fourth medical school is not the solution for more doctors.

Singapore requires more doctors, but establishing a fourth medical school is not the solution.

Recent reports about long wait times and foreign doctor recruitment raise the question of how Singapore can expand its healthcare workforce. Doctors Benjamin Lee and Jeremy Lim argue that a fourth medical school is not the solution.

SINGAPORE: Singapore’s healthcare requirements will only grow over time. With the number of seniors expected to double by 2030, many more of us will be affected by chronic diseases like diabetes, dementia, and cancer.

This will almost certainly increase the demand for healthcare workers. We are already feeling the effects of a healthcare manpower shortage, with long wait times at emergency departments – in October, some patients were asked to wait up to 50 hours for a hospital bed.

After a recent MOH Holdings tender on recruiting doctors from India sparked online debate, the Ministry of Health stated that while local medical schools continue to be Singapore’s main source of doctors, foreign doctors are also recruited to help ease workload.

The government has promised to add 1,900 hospital beds over the next five years, but this will do little to improve the situation unless we simultaneously expand our healthcare workforce to staff these beds.

Photograph of a doctor conversing with a patient. (Photo courtesy of iStock/Sarinyapinngam)
How does Singapore’s healthcare workforce compare to that of other countries? In comparison to countries such as Norway and Australia, we have fewer doctors, nurses, and pharmacists per 1,000 people.

While Singapore has maintained high standards of care despite having fewer healthcare workers (often topping Bloomberg’s annual list of countries with the most efficient healthcare), the combination of a rapidly aging population and an increase in chronic diseases means that the need for more healthcare professionals is unavoidable.

How should we go about doing so? Is the most direct way to establish Singapore’s fourth medical school?

A fourth new medical school will be expensive and may be unnecessary if it adds nothing to the current mix.

Our three medical schools each have their own distinct flavor and set of strengths: The youngest school, Lee Kong Chian School of Medicine, focuses on technology in medicine; Duke-NUS Medical School focuses on clinical research; and Yong Loo Lin School of Medicine focuses on training highly competent clinicians to meet the majority of Singapore’s service needs.

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It may be more beneficial to expand existing schools and build on their existing foundations rather than investing more resources in developing new infrastructure, designing curriculums, and hiring staff.

If all three medical schools increased admissions by 10%, they would be able to produce an additional 50 doctors, which is equivalent to the pioneer intake of medical students at Lee Kong Chian School of Medicine in 2013.

Encouragement of Singaporeans studying medicine abroad to return home could also be increased. Already, approximately 200 overseas graduates return to Singapore each year.

One simple place to start is to expand the list of overseas medical schools whose Singaporean graduates are permitted to practice locally, which was reduced from 160 to 103 in 2020, citing a declining need for overseas-trained doctors.

However, we must also consider removing barriers, such as the difficulty of adjusting to a different pace and healthcare system, in order for this group to return home and serve Singapore.

Planning healthcare manpower can be more of an art than a science. More trained doctors entering the system are insufficient if not enough of them remain in public healthcare, where manpower is most needed to provide more affordable care to a larger population.

The mental health of healthcare workers has recently come under scrutiny. Is there a positive shift taking place? (Image courtesy of iStock)

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Approximately 1,500 healthcare workers resigned in the first half of 2021 alone, compared to approximately 2,000 annually prior to the pandemic. Nurse resignation rates in public hospitals reached a five-year high in the same year.

Doctors are also leaving, some for private practice and others for good, citing factors such as low pay, long hours, and burnout. It’s a never-ending cycle: those who stay in the public sector are forced to work longer hours, which drives more to leave.

Of course, this is due in part to the COVID-19 pandemic, which physically and mentally exhausted our healthcare workers. However, it has brought to light other more systemic issues, such as the stresses experienced by junior doctors who may work 30-hour shifts.

The newly formed national wellness committee for junior doctors is a positive first step, but it remains to be seen whether it will have any impact.

Though Senior Minister of State for Health Janil Puthucheary stated in Parliament in November that the attrition rate of doctors in the public sector is “acceptable” at around 3% to 5% from 2019 to 2021, attrition is still a significant waste of resources, and more can be done to prevent it from worsening.

Instead of increasing the supply of doctors, how about lowering the demand for them?

For far too long, healthcare has been physician-centric rather than patient-centric. Doctors are important, but their importance is frequently exaggerated, with doctors frequently performing tasks that other colleagues could do (and possibly better).

This can include training current healthcare professionals to perform tasks that were previously thought to be reserved for doctors. The National Collaborative Prescribing Programme, for example, prepares advanced practitioner nurses and pharmacists to prescribe medication independently.

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Empowering our other healthcare professionals not only relieves doctors’ workloads, but it can also improve job satisfaction in these professionals and aid in workforce retention.

Redistributing work also entails reimagining roles such as health coaches and behavioral therapists to relieve doctors of some of their responsibilities. They can assist doctors in roles such as assisting patients with lifestyle changes, medication adherence, and other desirable patient behaviors in Healthier SG.

Technology can also assist our overburdened doctors. Artificial intelligence has the potential to analyze data and recommend treatment steps, allowing physicians to make better clinical decisions faster. This, combined with an electronic medical record system that assists rather than frustrates doctors, can help reduce their workload.

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Singapore is recovering from the COVID-19 pandemic, but the underlying demographic and epidemiologic shifts will continue inexorably. We are one of the world’s fastest aging countries, and we will require a large number of additional doctors and other health professionals.

However, we have a wide range of tools at our disposal to address the health workforce challenges. It is premature to seriously consider a fourth medical school, which may only be a costly stopgap measure if the remaining gaps are not filled.

Dr. Benjamin Lee is a resident in preventive medicine at NUHS. Associate Professor Jeremy Lim is the director of the NUS Saw Swee Hock School of Public Health’s Leadership Institute for Global Health Transformation.

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