Saturday 21 July 2012

Liak Teng Lit: Why the dung beetle is his hero

A man given to startling pronouncements, Alexandra Health group chief executive Liak Teng Lit gives Susan Long the lowdown on what ails the health-care system today: over-treatment, over-specialisation and over-generous subsidies.
The Straits Times, 20 Jul 2012

A 78-YEAR-OLD nursing home resident was wheeled into hospital in a comatose state. He suffered from dementia, had one leg amputated and the other was gangrenous due to poorly controlled diabetes. He had no known family members.

Mr Liak Teng Lit, then chief executive of Alexandra Hospital, was discussing with over 200 doctors and health-care professionals whether they should proceed to amputate his remaining leg.

Two-thirds voted 'yes'. Doctors, after all, are under oath to save lives. When he asked how many would want to be operated on if they were the patient, two said 'yes'. The rest said 'no'.

It was a moment of epiphany, he says. 'We discussed why we do things for our patients that we wouldn't want done to ourselves. The answer that came back was, 'I don't know what he wants, so I do my best. My best is to prolong his life.' But if we were the patient, we wouldn't want those kinds of extra days.'

The human body is designed to die eventually, he says. Fighting death hooked up to ventilators and fed through intravenous tubes results in the patient having 'unnecessary procedures which do nothing but extend pain'.

'But it's easier to overdo than to underdo, because if you overdo, nobody is going to scold you.'

In April, the straight-talking 59-year-old was appointed group chief executive of Alexandra Health, a health-care cluster that serves northern Singapore.

Sitting in his office in the award-winning Khoo Teck Puat Hospital (KTPH), whose construction he oversaw, he muses that this is the age of overdoing, especially for the well-heeled desperate to buy more time with loved ones.

The father of three children aged 23, 22 and 14 has given strict instructions to his wife, a pharmacist turned housewife, that the day he can no longer recognise his family is when he does not want any form of artificial intervention such as tube feeding or even oral antibiotics. 'When the end comes, it should come,' he says, adding that many doctors and nurses choose this path because they, more than anyone else, understand the limits of medicine and 'have seen enough'.

When his mother died at 78 of advanced colon cancer in 1993 and his sister at 56 of late-stage liver cancer in 2008, both opted for palliative care rather than further treatment. 'They had a good death, surrounded by loved ones. There was no unnecessary pain and we had a little celebration of their lives,' he recounts.

The runner, who clocks 25km a week and has finished eight marathons - his first at age 51 - says his preferred way is to die during a race. 'That's exactly the way I want to go, being healthy and fit,' says the man known for making jaw-dropping statements with a deadpan face.

Doing too much

BESIDES over-treatment, what ails the health-care system here is over-specialisation and subsidies, he charges.

Even though pay structures incentivise it, he disapproves of the specialist and sub-specialist tracks that doctors take early in their careers. Today, he laments that many doctors have become 'technicians' of a very small part of the body and operate in 'silos'.

The eye doctor no longer looks at the whole eye. Some do only cataracts, some look after the retina, others the tear duct. Typically, a patient comes in with a host of issues effecting multiple organs. He or she is worked on by six different 'technicians', each focusing on one sq cm of the body, who don't have time to talk to each other, and end up asking the same questions and ordering the same tests. 'Even if they do talk, who's to decide what is the overall thing to do for the patient?' he asks.

What is needed, he suggests, are more 'T-shaped' doctors who have a broad-based foundation before they specialise.

He frowns upon how subsidies have inflated the demand for health care and led to shortages: 'The truth is when we go for a buffet, almost all of us eat a little bit more than we normally do. If you subsidise something, at the margin, there will always be more demand.'

Subsidised wards are so cheap, some children may prefer their elderly parents to stay a day or two longer. But if every patient delays discharge by just half a day, Singapore will need to build another Singapore General Hospital that costs $2 billion, and about half a billion a year in subsidies, to run.

The demand for subsidies is a 'bottomless pit', he warns. 'If you're going to subsidise my petrol, I won't drive the Toyota Prius, I will drive the Lexus 460.

'Follow the British National Health Service? That may mean that the Government has to increase the goods and services tax to, say, 20 per cent to cover the cost of these additional beds,' he says, adding that Singapore's 3M framework - Medisave, MediShield and Medifund - is sound.

As diseases are increasingly diagnosed at the molecular level with more expensive drugs, costs will shoot through the roof.

His fear for Singaporeans today is that they clamour for their rights but disown their responsibilities. 'In cyberspace, there are howling monkeys who scream, shout and demoralise others.

'My worry is that everybody is screaming about his rights as a citizen to get subsidies, but he doesn't feel he has a responsibility to contribute or pay his taxes. They have the right to treatment but don't have a responsibility to take care of their health,' he says.

One speed system

THE Ministry of Health, he says, should be renamed the 'Ministry of Illness' because most of its work is in illness care. Health - how individuals live their lives - is what takes place outside the hospital, he says, pointing to the HDB blocks in Yishun Central.

The problem with hospitals here today is they are a 'one-size-fits-all' model trying to do 'fast medicine' everywhere, but 'doing nothing well'. Singaporeans rush to the hospital with minor ailments, routine vaccinations or check-ups that can be done by GPs, dieticians and nurses.

