just one mentor. In fact, I count myself very lucky to have three “foster parents” who constantly looked out for me, who would reach out and pull me along whenever there was a need. So, these are some of my role models. There are many more, but I will not mention all of them, or we will be here till tomorrow.

CT: Thanks, Prof Dan. Over the span of your career, you have also taken on a lot of different leadership roles. Do you recall which role was your most challenging?

DYY: I think the most unforgettable role so far was my involvement with the Joint Task Force response at the Ministry of Manpower, where I had the good fortune of meeting you [Dr Clive Tan] and many good and able men and women. That was the time when we had a COVID-19 outbreak among the migrant workers, and we were trying to bring it under control. I suppose what was unforgettable about it was that when we first went in, the virus was still very much unknown. The task given to us was mammoth and at times, there were no good solutions. The situation was volatile and there were times of uncertainty when we did not know how our strategies would turn out, which added to the complexity of the situation.

What I found most challenging about the experience was having to give the orders to our various healthcare clusters, workers and volunteers to go into the dormitories. As you would remember, the working conditions there were tough – it was hot, staff had to be all gowned up in personal protective equipment and safety was a priority. We had to share the logic and rationale clearly and convince the staff as to why they needed to go in; and they were fantastic – they lived up to their duty, their calling, and they did their job.

But the toughest part, I think, was lying in bed wondering whether, despite what we have done, the migrant workers were truly safe in their dormitories; whether we would see the light at the end of the tunnel; and whether all the sacrifices of our front-line workers were in vain or not. So when everything did come through and we managed to bring the spread under control, there was a huge sigh of relief. Going through it was a very challenging and humbling experience that I will never forget.

Shifts in the healthcare landscape

CT: The challenges within the healthcare sector are getting more complex now. Some have suggested that in healthcare, there is a shift from having a strong leader to strong leadership teams. What are your views on this?

DYY: I think of that in two ways. Firstly, leaders in the past also had great teams – Alexander the Great won campaigns with teams and the late Lee Kuan Yew also had a fantastic team to help build Singapore. We should not use it as an excuse that “I do not need to be a perfect leader; I have a team and I can take less responsibility.” Having said that, society and life are tougher now, and there are many facets of leadership that a single leader may not be able to achieve on his/her own.

Within healthcare, systems have gotten more complicated and more challenging. There are uncharted territories, unknowns and multiple areas to oversee, so you really do need a good team. Analogous to the example of the strategy in managing chronic diseases, in addition to pharmaceutical treatment modalities, you also need to integrate awareness of behavioural sciences and the cost-effectiveness of specific intervention and screening. Implementation also requires medical teams to demonstrate effective patient communication, and soft and pastoral skills. So certainly, having the huge complex village is critical to achieving the success. It has to be a more sophisticated version of bringing the whole team to reach where you want to go. In that sense, the complementary effort where everybody looks out for each other and makes sure that all your gaps are covered is extremely important.

CT: On leading and driving healthcare transformation at the national level, what are some of the major issues or challenges that you and your team are grappling with?

DYY: I will share from my personal perspective. To me, the biggest challenge is that nobody has gotten it right. Yes, we always want the system to be cheaper, better, faster – but when you throw in the aspiration for people to live longer and healthier, and have ready access to good care – there is an inherent tension that makes it very challenging for a healthcare system. Singapore has done very well for its healthcare system; our system is highly efficient. We achieved that through pushing our tertiary services and specialists in a way that make them accessible and affordable to most people. But I think society has come to a point where that model may not be able to hold up to the challenges of the future.

The concept of the “Three Beyonds”, in a way, is an effort to bring healthcare out of the hospital to the community, to re-centre on health and place more focus on value. However, I think we are at the point where we can go further to build a whole health ecosystem around the individual. It is a concept where we put the patient at the centre, then layer on the primary care and all the allied health services to support him/her in living a healthy life, and then finally building the secondary and tertiary care as the backup when the patient needs it.

Now, to achieve that goal, we really have to change peoples’ mindset. In transformation, we really need to break these deep silo towers and create a continuous health ecosystem that has a strong value proposition for the patient. The first thing we need to do is to paint that vision and picture for everybody to see what our healthcare system can be like. As daunting as it may be, it is also exciting because we have a chance to create a new picture on a blank canvas – everyone has a stake in the drawing. It means bringing the patients on board, alongside all the key stakeholders – primary, secondary and tertiary care systems, healthcare clusters, allied health services, social services, and everybody who is involved in making sure that our nation’s residents grow and go through life in best possible healthy state. The first thing we need to do is to paint that vision and picture for everybody to see what our healthcare system can be like. That is the grand plan; getting there is the tough part. I think that is the opportunity for us to really make a difference now.

Developing the future pillars

CT: Thanks, Prof Dan, for sharing on this future that we are working towards. Turning the focus to our young doctors, nurses and allied health colleagues – how do you think we should infuse some of these values and concepts a bit earlier in their training, to groom the next generation of thinkers and leaders?

