Why we must have foreign patients

Jeremy Lim, a partner in the Health & Life Sciences practice of Oliver Wyman, a management consulting firm.

A version of this article appeared in the print edition of The Straits Times on 22 July  2015.

Doctors need more patients to hone their skills, and Singapore patients benefit when a large pool of patients fuels biomedical innovation.

Medical tourism has been characterised as being about economic benefits and about attracting rich foreigners. Not any more – it’s not about them, it’s about us.

In 2003, then Acting Health Minister Khaw Boon Wan launched SingaporeMedicine, a national initiative to establish and enhance Singapore’s position as the medical hub of Asia. The ambitions were bold: one million foreign patients a year by 2012, the creation of 13,000 jobs and a contribution of $3 billion to the economy, or roughly 1 per cent of gross domestic product (GDP).

Since then, SingaporeMedicine has disappeared from policy discussions, becoming an agenda policymakers appear ready to excise from the collective memory. The SingaporeMedicine website has even been taken down, and once bold signage in at least one public hospital proclaiming “International Medical Services” has now quietly shortened to an ambiguous “IMS”.

What happened?

In launching SingaporeMedicine, Mr Khaw took pains to assert that “the dream of becoming a regional medical hub and containing healthcare costs are not mutually exclusive”, to allay fears that such moves would raise healthcare costs for all Singaporeans. He also pre-emptively explained using the analogy of Toyota Corollas, Lexus cars and Formula 1 racing that Singapore had to offer different types of healthcare to different target segments – Corolla-type care for the “bulk of our patients” with “maximum reliability, zero defects and lowest possible cost”, Lexus-type healthcare for those who can afford and want more, and Formula-1 cases to “show the world that we can hold our own against the best in the world and win”.

Fellow parliamentarians were not easily persuaded though. For example, Madam Halimah Yacob voiced concerns about distracting or diluting the public hospital core mission of serving Singaporeans. She said: “Foreign patients who come here do so because they want better and faster treatment and will have to be given priority… if we want to establish a reputation and continue attracting them. As it is, we are already suffering from a shortage of doctors, nurses and other allied professionals.”

By 2009, the Health Ministry’s tone had subtly shifted to arguing that SingaporeMedicine was only a secondary objective and that “our primary objective is to serve Singaporean patients, rendering good medical care at competitive prices”.

Despite the public concerns, Singapore has to soldier on. Foreign patients are vital to our healthcare system’s continued ability to provide quality healthcare for Singaporeans. In healthcare, high volumes deepen clinical acumen, sharpen surgical skills and enable higher quality for all patients, foreign and local.

I fear attracting foreign patients is no longer a “nice-to-have” but a “must-have”.

We may not have enough patient volumes in some specialities to even maintain competence and safety. Malaysia’s Institut Jantung Negara (National Heart Institute) aggressively markets itself internationally and performs almost 3,000 open-heart operations annually.

The National Heart Centre in Singapore? Fewer than 300 bypass operations in the last 12 months. What about the National University Hospital? Only 75 operations. “We have excellent outcomes despite the small numbers,” you might say. “How long more?” would be my response. Many of our heart surgeons cut their teeth in an era of plentiful patients and we continue reaping the fruits now.

Do we have enough patients today to train and build up the next generation of cardiac surgeons? Singapore has 43 cardiac surgeons island-wide: The latest numbers work out to only about a dozen operations per year per surgeon.

Is this enough?

The American Board of Thoracic Surgery stipulates that for surgeons in training, “operative experience requirements include an annual average of 125 major operations”.

Let’s be unequivocal – we need more patients.

The second reason we need more foreign patients is for biomedical innovation. For our biomedical research and innovation ambitions to be realised, Singapore needs medical scientists and clinicians to sub-specialise and focus on specific diseases or even sub-types of specific diseases.

And for this, we need patients, far more patients with certain selected diseases than Singapore’s modest domestic population could ever provide.