Alexandra Health is trying to do it differently by integrating its work, facilities and staff fully with the community. He wants the health cluster to offer 'head-to-toe lifelong anticipatory health care of the whole person', with a team caring for the whole person, not each doctor caring for one body part.

It has six nurses who run up to the neighbouring blocks to check on frail people and change their tubes. It is also exploring virtual consultations for bedridden patients who would otherwise need an ambulance to be brought to hospital to see a doctor. Bank call centres are his prototype, as half of all banking transactions are now handled by phone. His target for health care: 30 to 40 per cent.

He is also planning the upcoming Yishun Community Hospital (to be ready in 2015), where an elderly person, after staying at KTPH for three days for a knee replacement operation, can move into for two weeks to get used to new medicine and a new routine. In the works is also an off-site specialist's centre - for outpatient and day surgery - at Admiralty MRT station by 2016.

But his end goal is really to enable someone who is bedridden to stay home until the end, minimising visits to the hospital. He hopes that slightly younger neighbours in their 60s, who are still fairly fit, will step up by helping to prepare an extra meal and sponge bathe them for a monthly fee of say, $500.

Work like hell

IRONICALLY, the man who ended up overhauling many hospitals and the face of health care here was turned down for medical school. He was the free-spirited seventh out of eight children of department store owners, who spent most of his time building aircraft models and catching fish in the drains of Johor Baru.

His report card through primary school was 'a sea of red with very few islands of blue'. He only bucked up nearing his O levels, making it to Victoria School here to do his pre-university, then the National University of Singapore (NUS) to study pharmacy, his second choice. He topped it off with an MBA from NUS and a masters in pharmaceutical sciences from the University of Aston in Britain.

The man whose mantra is 'learn from everyone, follow no one, look for patterns, work like hell' was involved in restructuring major hospitals, including the National University Hospital, KK Women's and Children's Hospital and Singapore General Hospital. He was chief executive variously of Alexandra Hospital from 2000 to 2010, Changi General Hospital from 1997 to 2000 and Toa Payoh Hospital from 1992 to 1996. From 2010 till earlier this year, he was chief executive of KTPH.

He ruffled feathers two years ago when he said excess weight might weigh down a health-care worker's career prospects.

Around KTPH, signs abound encouraging people to take the stairs. Healthy options in the hospital canteen, such as brown rice, are priced cheaper. He methodically picks up every piece of rubbish in sight, disapproves of bicycles not parked in assigned bays and clears tables of cups left behind.

Change, he believes, starts with himself, then getting the right people on the bus with him, then 'slowly inching towards perfection'. He has set bold benchmarks for his hospitals: to be as verdant as the Singapore Botanic Gardens, to orientate guests as well as Ritz-Carlton Millenia hotels, to operate with Ikea's efficient simplicity and to turn beds around as fast as Singapore Airlines does cabins.

The man who subscribes to Buddhist philosophy has this advice for aspiring change makers: Don't expect any support from higher-ups or people around you. 'All laws, all rules, all organisations, all systems and processes exist to maintain the status quo.' His goal is to plant a million trees and do his part to make Singapore 'a city in a tropical rainforest'. He reckons he has so far planted or commissioned the planting of over 300,000 trees - about a third of his target - through all the projects he has undertaken to bring healing nature everywhere.

He says straight-faced that his hero is the dung beetle, which feeds on faeces. 'They walk the ground, burrow underground, clean up the environment, recycle nutrients and improve soil aeration. Most of all, they solve problems others leave behind.'

His views on...


'I think HDB really needs to redesign so that every six blocks or so, they have a common space with coffee shops, hairdressers and convenience stores, where old and young can naturally bump into each other and build a community. The way we live now, most people don't know their own neighbours. Twenty years from now, one in five Singaporeans will be above 65 and one in 10, above 80. Close to half a million people will be either bedridden or in wheelchairs. I half-jokingly told HDB, it is going to need staff to walk up and down the corridors sniffing for bodies.'
- On unneighbourliness in Housing Board estates


'I've been to many hospitals around the world, at least 400. Everywhere, the doctors and the nurses say they are the best, but I notice every time their own family is warded, they will make special arrangements. So I say that's cheating. Here, we define quality as when your own mother comes to hospital, you don't need to - and you're not allowed to - make any special arrangements.'
- On true quality


'If you drive past a polyclinic, you will see people who are grossly obese smoking away, enjoying government subsidies.

A doctor friend who works in a polyclinic recently recounted:

'A patient with diabetes comes to see me. He is obese, doesn't follow recommendations, and pretends he wants to get well. I pretend that I'm doing something by adjusting his insulin. Next month, he will come back, a bit fatter. He pretends and I pretend. I know that within a few years, he will lose his kidney, get a heart attack, have knee problems.''
- On how patients demand subsidies, but disown personal responsibility


'Have you been late for work in the last 20 years? Have you fallen sick in the last 20 years? When the MRT breaks down after 20 years, we have a national outcry. Even if you service a 20-year-old car regularly, it still breaks down once in a while. Let's get real. There's no perfect world where everything will be perfect forever.'
- On querulous Singaporeans

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