DYY: This question touches on what is most existential for university education. I often joke that medical school robbed me of my education, because in professional training you are taught certain skillsets and protocols, yet the true essence of a university is really to teach people to disagree with what they have been taught, to unlearn what they may have been indoctrinated with, and to challenge and redesign the future. That is what I think university education hopes to achieve.

In that sense then, we need to train our people to be more flexible and creative. The world is moving at a very fast pace. What has worked before in the past may not be good enough for the future. As the saying goes – “If you don't change course, you will end up exactly where you're going”. The question is, “Are you satisfied with where you’re going?” Therefore, to really be one step ahead of the curve, you need to leverage on the opportunities that are available to you.

Today there's artificial intelligence, revolutionary medical technology, and all these new care models. We need to teach our young generation to be flexible and creative. We have always said that the solutions for their generation have not yet been thought of by us, and so it is up to them to chart their own paths. What we can try to do is to give them the background knowledge, skillsets and more importantly, the thinking process and framework, so they may leverage on what is being developed to build their own world.

CT: Thank you, Prof Dan. That really resonated with me. You mentioned the next generation of leaders in the healthcare sector – I think this would be useful for our younger readers, the aspiring leaders of the healthcare sector in their late 20s and 30s, to learn about. What do you think are some of the attributes that our future healthcare sector leaders should have?

DYY: Well, I think despite the rapid changes in medicine, , the base attributes of a healthcare leader have not changed. The ethos, the public-mindedness and integrity, those will continue to be fundamental. People need to see leaders as being principled and upright; they need to have a mind for the public good and a heart for public service. But to be able to build the future, we also need nimbleness, creativity and the courage s to dream of novel ways of doing things. Only then can we leverage and capitalise on the opportunities that are available to us. . I would encourage the young generation to learn and use what has been taught to you as a foundation, but do not let yourself be restricted by it. Instead, strive to break through and create new possibilities.

Riding the wave of change

CT: Looking back at the last ten to twenty years, healthcare has undergone many waves of transformation, and it sounds like we're going through a wave of important systemic changes right now. With any change, I think there will be some doctors who may feel like they are not in control, that they are being caught up in this wave. I was wondering if you have any advice for these doctors, on how to be better prepared for this future?

DYY: The rapidly changing world will mean that everyone, doctors included, will have to be adaptable and dynamically agile to keep up with the times. Although doctoring in its basic sense – the traditional doctor patient relationship – has not changed, the approach, emphasis and the operating tools will shift quite significantly. Fortunately, it usually does not require a complete makeover but a pivot to embrace the new opportunities that come along. After all, the science of medicine is by nature, unassuming and ever-ready to embrace new evidence and chart new directions. An open-mindedness to learn, try, and evolve along the way, will help tremendously. At the heart of our trade, our relationship, responsibility and trust with our patients will not change.

I think in the future, with the world evolving so quickly, we will have to be more deliberate about paying attention to the end-to-end transformation process. This is what the Civil Service alluded to in the three core steps of transformation – dare to dream, clarity of plans, and effective execution. We are generally quite good with the first two stages – we do dream a little bit and are very good at drawing policies and plans, but the execution is always the most challenging part. And in healthcare, we know we have lots of models, lots of pilots and ideas, but execution could possibly be faster, and more focused on scaling up for maximum impact. To achieve that, we require more than just knowledge and skills – it also requires relational factors, to be able to convince, excite and bring people with you along this journey. Convincing not just your staff and your team, but also the patient. To be able to convince your patient to change, to eat and live healthily, is a new science, and these skills and techniques were not taught in medical school during my time.

CT: Some have likened this change management issue for the healthcare system to shifting a very big ship, which would take a really long time. Is that your opinion as well?

DYY: Yes, changing the healthcare system is a huge endeavour, just like you said. People have described the healthcare system to be fundamentally complex. The analogy of healthcare is like a geometric game where every point must stay equidistant with the other two. Shifting one point will shift everything else along with it, and movement will continue for a long time because everything is in relation to each other. Another analogy is that healthcare can be likened to a straitjacket. You can never undo all the knots; you just have to tighten it so that it is in balance, in homeostasis. Undoing one part may cause slack in another area and you may lose balance in the system.

I think those are the sort of fundamental challenges in healthcare, which is why it has been so difficult to tinker with it at the edges. But once we set the vision of where we want to go, it gives us a better chance of being able to move the whole system. Otherwise, we end up tweaking the system a little bit here and there, and the whole system does not move very much; worse if it becomes unstable, which makes it difficult to achieve our end point.

CT: What you mentioned sounds like complex adaptive systems and healthcare systems are indeed a well-known example of it. People who have to manage complex adaptive systems need to be trained to look at things differently, and to intervene differently because of the nature of such systems. In that sense, how are our healthcare leaders doing in terms of changing this complex system?

