N Balachandran Professorship Lecturer

Orthopaedics in Singapore-Brave New World ?

Dr Kevin Lee

"16,012; in 189 batches of identicals. But of course they've done much better," he rattled on, "in some of the tropical centres. Singapore has often produced over 16,500; and Mombasa has actually touched the 17,000 mark.”

And so goes one paragraph in chapter one of Aldous Huxley’s 1932 classic Brave New World, in which our little island state gets an honourable mention as one of the fictitious cloning facilities that manages to create 16,500 individuals from a single ovary.

I first read this book when I was twelve. At that time, I was both fascinated by the small parts of the book that I could understand and befuddled by the majority of the medical jargon that littered the whole of this great piece of work. That started my journey into this wonderful field of medicine as I resolved to unlock the message behind the book.

I re-read this again when I was in medical school, when I thought I was more equipped both technically and mentally to tackle the book and I ended up with more questions than answers. In this current day and age where stem cell and genetic research have not only raised hopes of discovering new cures for debilitating and fatal illnesses, but have also put the power of reproductive cloning in our hands, the dawn of a Brave New World is at our doors and now is a good time to reflect on the good and bad in our little world of Orthopaedics.

When I was still a student in junior college doing a project with the National University , I had no access to PubMed or Medline and there was no computerised databases of patients. Journal articles then were not available online and communication then was still largely snail mail. How times have changed and I marvel at the tools we have at our disposal now – the Internet, video-conferencing, online databases, online journal articles, web conferences and the often taken-for-granted and ubiquitous email. Long before the government got interested in research and biotechnology as the next engine of growth for our economy, we were already doing research into ways of improving our field of bone and joint surgery. Now that the government is getting into the act, I must say things are definitely looking even brighter. We are spending huge sums of money on bringing in talent from all over the world as well as building our next generation of clinician-scientists through scholarships and awards. We have managed to nail some big names like Professor Edison Liu and Dr Alan Colman and all this bodes well for our reputation as a biomedical hub. In the book Zen and the Art of Motorcycle Maintainence, Robert Pirsig wrote:” The truth knocks on the door and you say,’Go away, I am looking for the truth, and so it goes away’.”

Thank god our government has seen the light and in the field of stem cell research, I think we are right to have taken a logical and sensible approach and involved the public and religious leaders in formulating a workplan for researchers to follow. There are currently no legal restrictions governing embryonic stem cell research as such in Singapore . The Bioethics Advisory Committee (BAC) has made recommendations regarding embryonic stem cell research to the Life Sciences Ministerial Committee in February 2002. The Singapore government has accepted the BAC's recommendations and legislation is now in process. This gives us a great advantage over scientists in the United States where federal-funded projects are subjected to many restrictions which we do not face. We should thus push on in this next big race which I dare say will change the whole practice of medicine. Regenerative medicine is very real and is the next big thing, not only economically but also medically.

There is one problem though. I strongly believe we are under-utilising one large group of potential scientists in our field of orthopaedics- and that is practising clinicians. Too many of us who might have a greater research output are bogged down by administrative duties and service requirements as mentioned in the earlier paragraph. We are actually a vital link between the basic scientists and the real clinical world and should be given protected and paid time to do research. Appropriate renumeration should also be given to clinicians who devote their time and efforts to seeking new knowledge, and money should no longer be seen as a dirty word in the doctors/ surgeons vocabulary. True altruism is rare and I believe that it is the privilege of the rich. I know this is a controversial statement but let’s face it- doctors are humans with families to feed and taxes to pay. Unless you have old money, most people I know will not say no to more money.

The simple truth is this: Free good people who do good research from administrative duties and give them reasonable service standards to meet, and renumerate them well, and you will have money-making patents, instruments, devices and drugs coming out in time to come. More money can then be poured back into research and both the government and clincians/ scientists will be happy. Simple right ? Wrong. When money comes into play, nothing is simple. People will say that money is the wrong motivation to do research and it should be done for the pure passion and love for it. I dare say that the majority of us are guided by our conscience and we will still push forward in our quest for knowledge irregardless of whether there is money involved or not. Lee Kuan Yew’s theory comes into mind here: Pay the politicians top dollar to eliminate corruption. It is not a perfect system but I believe it works.

The other question is the issue of ethics when commercial concerns tie-up with our institutions to do research. When research is funded by companies out to make a profit, the bottomline is no longer the patient but dollars and cents. And we are no longer doctors but businessmen. And who should cheer the loudest when a Singapore biotechnology firm CellResearch Corporation discovers a new source of stem cells in the outer lining of the umbilical cord? The directors of this company when it goes for its IPO or the patient who has to pay thousands of dollars for his cell therapy?

The winners will be the companies and the government will be happy too because more investments will come in. The rich patients will also be cheerful for they can afford the new treatments. The poor patients will be happy in about 10 years when the patents run out and they can finally afford the treatment, if they are still alive. Everyone should just wake up to the fact that the business we are in is changing rapidly and might no longer be the business that we used to understand. I am not sure if the not-for-profit model for restructured hospitals is still in place. I ask this because I am confused. I keep getting emails saying that the institution that I am working in has done well or poorly in this or that quarter and that the net deficit or profit is so and so and that the bonus that I am getting is pegged to how well we have done financially. I might be an orthopaedic surgeon but I can tell that does not sound very not-for-profit to me. Money again is at work.

