Public and Private Sector (Personal Reflections 2)
I had previously mentioned that private sector specialists in Singapore are independent operators – the majority actually run their own clinics/practice as individuals. Most professional partnerships between doctors have been small in scale (i.e. 2 or 3 individual doctors), and a good number of such partnerships have come apart because of personal differences or the vagaries of business (this is probably normal in most fields of business). There are exceptions, most notably in the field of oncology, where the private sector is dominated by three large groups (Parkway Cancer Centre, Oncocare, and Singapore Oncology Consultants).
I used to wonder why there were not more partnerships or consolidations in the private sector, since the benefits seemed evident: economies of scale in terms of medicines and equipment for the clinic(s); coverage for weekends, public holidays, and actual holidays; ability to practice one’s subspecialty interests to a greater extent. In the public sector, the acute care hospitals have numerous junior doctors staffing them and most specialists can rest secure knowing that there are “on call” teams to take care of their patients during the night or over weekends/public holidays. If one’s medical or surgical department is large enough, one can certainly opt to practice far more subspecialty work – spine surgeons can do more spine operations and less of other orthopaedic operations; respiratory physicians can opt to spend more time managing asthma patients – there’s a colleague down the hall who would prefer to stay in the intensive care unit, for example.
Private sector hospitals do employ resident medical officers to staff their 24-hour clinics and handle hospital emergencies, but their numbers are few, resulting in ward nurses having great autonomy. Ultimately, the private sector specialist is called for all urgent matters regarding their inpatients, whatever the day or hour, a situation that can be very wearying in the long run. For certain medical specialties where referrals from other doctors form the bulk of their business (these include infectious diseases, of course), the sense of being chained to one’s handphone is even more acute, since missing a call – even for five minutes – could lead the potential referring doctor to seek an opinion from someone else in the same field.
Moreover, the system in the private sector is largely one of relationships and networks. Friends refer to each other, or to specialists who are more personable or with whom they have had good relations. Doctors are less likely to refer to someone they do not know, even if that someone has a good reputation or had been renowned in the public sector. It is the establishment of these relationships and networks that determines the success of an individual specialist in the private sector, and these networks are largely non-transferrable to another individual. Hence even in partnerships, most specialists basically function as individuals with their own referral networks, unlike what happens in the public sector. What I had written earlier about one of the potential benefits of partnership – coverage for weekends and leave – does not hold true for the large part. Also, most specialists – unless they have a truly rare skill set – will not be able to focus on sub-specialty work alone. A cardiologist previously specialising in sophisticated echocardiography will have to manage patients with heart failure or acute myocardial infarcts – his colleagues/competitors in the private sector are more likely to do the echocardiography themselves rather than send their patients to him for this service.
Despite the greater uncertainties and costs involved in private practice, I have observed a puzzling phenomenon. The majority of specialists I know in the public sector have – at some stage of their working careers – contemplated going private. The majority of specialists I know in the private sector have no desire to return to the public sector. In certain specialties (like infectious diseases), the opportunity for work satisfaction is far higher in the public sector compared to the private sector, as pointed out by a colleague of mine from Malaysia (he is now in the private sector as well), yet these specialists hardly ever return to serve the public sector. The level of unhappiness among specialists appear comparatively higher in the public sector (which does not seem to have changed despite narrowing the income gap) and this may have even more severe consequences in the medium term, as we are now churning out more specialists than ever before, and the private sector cannot continue to expand at the same rate.