When I trained in Johns Hopkins Hospital, my supervisor was Dr Patrick Walsh, a world-renowned expert in prostate cancer. He had performed personally thousands of prostate cancer operations and this intimate knowledge of the disease had enabled him to pioneer innovative surgical techniques and contribute immensely to the foundational understanding of prostate diseases. His patients come from all over the world, not just America.

This call to reignite SingaporeMedicine is not a blunderbuss, clumsy and unbridled pursuit of all manner of foreign patients. Similar to labour policy, SingaporeMedicine needs a scalpel-like precision:

•Where are Singapore’s strategic priorities in healthcare and where are the gaps?

•Which types of foreign patients with diseases of interest and value to Singapore do we need to help plug these gaps?

• How do we encourage, for our own interests, foreign patients with these conditions to choose Singapore and help us maintain our pole position as a regional medical hub and as an increasingly successful biomedical powerhouse? Better coordination between public and private healthcare sectors? Special visa arrangements? Subsidies for expensive technologies?

I don’t have the answers, but I do know we need to have that conversation.

Forget the one about foreign patients crowding out locals; it’s a red herring and hurts Singaporeans.

Let’s discuss how some types of foreign patients can benefit from the excellent care Singapore is able to offer today, and help us to help ourselves.

HCS: And don’t let’s drive away the foreign patients who come here for bioidentical hormone replacement therapy by making it unavailable in Singapore.

Bio-identical hormones

Dr. Karla Dionne, writing about Bioidentical hormones, says:

“I am optimistic that as patients become more informed and continue to ask for bio-identical hormones, the medical community will respond by recognizing and acknowledging the benefits of a natural hormone over a synthetic one.”

. . .

HCS: If only . . .

Patient autonomy

Patient autonomy key part of medical ethics

Letter to The Straits Times  4 June 2015  (Bolding by HCS)

IN THE article on May 27 (“Just had liposuction? MOH may be calling you soon”), (HCS: See http://www.hormonechoicesingapore.com/2015/08/15/confidentiality/ )  it was revealed that those who want to undergo liposuction to improve their looks must also agree to be interviewed by the Ministry of Health (MOH) on the outcome of the procedure.

The four fundamental tenets of medical ethics are patient autonomy, beneficence (to do good), non-maleficence (to do no harm) and social justice.

Patient autonomy includes the patient’s rights to give or withhold consent for treatment, privacy and confidentiality.

These tenets should not be violated or significantly compromised except in the most serious circumstances, and backed by the force of legislation. For example, the Infectious Diseases Act can over-ride certain patients’ rights to privacy and confidentiality in the interest of public health and safety.

Similarly, the Private Hospitals and Medical Clinics Act already empowers the MOH to access patient records for audit purposes without a patient’s consent, in the interest of improving patient safety and clinical quality.

Giving consent for an aesthetic procedure is different from giving consent to be contacted and interviewed by MOH officers post-procedure.

The two are separate and independent events that entail separate and independent decisions by the patient. A patient’s autonomy is compromised when the two decisions are bundled together in one consent form.

We hope the MOH can clarify and explain how it is empowered by legislation to do so and why it has chosen this path of significantly diminishing patient autonomy in its effort to regulate aesthetic procedures.

Wong Tien Hua (Dr)
Singapore Medical Association


MOH’s Reply

The Straits Times  18 June 2015

Patient autonomy in audits: MOH replies

THE Ministry of Health (MOH) thanks the Singapore Medical Association (SMA) for its feedback (“Patient autonomy key part of medical ethics”; June 4).

As SMA president Wong Tien Hua said, MOH has powers under the Private Hospitals and Medical Clinics Act to audit any patient’s clinical outcomes, should the need arise.

Our medical audits enable MOH to monitor and uphold the high quality of care and safety of aesthetic procedures performed in Singapore.

