Knowledge gaps must be addressed for clinicians to better support public health system: NUS Medicine dean

SINGAPORE - There are four main gaps in knowledge that must be addressed so that clinicians - typically thought of as focusing on treating disease at an individual level - can better support the public health system in the future, Professor Chong Yap Seng, dean of the National University of Singapore's (NUS) Yong Loo Lin School of Medicine, said on Wednesday (May 4).

These gaps lie in the areas of practising medicine well in a community setting rather than just a specialised one, improving human potential, health economics and health systems, he added.

On April 24, Prime Minister Lee Hsien Loong, speaking at the Singapore General Hospital's lecture and formal dinner, said there is a need to further develop the country's emphasis on public health, following valuable lessons from the Covid-19 pandemic.

Public health refers to the study of how the health of populations can be improved and protected. This is sometimes contrasted to clinical medicine, which is about finding the best way to treat individual patients.

The Ministry of Health also recently announced its Healthier SG strategy, which aims to get family doctors to play a key role in spotting diseases earlier and keep Singaporeans out of hospital as much as possible.

The scheme will also see an emphasis on preventive care and more involvement from various public agencies such as the People's Association and SportSG in promoting healthy lifestyles.

The deans of Duke-NUS Medical School and Nanyang Technological University's Lee Kong Chian School of Medicine previously told The Straits Times that they believe the push to strengthen Singapore's emphasis on public health will see the role of clinicians shift in the coming years, including taking on the task of conveying and explaining public health messages.

Professor Thomas Coffman, dean of Duke-NUS Medical School, said: "While providing therapeutic care to patients will remain the major responsibility of clinicians, understanding and incorporating the contemporary principles of public health and preventive care will take on increasing importance."

On Wednesday, Prof Chong said: "Most medical schools are more about 'sick care' rather than healthcare. The focus has always been on understanding disease and treating it... but is that right? I don't think so."

He added: "If you want to really start to promote population health, then you have to think beyond patients who are sick, to those who are relatively well, and how you make them more healthy."

To this end, there is a need for a "new breed of doctors" who understand human potential in medicine.

In this context, human potential refers to ensuring that early life factors all align so that a child is born with the very best start that he or she can possibly have.

Among other things, this may involve ensuring a mother-to-be is not only physically and emotionally healthy, but also getting the right nutrition when she conceives - a subject doctors may not have much knowledge of, said Prof Chong.

"Promoting health begins with giving people the best start to life," he added.

He highlighted that too many doctors are currently trained to function in a specialised setting, such as a hospital, rather than in a community setting, such as in a general practitioner clinic.

In the community setting, it is crucial to understand that the social determinants of health are probably more critical than other factors, said Prof Chong.

"You (need to) understand patients' family background, what kind of environment they're living in... you can tell them to get more sleep, but if they're working on shifts, they can't put what you say into practice," he noted.

Prof Chong said many doctors lack knowledge about health economics. Citing the United States as an example, he added that there is an issue where doctors recommend a whole battery of tests for patients who are covered by insurance, even if some of the tests are unnecessary.

If a similar practice were to take place here, it would drive up healthcare costs, noted Prof Chong, adding: "We can't afford to go the same way, being defensive and prescribing tests without understanding... the cost-to-benefit ratio."

He said doctors need to improve their knowledge of the health system and how it works, so they can properly hand over their patients to the next stage of their treatment.

Prof Chong said, unfortunately, not all doctors here are equipped with such knowledge, referring to patients returning to a hospital a few days after being discharged as they did not know where to find care.

Prof Chong said his school has taken several steps to address these gaps in its students. These include recruiting experts in family medicine to improve training in this area, conducting research into longevity and human potential, and offering courses in health economics and health systems.

From around August this year, the school will also introduce five pillars of knowledge that are common across not just the school of medicine, but also the schools of dentistry, public health and pharmacy in NUS. These pillars are: Communications and behavioural science; health ethics, law and professionalism; data literacy; social and emotional determinants of health; and digital literacy. 

Adding that despite all this, doctors will still have to learn some key skills on the job, Prof Chong believes clinicians who first work as doctors and then go on to specialise in public health can contribute to the public health system with their knowledge of disease and experience on the ground.

He added: "I think there'll be a need for physicians who actually go out and practise, and then go into public health... This gives an extra dimension to the care they provide, in order to promote health as well as to treat patients."