DYY: I think you brought up a very good point. We need to start getting the younger generation to think like this. . Many in my generation, in our old school ways , may tend to have a “this is how it has always worked” attitude; we take a spanner and tighten or loosen a screw here and there In complex systems however, you cannot do that because it would not work.. So I think it will require a whole new mindset and skillset. This has to be included as part of our leadership development process, so that our young people have that ability to take on the challenges of the future, rather than use a very old toolbox that they were brought up with.

Learning from the pandemic

CT: From your experience and vantage point, how did this pandemic crisis transform our healthcare leaders, especially since everyone in healthcare was involved in the response in one way or another?

DYY: COVID-19 has been called the great divider. Because of its many unknown aspects, people hold very strong differing views of what should be done. In a way, COVID-19 issues touch on some of the very fundamental tensions in society – the individual versus common society; being conservative versus being pragmatic; being consistent versus being nimble and flexible to change. Those are the sort of polemics that can cause a lot of angst, and in a big way it has changed how healthcare leaders think and imagine how we can get some of those policies through. Because they say policy is what you plan, but the impact is what you are able to effect . We need effective implementation – and that is where we need leaders who not only can come up with good ideas but are able to persuade people to follow those ideas.

Throughout this COVID-19 pandemic, I felt that our healthcare leaders have had the opportunity to sharpen the trust and relationship with the fraternity to align everyone in the same direction. Even amid the initial confusion, the whole healthcare fraternity and ecosystem have never been more aligned. A lot of things that we had previously thought impossible have also been made possible and accelerated by COVID-19. For example, we took years to develop telehealth, and COVID-19 gave us the opportunity to fully implement it. Many other new pilots (eg, hospital-at-home) have been accelerated through the development and implementation process under these circumstances and demands. I think we have gotten more nimble, and more aware of the multiple facets of policy decision making. Good things have been borne out of COVID-19 – we should leverage and learn from these opportunities to sharpen ourselves. People have said that the biggest mistake of COVID-19 would be to wait for things to go back to normal and go back to our old ways.

CT: You mentioned a lot about gains. There is an ongoing conversation about how we must actively lock in these gains, so we do not retrograde from where we are at now. Do you have any advice on how, as a healthcare system, we can lock in these gains?

DYY: I think there are two levels to it. The first is that COVID-19 allows us to look at the problem from very different perspectives. Naturally, when we are caught in the humdrum of the pandemic, we are only seeing parts of an elephant. Yet in our response planning, COVID-19 forces us us to take a step back and consider the other perspectives and overall implications. It has forced us to be more circumspect, more insightful and learn to develop a more holistic, big-picture view of the situation. The second thing we need to learn from COVID-19 is that in complex unpredictable scenarios, we have to be dynamically agile to plan, appraise, glean lessons and quickly re-strategise, The next challenge may or may not be another infectious agent, It is not what we have set up as standard operating procedure but whether we have distilled the principles we can draw and learn from it.

Staying mentally and physically healthy

CT: Prof Dan, tell us a bit about your work-life balance. There's so much demand on time, and work is also quite relentless, so how do you balance all these needs?

DYY: I have had people ask me how I balance all these multiple parts, and my response is that I do everything badly. (laughs) Having said that, I don't think my time demands are tougher than the average Singaporean. I have come across many average Singaporean, doing two jobs, working seven days a week; and they found a way to get on with life. What is important is that we make every minute count. Every minute that you have, you want to make sure that you make the best of it. For example, whatever time you have for unwinding with your family, you make sure that it is focused quality time. And you learn to reduce the time that you waste or not do anything with. To be fair, I think to be able to strike a good balance also requires the good fortune of having a very independent and supportive family. I am by nature also very low maintenance, so that helps. (laughs)

CT: So how do you unwind or destress?

DYY: I try to run, though my physique does not really show it. Not to sound too superficial, but I feel that one thing I learnt about running is that when you are gasping for life after a run – it is the closest to a feeling of being alive. So that is my way of de-stressing. Although I have not been too successful at it because of increasingly limited time.

CT: I can totally relate to that. Taking long walks and running just gets me into a different space.

DYY: Yes, I also like running in the sense that I time myself – every run I want to do better. I have this motto that every run must be better and faster than before. But ever since crossing 40 years old, I have realised that yesterday was always better. (laughs)

Final thoughts

CT: Prof Dan, as we reflect back at your own journey, from a clinician, to going into research, teaching and your current post as DDMS, how would you describe your journey in medicine and leadership?

DYY: I feel extremely fortunate and privileged to have met some excellent people in my life. Whether they are my mentors, my teachers, my mentees, people I work with or people who have helped and supported me, it has been a tremendous experience and they have defined me. And it is such a privilege to work and interact with people – that helps fuel the energy that drives me on. I often say that I do not know which is more exciting – having come so far together, or having so far more to go. I look forward to working with more people and learning from them- colleagues, juniors, students, friends and patients - for they enrich my life and I am so thankful for them.

CT: 50 is the new 30, right? (both laugh) Thank you so much for your time and for sharing your thoughts with our readers.