Our intent in including this information in the consent template for medical practitioners and healthcare institutions is to give patients the opportunity to be informed of and to agree to participate in MOH’s medical audits before they undergo aesthetic procedures.

In this way, situations whereby patients are surprised when they are contacted after undergoing the procedure are avoided.

Dr Wong’s letter might have given the impression that the patient must consent to participate in the audit for the treatment to proceed. This is not so. The patient’s autonomy is not compromised in this process: Should the patient not agree to participate in any future audit of his aesthetic procedure, neither the patient nor the doctor is prohibited from undergoing or performing the procedure, respectively.

Before they undergo any aesthetic procedure, we urge the public to exercise due caution by ascertaining that the medical practitioners and healthcare institutions consulted are properly licensed and accredited to perform the desired procedures and treatments.

When in doubt, they should seek a second opinion from their regular family physician or other qualified medical practitioners.

Lim Bee Khim (Ms)
Corporate Communications
Ministry of Health



HCS has received some queries about the confidentiality of patient records.

While the current debate revolves around aesthetic procedures, HCS is wondering why the same permission was not requested from patients using BHRT and Natural Desiccated Thyroid before, unknown to them, their records were examined and they were contacted by the Ministry of Health.

This was the original article about the new ruling by Salma Khalik in “The Straits Times”.


People who want to undergo liposuction to improve their looks must also agree to be interviewed by the Ministry of Health (MOH) on the outcome of the procedure. This requirement has both doctors and patients up in arms.

Meanwhile, the ministry told The Straits Times that it has interviewed more than 500 patients who have had aesthetic treatments, and “so far, MOH has not needed to proceed beyond the initial interview”.

The ministry has been clamping down on aesthetic treatments recently. From March, all liposuction procedures have had to be done in hospitals or clinics approved for day surgery, removing two in three clinics that had been offering the service.

Read the whole article at:

Treating thyroid patients like children – Dr Malcolm Kendrick

This is a very refreshing article by a well known UK doctor.  Such were the truths it revealed that many of the (at the time of writing) 264 replies came within the first two days after it was posted on his blog. Patients were virtually screaming (forgive the pun) with joy that at last somebody had recognised how they feel.

We do have some doctors in Singapore who recognise how we feel when T3 is missing but it seems that their hands are becoming increasingly tied with regard to helping us deal with it.

Some extracts from the article are posted here with permission but please read the whole article – Dr Kendrick speaks for so many of us. If only he could speak to the Ministry of Health!

Dr Kendrick admits:

To be honest, until about a year ago I had no real idea what T3 was either, but I have learned quite a lot since.

He certainly has. This paragraph really caught our attention (bolding by HCS):

The lab tests, especially for TSH, are far from 100% reliable, to say the very least. In fact the man who developed the test in the UK, at Amersham International in Wales, has told me that the test is virtually worthless in many cases (especially continuous testing when patients are taking thyroid hormone replacement).

And yet more good sense, which echoes what many of us at Hormone Choice Singapore have experienced (bolding by HCS):

Far more telling, from my point of view, is the fact that hundreds, indeed thousands of patients report that, although their blood tests were normal, they felt terrible, and that they have felt so much better when they have been given ‘excess’ T4 and/T3, or NDT (natural desiccated thyroid). Whilst there is no doubt that some of them are, to quote a medical colleague, ‘not tightly wrapped.’ I have spoken to many, many, people who are calm, rational and reasonable, and their stories are compelling. A hellish existence that was ‘cured’ by Dr Skinner and his like. I refuse to believe that all of these patients are ‘somatising’ fruitcakes.

Read the whole article at:


And comments at:




Revising guidelines for testosterone testing could more accurately diagnose deficiency

One of the issues under discussion among patients and doctors in Singapore is how to determine when there is a need to treat men with supplemental testosterone therapy.  This new study shows that levels of free testosterone are more informative than total testosterone levels

European Society of Endocrinology     16 May 2015

A new study presented at the European Congress of Endocrinology in Dublin suggests that some men suffering from testosterone deficiency may be missed under current clinical guidelines while others are misdiagnosed with testosterone deficiency. The researchers call for a revision of the clinical guidelines to ensure that men are receiving the best possible care.