After money, let me talk about training. Orthopaedics is truly an apprenticeship. We are surgeons, not physicians and we learn best by observing, assisting and performing surgeries under great surgeons, and not through books and theory. Albert Schweizer once said:” Example is not the main thing in influencing others, it is the only thing.” We can perform a hundred virtual computer-simulation or cadaveric surgeries and still get lost in the varied anatomy of a live human body. Nothing beats the tutelage and guidance of a Master-class surgeon and I will always remember what one of my teachers once said to me: “ A great surgeon makes the surgery so simple that you believe you can do it yourself”. I fear that this time-honoured relationship not unlike that of a pugilistic master and his disciple might be slowly eroding away.

The practice in all the restructured hospitals now sees the surgeon juggling several roles: surgeon, doctor, teacher, researcher and administrator. Even superman would have trouble wearing so many hats and end up dropping one or two of them. Unfortunately, teaching and mentoring might sometimes be the ones. With the emphasis on “quality standards” like lead-time or waiting-time, and with most surgeons’ renumeration dependent on the number of cases operated on and seen in the clinics, the incentive and time available to teach drops. And in this increasingly litiginous climate, the type of cases operated on by both basic and advanced trainees will drop in complexity, unless surgeons are given the necessary motivation to supervise them. All this will lead to what I call “dumbarisation”, where every level of trainees drop a level of competence.

As it is, with the larger cohorts of medical student intake, we are already seeing a sizeable number of students who obviously have neither the aptitude nor attitude for this field graduating into equally inept house officers and these people will need supervision and mentorship to lead them back from the dark side and this again needs time and effort. The apprenticeship system cannot, and must not be replaced. The rot has to stop and it has to stop now. I leave this topic with a quote by Robert Townsend:” If people are coming to work excited . . . if they're making mistakes freely and fearlessly . . . if they're having fun . . . if they're concentrating doing things, rather than preparing reports and going to meetings - then somewhere you have leaders.”

Thailand is a beautiful country. I had the opportunity to visit Bangkok ’s AO Centre- Bhumipol Hospital as the AOEA Fellow in 2004. I lived and operated with their residents and found that they were as knowledgeable and skilful as us, but the difference is their overwhelming humility and graciousness. Their friendliness and hospitality contrasts starkly to some of the treatment that fellows here receive. Arrogance is not confidence, and some of our residents who talk the talk before they can walk the talk have a lot to learn from our Thai friends. At Stanford University’s 114 th Commencement, Apple CEO Steve Jobs told an audience of 23,000 “ Stay hungry, stay foolish”. I wonder how many among us are hungry and how many of us are complacent and happy with the status-quo. With the current medical school fees, I wonder how many poor but bright students have given up their dreams of being a doctor. Are we self-selecting a group of financially elite doctors who can afford to pay their way through school and also break their bonds if they so fancy ? In the book Hunt For Red October, there was a line that went:” When he reached the New World , Cortez burned his ships. As a result, the crew was well motivated.” With the current medical school I struggled through medical school at the time when fees were about $13000 per annum. I was from a single income family with a young sister at that time and other than using my mother’s CPF and taking a loan from a bank, I supplemented whatever money we had by giving tuition on weekdays and working at the windsurfing/sailing centre on weekends. I was real hungry and real motivated because my ships were all burned and I had no way back to my old life. Someone in my same shoes today will have to work even harder and be even hungrier than I was to pay off his tuition fees. The road ahead for this guy will be tough, but he will be the hungry and foolish guy that Steve Jobs would like in his company. And it will this type of character that we need to fight off the competition from our neighbours in the race for the medical tourism pie, and not the soft, whiny boys that Philip Yeo so detests.

I also visited Bumrungrad Hospital at the invitation of Dr Suthorn and was swept away by their service standards and technological advancement. No wonder they have the lead in medical tourism. In fact they had JCIA accreditation long before our hospitals and have the lead in attracting middle-eastern medical tourists. We must leverage on our strength in research because we cannot compete on costs and other attractions like beaches and sights. We do have an advantage in having a united government without different lobbying groups obstructing key decisions.

It is heartening to see them take the lead in the field of biotechnology and genetic engineering and I think the rewards will pay off sooner than expected.

The opening of the Sports School and the soon-to-be-opened 650 million dollars Sports Hub in Kallang also bodes well for us in becoming a regional orthopaedic centre. We can become the centre for education and treatment of elite athletes from around the region and even beyond, and I am thinking of the markets of India and China . With the current intake of medical students at 300 compared to my cohort of 130, we could possibly train enough orthopaedic surgeons to run our satellite centres in the 2 most populous nations in the world.

The future of Orthopaedics is bright and I am grateful to be a part of it. Adventure is worthwhile in itself and it is better to have tried and failed than to have never tried at all. We will need passion, confidence and tenacity to move on to the next level on the world stage but the difficult part is to also maintain our sense of humility, integrity and sense of duty to our patients. In our push to open up new frontiers and boundaries, we must never lose track of what makes us first a human and then a healer. I end this essay with the words of Galileo Galilei:” I do not feel obliged to believe that the same God who has endowed us with sense, reason, and intellect has intended us to forgo their use.”

Dr Kevin Lee