If it ain’t broke, hurry and fix it

This story was first published in The Straits Times on March 29, 2013

PROFESSOR Philip Choo, 54, CEO of Tan Tock Seng Hospital (TTSH), doesn’t take strong stands in a loud voice. He makes insightful remarks in gentle tones. He doesn’t hold forth at meetings. He rallies people behind the scenes.

The self-confessed introvert finds public speeches and functions especially wearying, and walks 12km thrice a week to decompress in solitude.

It was severe acute respiratory syndrome (Sars) in 2003 that brought out the leader in him.

Then head of general medicine at TTSH, he stepped up to the plate, took tough decisions to recall all doctors on leave, excused no one from duty, and donned the N95 mask himself in the wards daily.

As Sars claimed 33 lives and fevers raged around him, he believed he would not outlive the outbreak. But he did and was awarded a Public Service Star.

Ten years on, he never talks about Sars, having filed it away as a “difficult time”. But the lessons that have stayed with him have emboldened him to take unpopular decisions today.

He is now in the thick of restructuring TTSH and the National Healthcare Group (Regional Health) which oversees health care in the central region of Singapore and where he is deputy group CEO. He feels he is up against Singapore’s fast-ageing population and the surge in sufferers of multiple chronic diseases.

Worldwide, he notes, even the world’s richest countries are mired in health-care bills. In the United States, Europe and Japan, with 13, 17 and 23 per cent of people aged over 65 respectively, one of the largest areas of expenditure is now health care, with the cost likely to escalate as their populations grey further. In Singapore, about 9 per cent of the population is above 65 today, with numbers expected to triple by 2030.

He notes that Singapore’s current hospital-centric health-care system, as with most developed countries, is just too costly.

It is great at acute episodic care, say taking care of a road accident victim, but lousy for those living with longstanding chronic diseases, like stroke and heart failure, he charges.

“I know I’m on a failed model. Today, we all wait for patients with problems to come to us. But unless you break from that cycle, start to put in resources to maintain the health of the general population, you will end up broke, like where the rest of the world is today.”He wants Singapore to be the exception.

Standardising health care

CONTROVERSIALLY, he is looking at bringing business principles for efficiency into health care. He talks about kaizen (Japanese continuous improvement philosophy) and “lean manufacturing” (systematically reducing waste) non-stop, which he learnt from the Toyota car factory in Japan during a study visit there in 2007. Over the past four years, he’s been busy introducing standardisation of care like assembly lines and categorising patients like car models.

He’s met with a chorus of outrage, he admits. “Standardisation” in health care is almost heresy to health-care workers, who have been taught to zoom in on the patient before them and offer individualised care, he notes.

But why should health care not follow the compulsory rule of business, which is to reduce variation, he argues. It’s entirely possible to plan as a system, as Disney theme parks and all hotels do, but deliver care in a personal manner.

“In health care, we already do that every single day. I roughly know what my patients need but I talk to them as individuals, demonstrating empathy,” he cites.

But won’t standardisation constrict care delivery since no two patients and diseases are created alike?

He disagrees. “You take what is best after research and experimentation and standardise it, so everybody gets the same good care every time. It’s the highest common denominator, not the lowest. Can you imagine flight safety with no standardisation, if we allow each pilot to check in his own way before take-off? Some days he does this much and other days he doesn’t? We’ll be horrified.”

Dr Kaizen

WHAT he’s done over the last few years is to divert almost a third of people who used to be admitted to TTSH elsewhere to be cared for in other settings.

Close to 70 per cent of all surgical procedures at TTSH, for example, are now done as day surgery.

Patients, who used to stay up to three days, have their care compacted into one. The moment their condition stabilises, patients are funnelled into community hospitals nearby. TTSH’s accident and emergency department also admits patients, for example with mild pneumonia, directly into the community hospitals. Teams have been sent in to expand care in nine nursing homes, so the ailing can be kept there.

He’s also working on identifying and grouping patients with similar needs together, taking a leaf from the Toyota plant, which he notes produces Lexuses, Camrys and Corollas all in the same assembly line because “they require roughly the same things”.

Of the central zone his National Healthcare Group (NHG) oversees, which has a total population of 1.4 million, only 350,000 have been treated at TTSH, its specialist clinics and nine poly- clinics. Using the data of the 350,000, he’s trying to categorise them into five groups – well, simple, complicated, serious, frail – based on how many chronic diseases they have and the level of complications.

With that, he’s designing a common template care model for each group. The aim: To maintain patients within each category as far as possible. For example, keeping the “well” healthy, preventing hospital admission for the “simple” and the “complicated” by phoning them often to check on them, cutting down admissions for the “serious” group by actively managing their care and preventing worsening of the “frail”.

After that, he plans to “get to know” the remaining 1.05 million who have never used public health care and are unknown to him.

“Today we don’t know them, we have to wait for them to become unwell to see us. The thinking is ‘I’m so busy, I’m not going to go out to look for more patients’. But we have to change that mindset as it represents a very expensive model of care we can’t afford,” he laments. “More knowledge, not less, is better. If I know my population and who is at risk but has not sought help, I can come up with specific intervention programmes.”

For starters, NHG is working with other agencies to do a door-to-door survey on Toa Payoh rental flat dwellers. They will list each resident’s health and social needs, offer them health screenings, and design a working model to deliver help to them in a coordinated fashion.

If there’s one thing he hopes to get done in his lifetime, it’s to get his new health-care model, offering good, affordable, standardised care, up and running.

Singapore, he believes, is about the only country able to plan for it right now. It still has a stable government able to think long- term, long-staying leaders at the operational level to carry it out and sufficient reserves to invest in the future, he says.

Old before his time

HE WAS the third of four children of a Singaporean general practitioner who practised in Kota Baru in Kelantan and a Malaysian housewife.

A year after the May 13, 1969 racial riots in Kuala Lumpur, his parents sent him to study here at age 10 with his siblings and brought them up by phone.

At St Michael’s Primary, St Joseph’s Institution and Catholic Junior College, he struggled with dyslexia and had to memorise facts up to 40 times for exams.

During school holidays in Kota Baru, watching the respect accorded to his father by the townsfolk, he was drawn to medicine – the only one among his siblings, who all worked in finance jobs.

As a University of Singapore medical student and young doctor, he found himself inexplicably gravitating towards older patients. “I can’t explain it but I feel comfortable with the elderly. I know what goes through their minds, I can understand what they say or don’t say.”

He chose to delve into geriatrics in Glasgow, a sub-speciality of internal medicine and family medicine that focuses on the care of elderly people, because he “didn’t want to choose between organs but wanted to see the whole patient”. His more practical peers dissuaded him. It was the antithesis of the “perfect specialisation” – old patients were usually poor, the working hours punishing, with little potential for going into private practice.

But he relished it, especially the challenge of caring for the frail elderly with vague bed histories and multiple problems, coupled often with mental issues and physical disabilities too.

He became Singapore’s first geriatrician in 1990 and worked towards setting up a dedicated department at TTSH and making geriatric medicine “an accepted speciality in its own right”. By 1994, he was head of department, then appointed divisional chairman of medicine a year later. Post-Sars, he was named chairman of the medical board from 2003 to 2011, before he assumed the CEO role two years ago.

Autumnal lessons

HE IS thankful for the retrospective life lessons attending to autumnal patients has bestowed on him. He has seen patients with 10 kids, all unwilling to look after them. And those with one kid who sacrificed everything to care for them. He’s surmised it all boils down to the depth of bonds forged. His conclusion: “You reap what you sow.”

He identifies so closely with his elderly charges that he has told off a woman complaining loudly about the inconvenience of her mother’s care within earshot of her daughter. He told her: “Stop what you’re doing. Your daughter will think this is the right way to treat her mother.” It resulted in an angry letter of complaint, he adds sheepishly.

The father of two children aged 22 and 19 – the older one is studying medicine here – who is separated from his family physician wife, spends a quarter of his time doing a couple of outpatient clinics and teaching once a week.

He reflects: “You get great joy when you work as a doctor but the change is actually limited to individual patients. But if you can change systems and mindsets, you broaden your reach a lot more. The issue is that the returns take a longer time to come back to you.”

He’s also reconciled to the naysaying. “If you are trying to change the system, you can expect a lot of noes because you are a deviation from the norm. Once you accept that as part of life, it’s fine,” he says with a shrug.

He doesn’t lose sleep or take the opposition personally. Sars and his older patients taught him to forge on, regardless.

This story was first published in The Straits Times on March 29, 2013

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