Testosterone deficiency, also known as male hypogonadism, can lead to decreased libido and infertility, but it has also been associated with a higher risk of developing metabolic syndrome, diabetes and osteoporosis. In men, testosterone levels gradually decline with age. In recent years, an increasing number of ageing men are presenting with symptoms suggestive of hypogonadism and testosterone levels that are around or below the lower limit for young men. To date, the diagnosis of hypogonadism in these middle-aged and elderly men and their management remains controversial.

Researchers at the University of Manchester, UK and the University of Leuven, Belgium (represented by Dr Leen Antonio) used data from the European Male Aging Study (EMAS) to determine the relative importance of total and free testosterone measurements in diagnosing testosterone deficiency in aging men.

Testosterone exists in the body in two states; bound to proteins (98 % of total testosterone) and non-protein bound or free (2% of total testosterone), the latter being the biologically active fraction. Current clinical guidelines suggest that testosterone deficiency is diagnosed by measuring total testosterone levels. However Dr Antonio’s study shows that levels of free testosterone are more informative.

Only free testosterone can enter cells and is responsible for testosterone action. When men get older, total testosterone levels decrease while the levels of the protein that binds it increases. This means that the level of free testosterone decreases more than the total testosterone with age.

Dr Antonio, “We show that middle-aged and elderly men with normal total testosterone levels but low free testosterone levels have more symptoms of hypogonadism compared to normal men than those with normal free but low total testosterone – these men currently miss out on treatment because they are not diagnosed with testosterone deficiency.”

“On the other hand, men with low total testosterone but normal levels of free testosterone do not suffer from testosterone deficiency, yet are misdiagnosed with the condition and can be treated with testosterone inappropriately.”

Dr Antonio and colleagues propose that new guidelines should recommend measuring free testosterone, in addition to total testosterone, in the evaluation of men with hypogonadal symptoms.



Real evidence based medicine

Trish Greenhalgh and Neal Maskrey

Trish Greenhalg is Professor of Primary Care Health Sciences and Fellow of Green Templeton College at the University of Oxford. She has twice won the Royal College of General Practitioners Research Paper of the Year Award and in 2001 received an OBE for services to Evidence Based Medicine.

Neal Maskrey is an Honorary Professor of Evidence-informed decision making at Keele University and consultant clinical adviser in the Medicines and Prescribing Centre, National Institute for Health and  Care Excellence, UK.

In this video, these experts explain the concept of real evidence based medicine (EBM) as it should be applied to real patients.

Note particularly 6.30 to 7.47

. . . if you look at the research literature on expert judgement you will find  that experts . . . don’t mechanically follow rules. They do something much more intuitive and much more rapid and what they then do is they come to a rapid decision and then they go back and unpack why they got to that decision and they justify it by using the evidence  . . . one of the things that clinicians say again and again is “I don’t want to be tyrannised by these guidelines. I don’t want my patients to be tyrannised by these guidelines.” And it seems that their clinical judgement is being challenged by these guidelines and what we want is for the clinical judgement to be supported by the guidelines so EBM will be delivered in a much more nuanced and granular way than people sometimes assume it should be.

Also 7.57 to 8.30

There are, of course, in every consultation two people involved in making the decision. The clinician has their own expertise and the patient has their own expertise.

How sad that, while the rest of the world is reassessing the concept of Evidence Based Medicine, Singapore is taking the backwards step of applying the guidelines in exactly the mechanical way that these experts feel should be avoided!


The evidence must come not from tests but from a thorough observation of the patient

Emeritus Prof Sir Gordon Arthur Ransome (1910-1978)

Today one of the four colleges at the Duke-NUS Graduate Medical School is named after Emeritus Prof Sir Gordon Arthur Ransome, remembered by many as the founder of modern medicine in Singapore and admired as an outstanding and brilliant clinician. His contributions to medicine in Singapore went back to 1938, when he was made Associate Professor of Medicine at the then King Edward VII College of Medicine. He also founded the Singapore Academy of Medicine and was its first Master.

The following is taken from an oration to mark Prof Ransome’s retirement in 1971: The life and times of Gordon Arthur Ransome by Seah Cheng Siang in Annals of the Academy of Medicine, January 1972, Vol. 1 (Bolding by HCS)


Foremostly, Professor Ransome taught by example. Himself a well-trained clinician, he has handed down to hundreds of doctors, clinical methods which were learnt from his teachers and also those innovated by his own increasing experiences.

In taking a meaningful medical history, he has on many occasions, and still does so now, sit by the bedside, eliciting point by point the story of the patient’s illness, with students watching on. From the history and adopting Lord Horder’s methods, a list of possible diagnoses to account for the presenting symptoms, is then compiled.

In front of the students, Professor Ransome will then examine the patient meticulously. A very careful inspection from head to foot is followed by an examination in minutia of the different systems. . .

From the signs culled, and with the results of some laboratory tests, he has nearly in every instance been able to arrive at a definitive diagnosis. A firm diagnosis by this method and not by intuition, is always teachable. He converted many a doctor from practising intuitive diagnosis into exercising a perceptive scientific method.

Another interesting insight into his powers of diagnosis comes from Sir Gordon Arthur Ransome  by Beng Yeong Ng and Jin Seng Cheah in Annals Academy of Medicine May 2008, Vol. 37 No. 5 (Bolding by HCS)


 He taught from first principles and emphasised the importance of the use of the 5 senses in the practice of medicine. He placed importance on the art of listening, the essence of the artistry of bedside medicine. Effective listening involves all the senses, not merely the ears. To succeed in healing, a doctor must be trained, above all else, to listen. His skills as a diagnostician were renowned. He believed that X-rays findings tended to lag behind the physical signs. Without any laboratory tests, he was able to arrive at an accurate diagnosis just by taking a comprehensive history and examining the patient skilfully. He was nicknamed “kosong” (meaning “zero” in Malay) as he would give a student zero marks for poor performance in clinical examination. 

This letter from Dr Quek Koh Choon, one of Prof Ransome’s former students, appeared in the Sunday Times on 26 April 2015 and again highlights the importance Prof Ransome attached to observation – note “Tests and investigations were needed only to confirm the diagnosis. (Bolding by HCS)


If Professor Gordon Arthur Ransome were alive today, he would be pleased to see how Singapore has become a great medical centre (“Prof hopes S’pore becomes medical hub”; last Sunday). 

I was privileged to have been taught by him, and to also have had the opportunity to work with him.

He taught me that the practice of medicine is not just a science, but also an art. He emphasised the need to observe the patient as he came into the consultation room – to watch his gait and facial expressions – and also advocated listening to the patient well.

These days, many patients say that many doctors are not listening enough to their complaints, and that they are quickly dismissed to undergo a battery of tests and investigations.

Prof Ransome did not think it wise to resort quickly to investigations. He believed that a great deal could be learnt from a patient’s history, and that astute observation and a thorough examination were key in clinching the diagnosis. Tests and investigations were needed only to confirm the diagnosis.

I used to accompany Prof Ransome on his ward rounds, and he surprised me when, at the end, he invited me to sit down with him and asked for my opinion of the various cases.

I was the most junior doctor then, and the experience certainly jolted me and taught me to value mutual respect among fellow colleagues and to be open to consider an opinion, even from a novice.

Prof Ransome treated all patients with respect and kindness, and did his best for them no matter what their status and background were. Once, he was called to attend to a VIP while examining a patient in a C ward. He said that the VIP had to wait as he was still attending to his patient.

He was a doctor devoted to the practice of medicine. He did not care much for accolades and prestige. Patients were his priority.

He was truly one of the great founders of modern medicine in Singapore. His inspirational values should be remembered by all who follow in the tradition of good doctors and healers.

Quek Koh Choon (Dr) 

We can only guess at what Prof Ransome would have thought of today’s Ministry Of Health insisting that all diagnosis be based only on test results and supposedly evidence based medicine. One can sense his disappointment and hear him cry, “What about the patient? The patient will tell you what’s wrong if you just listen! Just listen – with all your senses! I am giving you zero!”


S’pore Losing Medical Tourists to Neighbours

At a time when the number of tourists coming to Singapore has dropped and the Singapore Tourist Promotion Board is planning to launch a $20 million campaign to boost tourism, the drop in the number of medical tourists to Singapore is contributing to the problem.

This article from The Straits Times by Marissa Lee discusses the danger of Singapore losing out to neighbouring countries in the market for medical tourism. Patients currently coming here for bioidentical hormone replacement therapy (BHRT) could be among those who “walk” (fly).


Hormone Choice Singapore has spoken to a number of people living in neighbouring countries who currently come here for their BHRT treatment. They say that if this becomes unavailable in Singapore, they will be going to Kuala Lumpur or Bangkok.


The Non-Science Witch Hunt Against Hormone Replacement Therapies for Deficiency Syndromes Must End: An A4M Position Paper on Physician-Prescribed HRT

The first paragraph of this Position Paper from The American Academy of Anti-Aging Medicine (A4A), 23 September 2013, seems to describe just what is happening in Singapore at the moment. (Bolding by HCS)

Since the inception of the anti-aging medical movement in 1991, various establishment parties have ruthlessly leveraged their positions of power in academic, political, and regulatory arenas for the purpose of attempting to limit the use of hormone replacement therapies (HRT) in adults with documented clinical deficiencies. For over 15 years, a prolonged and calculated campaign of deceit, fraud, and suppression has threatened physician licensures and liberties to treat and prescribe life-improving therapies, leading potentially to the direct compromise of patients’ health and longevity. Dozens of physicians have been sanctioned and punished with loss of license and academic standing. This pernicious abuse of position and power is particularly prevalent with regard to RECENT challenges made against human growth hormone (HGH), testosterone (TRT), and DHEA replacement therapies that are trumpeted by the mainstream media. Biased reporters frequently – and inappropriately – demonize legitimate physicians and clinical compounding pharmacies who are reluctantly positioned on the frontline of a decades’ old agenda to limit freedom of choice and information, and the physician’s most essential responsibility to select the best course of therapy and medication for their patients. . . .


The American Academy of Anti-Aging Medicine (A4M), its numerous worldwide affiliated scientific and medical societies, and befriended organizations, supports the judicious application of modern and advanced medical technologies to address the changes in chemical, hormonal, physical, and nutritional needs that occurs with aging. Such repletion includes the restoration of hormones to an optimal physiological state when deficiency is determined by objective assessment.

Hormone replacement therapy (HRT) is an essential and extensively documented protocol for clinical intervention in the disorders of aging. HRT maintains an unblemished safety and efficacy profile that has been documented by 20 years of clinical application. Yet, a perfect storm of misguided media combined with biased parties whose livelihoods hinge on disparaging the anti-aging medical movement has grossly compromised access to HRT, placing the lives of hundreds of thousands of patients worldwide in potential jeopardy.

Experienced anti-aging physicians have been prescribing HRT for more than 20 years. PubMed contains more than 20,000 peer-reviewed studies of HRT, of which a preponderance document the life-enhancing and/or life extending benefits of HRT in aging adults. See Appendix A “Literature Review“ which presents a selection of such studies that represent the objective evidence that supports the A4M position.


Read the rest of the paper at: