Page 1

Tomorrow ’s

MEDICINE Translating the Academic Medicine Vision

issue 02/2012 The Academic Culture Survey pg4 From patient to physician pg22

C I M E D A AC RtoE TmU CUhL s at it ean lth W a in SingHe e n o y r e v e pg3


The Academic Culture

In this issue, we look at the bustling Academic Culture that makes our campuses come alive with vibrant collaborations and clinical and academic excellence Page 4 The Academic Culture Survey Page 12 Academic Culture in Allied Health Page 14 Nursing in Academic Medicine



A Community of Excellent Educators

A look at the ecosystem of education in SingHealth and how each member contributes to helping us score in education



Newly Engaged

SingHealth leaders in conversation with staff on hot topics in healthcare



From Patient to Physician

A Duke-NUS student turns his condition into a passion in medical research OUTCOME

Sight on Eye Research


Two studies by SNEC shed new light on eye conditions

OTHERFeatures Page 20

Letters from Overseas: Dr Ravindran Kanesvaran

Page 24

Take 5: Assoc Prof Lee Kim En & Dr Natalie Koh

Page 30

Solving the Problem with Arthroscopes Page 32

Page 36

SingHealth Review

Our Heritage: Female Luminaries

Translating the Academic Medicine Vision






For a Better Tomorrow

Prof Ivy Ng Group CEO SingHealth


arly in my clinical practice, I remember this young boy referred to the Genetics Clinic for mild dysmorphic features and possible mental retardation. At four years old, even though his motor functions were satisfactory, he was unable to speak and could not respond to simple instructions. Investigations revealed he had profound hearing loss but was otherwise normal. Though treatment was started for him, he continued to struggle and never attained normal speech. He has become what has traditionally been called a ‘deaf-mute’ because his hearing impairment was identified too late. Contrast this with a more recent patient of mine. She was diagnosed with severe hearing loss in infancy. She then had a cochlear implant done followed by intensive auditory-verbal therapy, enabling her to listen and speak. She is now doing well in mainstream school. Talking to her, it would be hard to guess her medical history. Universal Newborn Hearing Screening is now available in Singapore. The goal is to screen all babies by one month, diagnose hearing impairment by three months and start intervention by six months of age. With this aggressive approach to early diagnosis and treatment, the outcome for normal speech and quality of life are excellent. It was announced in The Straits Times (5 November 2011) that the School for the Deaf would close in 2016 due to shrinking enrolment, as “early diagnosis in babies and advances in hearing aids and cochlear implants” have allowed “most hearing impaired children to hear well enough to attend mainstream

schools.” Just within my time in clinical practice, I’ve witnessed this dramatic improvement in the care and prognosis of hearing impaired children. At one of the physician engagement sessions hosted by SingHealth and Duke-NUS leadership, the neonatologist leading the Universal Newborn Hearing Screening programme in Singapore, Dr Mary Daniel, shared how satisfying it was to effect such dramatic change in the lives of so many children. A paediatric ophthalmologist, Dr Yvonne Ling, at the same session shared how a proactive approach to retinopathy of prematurity had markedly decreased the incidence of blindness in severely premature babies, and how enrolment in the School for the Blind had also decreased significantly. So what is Academic Culture? It’s a culture of always seeking a better tomorrow for our patients! It’s never being satisfied with the care that we give today. Our patients need us to seek out new ways to make their lives better – to diagnose them earlier and more accurately, to provide better treatments, to make these treatments accessible to them and to never accept poor outcomes but to keep asking the right questions and persevering for the right solutions. We can dramatically make the lives of our patients better. They don’t have to be handicapped by being deaf or blind or suffer needlessly. We can have a vibrant academic culture in our Campuses Let’s press on in Defining Tomorrow’s Medicine! 


MICA(P) 109/10/2011

Translating the Academic Medicine Vision

SingHealth Editorial Team Katheryn Maung Arthur Wong Stephanie Jade Arlindita EDITORIAL ADVISOR Tan-Huang Shuo Mei Acknowledgements Prof Ivy Ng Andrew Tan Angelina Lim Prof Bob Kamei Dr Celia Tan Juriyah Yatim Assoc Prof Lee Kim En Lim Tze Peng Loh Pei Shan Dr Louis Tong Low Ai Ying Marc Wong Michelle Ho Dr Natalie Koh Dr Oon Chiew Seng

Dr Oon Chong Hau Priscilla Kuan Ravi Chandran Dr Ravindran Kanesvaran Tan Ah Pang Assoc Prof Tan Kok Hian Tan Siok Bee Tan Wei Ming Tang Hui Nee Toby Huynh Dr Tracy Carol Ayre Violet Kwek Prof Wong Tien Yin Adeline Sim

Tomorrow’s Medicine is a quarterly publication to help translate our Academic Medicine vision by sharing our journey and relentless efforts in improving patient care and outcomes to define tomorrow’s Medicine.

Design Redstone Communications - Steve Teoh & Sophia Ho Copywriting Hedgehog Communications - Monica Lim & Debbie Chia

All rights reserved. Reproduction in whole or part is prohibited without the written permission of SingHealth and the publisher. The views and opinions expressed or implied in the publication are those of the authors or contributors and do not necessarily reflect those of SingHealth and the publisher. Whilst due care has been exercised, both SingHealth and the publisher do not accept responsibility for errors in advertisements or articles, unsolicited manuscripts, photographers or illustrations. Tomorrow’s Medicine reserves the right to edit all materials submitted for publication. While contributors will be given the opportunity to comment on articles for factual accuracy, this policy is about ensuring a consistent and clear writing style throughout.

Read Tomorrow’s Medicine online at

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ACADEMIC CULTURE In the vibrant healthcare system on our One Campus, synergies are being built to further our pursuit of Academic Medicine and improve care for our patients. We take a look at the bustling Academic Culture among doctors, nurses and allied health professionals that makes our campuses come alive.



Assoc Prof Tan Kok Hian

Academic Chair, OBGYN ACP SingHealth

The Academic Culture Survey

Associate Professor DUKE-NUS


Division Chair Obstetrics & Gynaecology, KKH

Academic Culture

Associate Professor Tan Kok Hian is the Academic Chair of the OBGYN Academic Clinical Program (ACP). He serves as Associate Professor in Duke-NUS and is also the Chair of KKH’s Division of Obstetrics & Gynaecology. In November 2011, Assoc Prof Tan conducted a survey on Academic Medicine which revealed promising sentiments on the ground.


hat is your take on academic culture? Academic Culture in SingHealth has yet to reach its peak. We pride ourselves on our clinical activities, but teaching and research are equally important to scale new heights in Medicine. Academic endeavours will also bring our clinical work to a higher level. Some of us call it the “clinical service plus” culture – where we provide clinical service with an added difference to achieve excellence. Tell us more about the academic medicine survey you conducted at KKH! I initiated the survey to obtain some data as a measure of the ground sentiments towards our academic endeavours and on how to improve these sentiments. It will also form a good baseline to follow up on our exciting ACP journey. The survey was sent to our OBGYN ACP faculty and staff, and we received good response rates of at least 70% from both senior and junior doctors from KKH and SGH. The Paediatrics ACP was interested and followed suit by conducting the same survey the next month. The survey was structured around 13 areas with four questions each and respondents gave feedback on a weighted scale (5-point Likert scale). What were the findings? In general, the survey results show that people are keen to engage with academic medicine but are hindered by a lack of resource. Communications and feedback are well-received, and they feel that there is enough support and encouragement by the supervisor and department. I was happy to discover

By Debbie Chia

that staff were very positive on having a learning and innovation environment, but there will be an issue if the resources are not readily available or provided. For me to lead the ACP, the survey indicates I will need to work on clinical staffing more than anything else. How else can we grow an academic culture? Perceptions change when people see positive changes being implemented. We must be able to allow people to find their niches and develop their full potential in their best areas; to let those who are keen on research and education flourish and to facilitate our clinicians to achieve mastery levels so that they in turn will facilitate academic activities at the same time. Creating different roles such as Clinician Practitioner, Clinician Investigator/ Scientist and Clinician Educator will enable staff to better fulfil their potential and be recognised for their different contributions. This flexibility and niche recognition allow better job satisfaction and many will aspire to do their best, be it in clinical service, education or research work or a combination of these. What about encouraging academic teamwork across institutions? The ACP is a cluster-wide programme that will help to break physical or mental barriers of collaboration between the different institutions. ACPs will be aided and facilitated by other cluster-wide structures like the Joint Institutes with Duke-NUS. If we share similar academic goals and aspirations, we will be more eager to come together, communicate and collaborate better and achieve our common objectives. 

Top 3

Composite Scores OBGYN & Paediatrics (% positive response) Supervisor & Departmental Support for Academic Medicine Communications & Feedback on Academic Medicine

Academic Faculty Development

Organisational Learning

Communications & Feedback on Academic Medicine

Learning & Innovation Environment

64% 58% 57% 72% 70% 67%

Top 3

Item Questions -

OBGYN & Paediatrics (% positive response) Faculty development is important for professional growth There is good co-operation among various hospitals and institutions that need to work together My supervisor/head gives an encouraging word/signal when he/ she sees a job relating to Academic Medicine performed Faculty development is important for professional growth Staff benefit from these scholarly activities We are constantly looking for ways to improve Academic Medicine

88% 83% 75% 94% 89% 89% 5


A Community of Excellent Educators SingHealth strives to be the leader in Academic Medicine and healthcare education. The formation of the SingHealth Education Council this year are part of the overall strategy to help us score in academic excellence. By Monica Lim


t SingHealth, our common purpose is to improve the lives of patients, now and in the future. In order to build a pool of competent medical and healthcare professionals committed to delivering excellent patient care tomorrow, we need to invest into providing quality education and training today - for our doctors, nurses and allied health professionals, as well as nurture clinician-educators who are passionate in developing and mentoring the next generation.

In order to coordinate and orchestrate all the training and education activities across all institutions within SingHealth, the Education Council (EC) was formed to oversee and drive all training and education initiatives across the Group. Its inaugural meeting was conducted in February this year. The EC is chaired by SingHealth’s Deputy CEO (Research & Education) Prof Soo Khee Chee and deputised by Group Director of Education, Assoc Prof Koo Wen Hsin. Members of the EC

include senior representatives from all institutes and communities who play a role in education and training e.g. ACP Chairs, SingHealth Residency Designated Institutional Official, and leaders of other education entities like SGH Postgraduate Medical Institute, Postgraduate Allied Health Institute,SingHealth Alice Lee Institute of Advanced Nursing and SingHealth Academy.

SINGHEALTH EDUCATION COUNCIL Chair, SingHealth Education Council

SingHealth Deputy CEO (Research & Education) SingHealth Group Director, Education

KKH Inst. Director of Education

SGH Inst. Director of Education

National Specialty Centres ACP Directors/ ACP Chairs

Duke-NUS Vice Dean, Education

Family Medicine ACP Chair

Academic Medicine Education Institute (EI)

Designated Institutional Official (DIO)

Executive Organisations



Academic Culture

One EI For All We spoke to Prof Bob Kamei, Vice-Dean (Education), Duke-NUS to glean some insight on the Institute.

Our vision in education is to: • optimise our systems and structures, and our talents and resources, at the SingHealth level. • develop a synergistic and coherent education and training development masterplan which provides up-to-date curriculum for the respective fields, a progressive training pathway for students and a structured competency development framework for teaching staff, with the necessary support plans and infrastructure. • attract, develop and retain clinician educators, with attractive, fair and structured career plans, develop a monitoring system to track individual’s contribution to training and education activities and create a community of educators from different professions. • collaborate with other credible and like-minded healthcare or academic partners, e.g. the formation of the Education Institute with Duke-NUS and the partnership with the NUS Yong Loo Lin School of Medicine. Funding under the Health Manpower Development Plan (HMDP) and Talent Development Fund (Education) will continue to be awarded annually to deserving staff.

To catalyse cross-fertilisation of ideas and sharing of resources, The Academic Medicine Education Institute (EI) is being established with Duke-NUS to work in tandem with all Academic Clinical Programs (ACPs), as well as the Nursing and Allied Health communities. The Academic Medicine EI creates a community of educators and will serve all individuals. It will faciliate the necessary competencies to all our educators and trainers, whether they are doctors, nurses, allied health professionals or administrators, who play a role in educating, training or developing our staff or student learners. In addition to serving the individuals, the Academic Medicine EI will support education and training of the various professional groups in the areas of faculty and curriculum development through Academic Clinical Programs (ACPs), SingHealth Residency, SingHealth Alice-Lee Institute of Advance Nursing, SGH Postgraduate Allied Health Institute and Postgraduate Medical Institute. AM Education Institute will also develop a system that monitors the contribution of each individual to teaching, as well as their competency development. 

What are the objectives of the Academic Medicine EI? We want to create an educational community that possesses synergy between groups, supports academic promotion and the development of teaching skills. The ACPs have an important role to play and the Academic Medicine EI provides the scaffolding to help the ACPs fulfil this role. We do this by helping ACPs document the educational achievements of their faculty, assist the individual faculty members grow their academic expertise and execute their teaching responsibilities effectively. The EI is also for educators in Nursing and Allied Health. With the creation of a community of educators from different specialties and professions, they can exchange experiences, share best practices and foster ties to trigger academic success. Basically, the Academic Medicine EI can provide resources to help those passionate about education improve their teaching skills and contribute to developing the next generation of healthcare professionals. This all is in the spirit of Generativity – sharing our knowledge to nurture the next generation and stretch our academic impact. Who can be a member? All educators and trainees (students, residents, HO/MO, Registrars) in SingHealth. Those interested in signing up for the EI, do look out for details to be announced later this year.



Newly Engaged SingHealth leaders have been paving the way and taking steps to engage staff of all roles and levels on hot topics in Healthcare. The message is clear – we can drive excellence in each domain area together and include every healthcare professional in this journey.


Group CEO Prof Ivy Ng seeking physicians’ feedback and sharing the plans for Academic Medicine at a Physician Engagement Session

Academic Culture

E best care.

ach of us in SingHealth plays different but equally important role and we have the power to touch the lives of patients and provide them with the

As the main drivers of the Academic Clinical Programs (ACP), physicians are an integral group. Since June last year, SingHealth senior management have been regularly engaging doctors at Physician Engagement Sessions across the cluster to seek their feedback as well as to share with them the plans for Academic Medicine in our partnership with Duke-NUS. These sessions have been led by Group CEO Prof Ivy Ng, and Deputy CEOs Prof Ang Chong Lye and Prof Soo Khee Chee, co-hosted by Duke-NUS senior management Dean Ranga Krishnan and Vice-Deans Prof John Rush and Prof Robert Kamei. To date, they have met some 350 SingHealth physicians and addressed concerns and issues about Academic Medicine first-hand. It’s not just physicians who play a part in Academic Medicine and no professional group can bring clinical excellence on their own. SingHealth leaders also initiated conversations with staff from various domain areas across institutions at the Group Director’s Forums. Each Forum includes managerial staff from all institutions in their respective domains, including HR, Operations, Nursing, Allied Health, Research & Education, Finance, Service Quality & Clinical Quality and Communications. Similar engagement sessions are also held for staff at various institutions. These Institution Townhalls are hosted by each Institution’s CEO/Medical Director for staff of all functions to have a dialogue with GCEO and share their views and ideas on how to make their institution a centre of excellence. For SingHealth Corporate Office staff, the sharing platform, Synergy, is held monthly at different SingHealth institutions. It aims to bring collaboration and sharing among various Corporate Office departments in SingHealth. 

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Highlights from conversations with staff (taken from Group Directors’ Forum and Physician Engagement Sessions Jun ‘11-Apr ‘11)

Lively dialogue with questions by audience at Group Director’s Forum on Research & Education, 28 March

What do you think?

How will manpower and resource issues be addressed? Acknowledging the fact that clinicians are now expected to take on more roles, ACPs can provide the resources to recruit talent from around the world to share the load, consider job redesign and empower nursing and allied health colleagues. Also, with the success of the SingHealth Residency program, we should have a sufficient number of trained doctors within five years.

Five questions discussed at the Group Director’s Forum

1 How can SingHealth be amongst the Top 5 in the world, in all areas of excellence? 2 What great organisations should we benchmark ourselves against? 3 What are their attributes/best practices we can adopt? 4 What are our strategies to get there? 5 How do we measure our progress?

GCEO Prof Ivy Ng and GCOO Mr Tan Jack Thian hosted discussion with Operations staff at Group Director’s Forum, 9 March What is our focus in excellence? Prof Ivy Ng encouraged staff dealing with Operations in various institutions to focus on our common priority- our patients. Our KPI should never detract from this. For example, inventory management should not be at the expense of inconvenience to patients, like restricting them from bringing wheelchairs from one centre to the other. The National Library’s book drop system was cited as a good example of excellence with focus on the user in mind. Areas that can be improved include enhancements in inter10

institution processes and accountability of movements between institutions. Who can help us in improving? At the Group Directors’ Forum on Operations, GCEO shared that we can tap on the wealth of resources we have in Corporate Office to improve service delivery and operations. The SingHealth Clinical Governance & Quality Management (CGQM) department has the expertise to consolidate best practices and run training programs for operation staff. The corporate office risk management group can be approached to understand the enterprise risk management (ERM) and its applications to improve operation processes. What are the opportunities for multidisciplinary sharing across the cluster? Academic Clinical Programs (ACP) span across the cluster and will help to bring about greater synergy among institutions. The Academic Medicine Education Institute and Research Institute set up jointly with Duke-NUS will also better facilitate collaborations in Education and Research and connect people and resources. Research Grand Rounds have been organised since November 2011 as a platform for sharing by researchers and to keep each other abreast of other research activities in the cluster. It seems ACPs are only for physicians. Is there anything similar to support other professions? ACPs were only rolled out last year and we can say they are still at their infancy stage, but they are not meant to be limited to physicians only. The Allied Health Professionals and Nursing groups will be integrated in subsequent phases into the established ACPs.

To facilitate the education of more medical students, bed-side teaching will be complemented with technology e.g. use of simulation. What will become of those who excel in clinical work but not research and education? How will they be rewarded? The majority of our doctors will still be Clinician Practitioners, even though they are to contribute some of their time to supporting research or education. However, this does not mean Clinician Practitioners are less valued than those in other Clinician tracks (Clinician Educators or Clinician Researchers). The emphasis on the Researcher and Educator tracks is simply because they are currently still in their infancy. No matter which track our healthcare professionals are in, clinical excellence remain a firm foundation. A doctors’ pay review has taken place and doctors can expect greater recognition across all areas – care, education and research. Our clinicians can send their comments and feedback to

Academic Culture

Giving Handles to Academic Culture


or many at SingHealth, we know the direction we’re headed and we can feel the excitement in the air, but it’s hard to put our finger on the concept of academic culture. For Dr Tan, the answer to measuring the immeasurable is to focus on outcomes. “It’s what I call giving handles to academic culture,” she explains. “We want to make visible the invisible.” One of Dr Tan’s chief priorities is to strengthen connections with local and international academic experts, similar to the academic link SingHealth already has with Duke-NUS. For the 3,000 Allied Health Professionals (AHPs) to move forward, there needs to be a similar linkage to academic institutions for each of the profession groups, so that they can benchmark standards, advance ideas and tap on collective knowledge. As the head of the SGH Postgraduate Allied Health Institute (PGAHI), Dr Tan is visibly fervent about the educational foundation for AHPs. Apart from looking externally, she is also determined to grow domain experts within SingHealth’s talent pool. “We want to harness thought leaders among staff – people with vision

For many at SingHealth, academic culture is an elusive concept. Dr Celia Tan, Group Director, Allied Health, articulates the concept and her plans to tackle the future. By Monica Lim and enthusiasm across all levels. In this way, we can develop our own capacity for mentors and sustain the growth of the profession.” Supported by SingHealth sponsorships, the AHPs have been steadily growing their pool of experts. In 2000, there were no AHPs with PhD or doctorate degree. Today, there are 12 and by 2015, this number will rise to about 20. Dr Tan herself has just been appointed as Adjunct Associate Professor with Curtin University. It is Dr Tan’s wish that more healthcare professionals will see the value of crossdiscipline and cross-profession synergies. At the working level, doctors, nurses and AHPs already work together in multidisciplinary teams but her vision is to see this collaboration carry through even in education and research. In fact, AHPs have begun to make a name for themselves as educational leaders. At the recent Asia Pacific Medical Education Conference, Dr Tan was heartened by the encouraging response from doctors to a workshop she organised and says this augurs well

Read about winning projects of the Allied Health Innovative Practice Awards on page 12 >>>>

“At the working level, doctors, nurses and AHPs already work together in multi-disciplinary teams but the vision is for this collaboration to carry through in education and research.” for the future, where different specialties and professions can come together to improve knowledge. So what is her vision of Allied Health five years from now? “I hope to see that our developments in research match that of education,” she says, candidly. “The entries that we received for the Allied Health Innovative Practice Awards this year were of a higher calibre than before and have a larger impact. This signifies that more staff understand the need to make real improvements in their profession and we will certainly want to recognise and reward this mindset.” 



Innovations In Allied Health Three entries won this year’s SingHealth Allied Health Innovative Practice Award. Find out how Allied Health Professionals are changing the lives of our patients – from going down to preschools to support kids with developmental needs, to using video games to help stroke patients recover movements. By Monica Lim

IP M e l b i s ’I m Pos



Preschoolers with mild dev elopmental through the disabilities o cracks, unno ften fall ticed by pare unaddressed, nts and teache the gaps betw rs. Left een these ch continue to w ildren and thei iden as they pr r peers will oceed to Prim ary School.

pment Develo al d il h C f ion to artmen Profess KH Dep ui Nee, Head, K : m a H KH Te ager, K r: Tang Leade Services Man


The MIP is the first proactive early detection and intervention programme in Singapore for children with mild developmental needs. A multi-disciplinary team, comprising staff from the clinical and educational fields, works closely together to: a) bring learning support and therapy services into a child’s most natural learning environments, b) actively involve and train parents and teachers to better support their child’s development, and c) boost capabilities in the preschool sector through a special group of Learning Support Educators An Individualised Education Plan is customised for each of these children, to plan for their learning growth. Therapy or support sessions are carried out during school hours at the preschool, providing a familiar school environment and reducing the rate of dropouts. All therapy is heavily subsidised to ensure its affordability.

’s t at h W ex N 12

similar ns to help set up s received invitatio ha ools. ch am es te pr IP d M te e na Th her pre-desig ot at s ce rvi se d e school-base t the programm cussions to roll ou It is currently in dis ools over the next ch es pr pre-identified ss ro ac es as ph in five years.

The SingHealth Allied Health Innovative Practice Award, now into its 5th year, recognises Allied Health Professionals who hold that spirit of inquiry and drive to pursue innovative care for better patient outcomes.

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Team: SG H Physioth erapy Dep Leader: L a ow Ai Ying , Physiothe rtment rapist, SG H



Poststr exper oke patien disab ience limb ts common ility pa ly reduce , resulting in ralysis and d d e q pressio uality o report n ed f li of their that these fe. Studies and have patien hospit ts spe al stay nd and ly being inactiv most ing in e, alon bed. e


What’s Next

Leveraging on virtual realit y (VR), a mul with Singapo ti-disciplinary re Technologi team at SGH es to pilot the alternative to collaborated Sixense system traditional st as a fun and roke rehabili and repetitive innovative tation strate movements en gies. The en courage the us the postural co gaging e of the affect ntrol of these ed limb and ch patients. The patient’s avai allenge system is also lable range of customisable active movem to each ents. A pilot study comprising of 20 patients w therapy versus ith stroke, rand and standard omised into st therapy with weeks, both andard VR training, w groups demon as conducted. strated signifi in the VR grou After two cant gains in p demonstra mobility. How ted greater bu range of uppe ever, patients t non-significa r limb muscu nt improvemen lature strength virtual games t over a . These patie and felt the ga nts reportedly mes had assi bonus, the sy enjoyed the sted in their stem provides recovery. As feedback, allo improvemen an added wing patients t in perform and therapists ance. to track


nt epartme rmacy D armacist, SGH a h P H G Ph Team: S Peng, Senior ze T im L : Leader

Academic Culture

Ther larger e are plans rand for a trial. T omised con h trolle e sy implem ented stem may b d e in the ward a reha s therap part of self bilitation -dire y to time s maximise p cted pent in a VR reh the ho tients’ a explor bilitation ca spital. ed n for hom as a treatm also be ent op e-base tion d Using the Six rehabilitatio n. e therap nse se ists ar nsors, e a ble to patien tra ts improv ’ performan ck ce ement remote ly.


Singapore has on e of the highest pr evalence of pathogenic Mul tidrug-Resistant (MDR) bacteria the world. We run in the risk of reachin g a level of antibiot resistance where ic even last-line antib iotics like carbap and polymyxins alo enems ne are unable to treat infections caused by ‘super bugs’.


A multi-disciplinary team embarked on a Multiple Combination Bactericidal Test (MCBT) project, which screens 82 antibiotic combinations at one time, to provide physicians with an evidence-based treatment option for MDR infections within 48 hours of carrying out the test. This is in contrast to the previous approach of choosing antimicrobial combinations based on prior experience or ‘trial and error’, which has a high failure rate and increases the resistance rates of bacteria. MCBT targets MDR bacteria directly by eradicating pathogens already harbouring resistance mechanisms and prevents the risk of emergence of more complicated MDR bacteria.

What’s Next

SYNERGY is the firs t team to offer MCBT in Singapore and approval has already been grante d for the planning of a testing service to be offered for all patients at SGH. There is high potential for impleme ntation of the service nationa lly and regionally.

If you are also involved in an innovative project, look out for the call for entries to the Allied Health Innovative Practice Awards later this year! 13


Nursing the Future In the pursuit of Academic Medicine, SingHealth nurses are helping to nurture a vibrant Academic Culture. By Debbie Chia

Dr Tracy Carol Ayre

Group Director, Nursing SingHealth 14

Academic Culture


ust appointed on 1 March this year, SingHealth Group Director of Nursing, Dr Tracy Carol Ayre, is confident about the nursing contribution to Academic Medicine. “In our own way, we have made good strides. We took a long time to get where we are now, but we are at a stage where we have managed to pull in grants and may have 15 to 20 nurse-led research projects going on at any one time,” she outlines.

“It is ingrained in our nurses that they are not just ‘do-ers’, but also critical thinkers who can influence their practice and advance medical knowledge. From the outset, they know that innovation and research is intrinsic to their work and our culture. All our nurses know this.” – Dr Tracy Carol Ayre Citing Advanced Practice Nurses (APNs) as a key example, Dr Ayre praises their work as adjunct lecturers at tertiary institutions such as National University of Singapore and Curtin University, which highlights their role as educators.

“It is ingrained in our nurses that they are not just ‘do-ers’, but also critical thinkers who can influence their practice and advance medical knowledge. From the outset, they know that innovation and research are intrinsic to their work and our culture. All our nurses know this.” This is the SingHealth difference, she says, and it translates into quality care for patients. “Our nurses have to be up-to-date with current research and know the best practices in the field. Only then can they transfer this knowledge to their patients and other staff. It is about maintaining our standard of care.” She adds, “Patients depend on us and we need to give patients that knowledge base so that they can eventually care for themselves too.” The recipient of the 2007 President’s Award for Nurses first decided to join nursing “to make a difference”. Having witnessed her grandmother pass away amidst limited communication from the healthcare team, she felt that things could have been done better, even at the tender age of 14. Today, she has realised that dream by leading a team of nurses into the future, one with Academic Medicine at its core. Passing on the baton is her predecessor, Assoc Prof Lim Swee Hia, who has helped nurture this academic focus through constant engagement with nurses on the ground. Decades of training, education and active leadership means that the academic culture is well and truly alive in nursing. The challenge for Dr Ayre now is to continue to build

“The role of the nurse as teacher to nursing students, newly graduated nurses, colleagues or patients, is deeply ingrained in the culture.” – Ms Tan Ah Pang upon it so that every generation of nurses will believe in it. And for Dr Ayre, the direction ahead is clear: moving towards bigger and wider inter-collaborations with other institutions as well as other countries. “We do not believe in working in silos. Holistic and quality healthcare is not just about nursing but the interface and synergy between nursing, and other disciplines within healthcare,” says Dr Ayre.



On top of her mind too for the next three years is the grooming of talent and future leaders. “We must retain our talent pool and grow our base in the face of other emerging institutions,” she says and cites giving leadership training and research opportunities as well as offering quality tools as ways to groom academically accomplished nurses of the future. Nursing an Academic Culture In the journey towards Academic Medicine, SingHealth nurses - who form approximately 40 per cent of the workforce - have been there every step of the way. Their efforts at the frontline, in collaborative work or as international representative have helped to nurture a vibrant academic culture that is now fundamental to their mission. Advanced Practice Nurses (APNs) such as Ms Juriyah Yatim and Ms Tan Siok Bee, Assistant Director of Nursing from SGH, are such role models who are at any one time performing duties as clinician, educator, researcher, collaborator and leader. Nurses are involved in preceptorship and mentoring, patient empowerment and

advocacy, and caregiver training. A few APNs such as Siok Bee also educate future clinicians and nurses as adjunct lecturers at NUS, Ngee Ann and Nanyang Polytechnic and other institutes of higher learning. Ms Tan Ah Pang, Deputy Director of the SingHealth Alice Lee Institute of Advanced Nursing (IAN) shares, “The role of the nurse as teacher to nursing students, newly graduated nurses, colleagues or patients, is deeply ingrained in our culture. At SingHealth, the nurseas-teacher role is dynamic and one that engages the needs of learners actively.” For Juriyah, this means constantly encouraging the “why?” in her students and colleagues. She explains, “All research starts with a question. If you develop an inquiring or questioning mind, it will lead you to further exploration and research to gather evidence and answers.” As newly appointed Vice Chairperson of the Nursing Research Council in SGH, Juriyah is responsible for mentoring future research nurses on their journey towards academic excellence. She relates, “There are many young nurses who are interested in research and publishing, but perhaps do not know where to start. The research council provides a stepping stone for them to explore and develop their ideas. We have mentors to support and guide them from initial sketches to eventual presentation and publication.”

“We have mentors to support and guide [young nurses interested in research and publishing] from initial sketches to eventual presentation and publication” – Ms Juriyah Yatim

Ms Juriyah Yatim

Advanced Practice Nurse SGH 16

“We may start them off with a literature review, just to stimulate their critical thought processes. If they demonstrate the interest and passion, we take it further.” Nurses from the SingHealth group are publishing more and more journal papers and are being awarded research grants for their work. Many have even gone on to present their findings at local and international conferences. Topics range from wound care to patient swallowing assessments in papers written either by nurses as sole authors, have been in collaboration as interdisciplinary teams. The upward trend is set to surge in the years to come. And driving it is the fundamental desire among nurses to improve patient care. As Juriyah states, “It is not about conducting research or publishing papers for the sake of publication. It is when the findings are implemented at bedside, then we nurses can see and feel the real impact of research on improving patient care.” Also in the pipeline in advancing the academic culture is the SingHealth Nursing Research Module about to be launched on the SingHealth Learning Management System known as BlackBoard. The interactive online tool is slated to increase research collaboration and interaction as well as enhance learning among nurses. Ah Pang reiterates the importance of interdisciplinary projects as nurses: “Coming together as a team will bring specific strengths of each discipline to focus on the care of the patient and will supplement any weaknesses of other teammates. Effective interdisciplinary teams decrease costs, improve patient satisfaction, and reduce morbidity and mortality through patient safety and error reduction, while improving overall healthcare worker satisfaction and professional relationships.”

Academic Culture

Alice Lee IAN was established in 1997 and moved to Bestway Building in 2006

“Nursing strongly believes in training, up-skilling and enhancing competencies so that all nurses can perform optimal patient care,” – Ms Tan Siok Bee In tandem with academic research, training continues to be the nursing division’s bedrock. “Nursing strongly believes in training, up-skilling and enhancing competencies so that all nurses can perform optimal patient care,” says Siok Bee. 

Alice Lee IAN was appointed a Continuing Education and Training Centre by the WDA in January 2010 The SingHealth Alice Lee Institute of Advanced Nursing (Alice Lee IAN) At the core of training excellence is the Alice Lee IAN. The institution was established in February 1997 to ensure the provision of a well-trained and professional talent pool of nurses. Its establishment was a significant milestone which signalled recognition of the quality of teaching programmes available and gave a boost to the SingHealth’s efforts at providing advanced practice-based nursing education and training for nurses in Singapore and the region. As a testament to the quality of programmes at Alice Lee IAN, its enrolment figures have increased sevenfold since 2003, with 8,202 nurses being trained in 2009 and 10,086 nurses in 2010. It has trained over 2,000 overseas participants from 70 different countries from 2005 to 2011. The institute also provided 11,689 clinical attachments for nursing students. The education centre was also appointed a Continuing Education and Training (CET) Centre for Healthcare Support by the WDA, and is pivotal in training the next generation of healthcare support workers to provide direct care to patients and take on additional responsibilities to support nursing and medical professionals. Prof Ivy Ng, Group CEO of SingHealth states that playing a fundamental role in realising the vision of Alice Lee IAN is its Senior Director Assoc Prof Lim Swee Hia, who will “lead in collaborations with universities and foster greater synergy among SingHealth institutions to develop nursing training programmes, and grow educators and faculty, towards building the institute as a postgraduate nursing school.”

Ms Tan Siok Bee

Assistant Director of Nursing SGH

From trainee to trainer, student to teacher and mentee to mentor, it is part of the nursing journey to one day pay forward what one has learnt to future generations. Thanks to current leadership of the nursing team, this culture continues to be nursed thoughtfully and lovingly, now and in the future.



A Vision of One Campus Every year, millions of patients step into our campuses to receive leading edge Medicine and quality care. We take a look at what goes on in Care, Research and Education on our One Campus, all strengthened by our partnership with Duke-NUS.

One Campus

New 12-storey digital National Heart Centre Singapore opens in 2013.

(statistics FY10) Over 4 million patient visits and 220,000 surgeries Medical Specialties: 42 Doctors: 2,307 Nurses: 7,825 Allied Health Professionals: 2,937 Academic Clinical Programs: 6 established, more coming

• 38 SOC Consult rooms • 6 Cath Labs • 3 Major OTs • 24 Short Stay Unit Beds • Patient-centric system to optimise visits and reduce waiting time


• Principal Investigators: 294 • National Outstanding Clinician Scientist Award: 2008, 2010, 2011 • President’s Science Award: 2009, 2010 • ASCO Merit Award: 2010, 2011 • STA Young Investigator Award: 2009 • STA Young Investigator of the Year Award: 2010 • Asia-Pac Academy of Opththalmology Award 2010 • STaR Award Winners: 2 • Clinician Scientist Award: 12



• No. of Residency trainees : 57 in FY10, 231 in FY12 • 7 Programs in FY10, 14 Programs in FY12 • Duke-NUS and YLL students selecting us as 1st choice for Residency: 39% in FY10, 45% in FY11 • Academic Medicine Education Institute (see page 6-7)

The Academia opens in 2012 (see page 33)

Care Innovation

• Enhancing Performance, Improving Care (EPIC) for continuous care improvement (see page 30-31) • 55 projects produced, 364 professionals trained in EPIC • Leadership training framework to develop staff

Where’s the Buzz?

• Vibrant murals and banners around campuses • News and profiles of our people in media • Management-staff engagement sessions • Academic Medicine updates on the internet, intranet and social media



Discovering Duke My name is Ravindran, and I’m an Associate Consultant in Medical Oncology at NCCS. I am currently receiving HMDP training in my two areas of interest, namely, genitourinary (GU) oncology as well as geriatric oncology, at Duke University Medical Centre in Durham, North Carolina.


practise at the Duke University Medical Centre, with part of that time spent at the Duke Centre for the Study of Aging and Human Development, one of the pioneering centres for ageing research in the US. My stint here is for one year and I have completed six months so far. Overseas travel for meetings and training – in the form of fellowships – is important for me to learn new skills and enhance collaborative efforts with other leading cancer centres in my areas of interest. Apart from my fellowship at Duke, I used to (and still do) visit Chicago every year as the biggest oncology meeting i.e. the American Society of Clinical Oncology Annual Meeting is held there. I also attend the European Society for Medical Oncology meeting, which is held yearly at various locations in Europe. I usually attend these meetings to present my research work, and to engage and network with leading minds in the field. Having said that, I am fortunate to have been given the opportunity to spend a prolonged time at Duke as that time has afforded me greater potential for learning, research and collaboration with great minds in my areas of interest. Of course, I had the chance to explore North Carolina, which I have found to be very interesting. Training at Duke In the Duke Centre for Aging, I work with Prof Harvey Cohen, Director of the Centre. I actively participate in their Geriatric Evaluation and Treatment Clinics while taking part in teaching activities with the Geriatric Fellowship training programme. I am also engaged in collaborative work with the palliative care team here in the area of communication in cancer clinics. Through my involvement in the Geriatric Fellowship training programme, I have had the opportunity to participate in a number of interesting and useful courses. One noteworthy course was the Stanford Faculty Development Workshop in Clinical Teaching.


I learnt very useful medical teaching techniques to enhance the learning experience for medical students, residents and registrars. Further, the ‘GeriTalk’ course on communications has equipped me with better skills to communicate with patients. In the area of GU oncology, my supervisor is Dr Daniel George, Director of the GU oncology group here in Duke. I work very closely with him and his team in the area of clinical practice and research. I also work with Dr James Tulsky, Director of Palliative Medicine, and his team in studying doctor-patient communication. From a clinical perspective, I’ve learnt about many of the new therapies used in GU oncology. Although we use similar drugs in clinical practice in Singapore, the unit here has better access to many of the newer cancer drugs still in clinical trials. These and other new therapies available here have shown a lot of potential in terms of improvements in the survival and quality of life of the patients. I hope to use the geriatric training I am getting here to further enhance care amongst the elderly cancer patients treated in NCCS. Also, I hope to continue research collaborations with the faculty here at Duke in the areas of GU oncology and communication in the cancer clinics. I believe that outcomes from these research collaborations can be used to improve cancer care in Singapore. Living in North Carolina Living in North Carolina enables me to chew gum and drive affordable sports cars! However, it can be expensive to eat out, with a distinct lack of good Asian fare. Although there is a Singaporean-Malaysian restaurant in the nearby town of Chapel Hill, its quality leaves much to be desired. I suppose I will have to wait until I am home to taste the real thing again! 


’s Duke n a r d n i v a Dr R s Travel Tip

Durham, North Carolina.

Places to see A unique place to visit here in Duke would be the Duke Lemur Centre. It has the largest collection of lemurs outside of Madagascar! Other notable places in Duke include the Duke Chapel and the Sarah P. Duke Gardens. A town called Asheville, about a 3-hour drive away, is a lovely place to visit. It has the largest private residence in the US - Biltmore Estate - and a very vibrant arts and crafts scene. Where to eat Durham is well known for its Southern BBQ cuisine. Many of the restaurants that serve this fare and other types of Western food can be found in the American Tobacco House and on ninth street in Durham. American Tobacco House is a downtown tobacco house turned upscale pedestrian shopping and dining areas. Franklin St. in the Chapel Hill area is another popular place with a variety of great restaurants. Don’t forget to bring… Chilli sauce if you need spice in your food, although an American brand called SriRacha is actually not too bad. And a travel adapter for electronic devices, of course!

At Christ Duke Medic ma in (I’m in s party 2011e . the mi ddle)

The Duke GU team and I went on a hard-hat tour of the newly built Duke Cancer Center

SingHealth Health Manpower Development Plan (HMDP) trains our healthcare staff by sending them to the best training centres in the world to learn new skills, harness new technology and find new solutions for patients. 21


From Patient to Physician Marc Wong is a first year medical student at Duke-NUS who suffers from thalassaemia major. As a medical student, Marc is now on the road to paying it forward – where doctors once took care of him, he will soon be able to play an active role in improving Medicine and patient care. By Monica Lim


rowing up, I kept my condition to myself. I grappled with accepting my condition and hesitated to tell my friends about it. Suffering from thalassaemia major means I need lifelong care and blood transfusions once every three weeks. PE lessons were especially challenging as I wanted to appear as fit and normal as my classmates. Over time, I learned how to manage my condition and even toggled with transfusion dates prior to marathon runs. After graduating from NTU in Biological Sciences, I joined A*Star’s Institute of Molecular and Cell Biology, studying immune signaling pathways and there, I discovered my growing interest in genetic disorders. The teachings from my Church, the encouragement from friends and the assurance of God’s goodness helped me to view life positively. I heard the calling to be a doctor and decided to pursue what I deeply desired – to be able to serve, touch and impact the lives of patients. So I applied to Duke-NUS. My childhood doctors inspired me greatly, caring for me not just physically but also personally and emotionally. In KKH, I was first under the care of Prof Phua Kong Boo as a child, and then as I grew older, I received care under the wings of


“My childhood doctors inspired me greatly, caring for me not just physically but also personally and emotionally.” Assoc Prof Tan Ah Moy. She frequently comes by when I am having my transfusions. Sometimes, I almost feel that she cares for me like my own mother! Great doctors like her have inspired me to follow in their footsteps. Baptism by Fire at Duke-NUS I am now a first year student at DUKE-NUS. Life at Duke-NUS has not been easy! The amount of new information we need to learn is massive and hard to master within a short time. Thankfully, the very interactive teaching methods here enables us to internalise and trigger deep learning. It has been stressful, but like a good workout, going through the rigour gives you a positive feeling. Recently, in preparation for our practical clinical skills exams, my classmates and I determined that I had carotid bruit (a

noise caused by turbulent blood flow in the carotid) and I panicked! It was a classic medical student syndrome. Worried, I sent a text message to Assoc Prof Tan Ru San from NHCS, who set aside time the very next day to see me and personally examined me without any scheduled appointment. After auscultation and an echocardiography he simply said, “There is nothing wrong. Your hearing must be better than mine. No bruit, no bruit!” That cracked me up, eased my anxiety and allayed my fears. I feel privileged to have senior doctors from SGH and other institutions in SingHealth teaching us. They distill their years of experience and give us the essence of what is important to know so that we will be ready and equipped with the skills and knowledge to go into the wards.

As I study Medicine and discover more about the inner workings of the human body, I try and apply what I have learnt from my experience in research, which is to find a good question to ask. I realise that the more we discover about the human body, the more we find out about our own body. My background in research helps me to identify what I don’t know and think of possible ways to fill in those gaps.

“I would love to be part of the process that translates clinical and medical discoveries directly into where it truly matters - the lives of patients.” It teaches me how to approach problems systematically. These would include ways to generate a hypothesis, to define a research question and to systematically tease apart similar facts so as to answer the question. Hope for the Future I am excited to be one small step closer to fulfilling my dream of being able to treat genetic diseases like mine. I am currently looking for a lab to work in and hopefully, be able to make a contribution in the field of gene and cell therapy. I would love to be part of the process that translates clinical and medical discoveries directly into where it truly matters - the lives of patients. Being a patient myself has helped me experience the uncertainty and emotions associated with having underlying medical conditions. This allows me to relate to patients and motivates me to work harder to better care for future patients. I hope to emulate the doctors who have treated me, and to be as relatable and sincere as they have been to me. 

Marc Wong is a first year medical student at Duke-NUS 23

Take 5 with Assoc Prof Lee Kim En &Dr Natalie Koh By Debbie Chia


n his office at the National Neuroscience Institute (NNI), Senior Consultant Assoc Prof Lee Kim En is surrounded by evidence of his passion in teaching. Lovingly compiled scrapbooks, poems, collage boards and memorabilia from his students dot the walls, cupboards and desk. He displays them like a proud parent would. Today, Assoc Prof Lee is joined by Dr Natalie Koh, a 1st year SingHealth Resident in her rotation in Neurology for this interview. Both mentor and mentee convey a comfortable relationship filled with mutual respect and constant encouragement. They allow each other to answer each other’s questions and laughter often fills the room. “My students often ask me why I bother to teach,” he jokes, and adds, “Having to teach might be shocking to some doctors. Teaching is not something a medical student thinks of when they enter the profession or they would have taken a teaching degree. They are here to help people first,” Assoc Prof Lee says.


Yet, he has found a way to combine both his passion as clinician and educator. He has long forgotten the number of batches of students he has seen through, but Assoc Prof Lee never forgets a face or a name.

“Being a teacher is not what a doctor originally sets out to do. Yet, it comes naturally when you feel gratitude for having had a teacher come forward, enlighten you, and show you the way. It’s as simple as that.” – Assoc Prof Lee Kim En “We’ve all been students ourselves and we’ve all felt an extra push when a teacher recalled our name,” he chuckles.

Of his role as a Clinician Educator, he shares, “It is important for me to still be practising clinical work, otherwise I would just be another textbook teacher based in the classroom. This is the fundamental and unique part of clinical teaching.” “As teachers, we have an impact on the future of medicine. It is a serious responsibility,” he intones and explains, “Teaching is a way to maintain standards. We are getting students better educated, better than what we’ve always been. Collectively, we have an impact.” For Assoc Prof Lee, his lesson plans also include 7.00am sessions at Kopitiam, and occasional afternoon sessions at Starbucks, a defining highlight for his students. Every morning for an hour, he and his students sit down over a cup of coffee or tea, and discuss every possible aspect of Neurology. On Saturdays, the session goes on for four hours over breakfast. The informal setting encourages his students to share candidly and discuss every concern from patient care to time management.

A few of the many thank you cards Assoc Prof Lee has received from his mentees

Natalie recalls, “As students, HOs and now MOs, we meet there, have a cuppa and basically, chat. Medical concepts will be conveyed in an informal and nondidactic way. There are life lessons too and the discussion is free flowing. I feel strongly that Assoc Prof Lee is someone who above and beyond an inspirational teacher, is a role model whose values and passion for life are what one hopes to emulate.”

“I feel strongly that Assoc Prof Lee is someone who above and beyond an inspirational teacher, is a role model whose values and passion for life are what one hopes to emulate.” – Dr Natalie Koh “Assoc Prof Lee is the sort of doctor that growing up, I’d imagined what a doctor would be. He is a genuinely warm person, who cares for people and wants to help them. Someone once asked him what he did when he goes on leave, and his student replied, ‘Assoc Prof Lee is thinking about his patients, his work and his students’. I have often felt that being mentored by him was one of the best things that happened to me in medical school.” Natalie says. Of his own teachers, Assoc Prof Lee is quick to name the mentors who have made an impact on his life. Prof Rajasoorya from Khoo Teck Puat Hospital first inspired him by being an astute clinician and an astounding teacher. Assoc Prof Lee was taught that being at the frontline, one has the responsibility to think of what’s best for the patient at all times.

Scrapbook made by Assoc Prof Lee’s mentees

Assoc Prof Lee also cited Prof Low Cheng Hock, a General Surgeon at TTSH. “He is an all-time

favourite of medical students. He is very approachable, a great teacher and friendly. Having been guided by him reminds me of the possibility of making even complex subjects understandable.” Assoc Prof Helen Tjia was one more name he shared. She was an inspiring force that influenced his eventual decision to pursue Neurology. Asked if she too would be following in the footsteps of her mentor, Natalie had this to say: “As a junior doctor, one remains passionate about many subjects. Neurology is certainly a favourite. It would be a privilege to work in as ideal an environment as NNI, where going to work is such a joy.” So what makes Assoc Prof Lee’s teaching so memorable and impactful? Most probably, it is the way he teaches his students. “I compare medicine with flying an airplane, and myself as a flight instructor,” he describes. “As an instructor I have this responsibility that my students attain the confidence and competence to fly the plane on their own. To do that, we have to go back to the basics and be brutally honest with their shortcomings.” Of the last point, Assoc Prof Lee elaborates, “It might go against the grain of the best or most fashionable education about giving constant and positive encouragement, but I feel that you have to be really honest with your students. It is almost a moral responsibility.” Another teaching analogy Assoc Prof Lee brings up is skydiving. “At the correct environment and altitude, the paratrooper must exit the door and it is a challenge that I must prepare them for. Are they ready for the final take off? And when they land, is it where they want to be? Like a paratrooper, my students should be able to survive, thrive and blossom wherever they are.” 


We get to know Assoc Prof Lee and Dr Koh better and see their Take on 5 questions. Assoc Prof

Lee Kim En 1. How do you keep a work-life balance? My wife, my children and I have long accepted teaching, Medicine and my personal life to be rolled into one incredible mix. 2. What is your passion outside medicine? I listen to music, read the Bible, and enjoy essays as well as short stories. 3. What did you want to be when you were 10 years old? I always wanted to be a doctor. It is my biggest dream fulfilled and achieved. I never understand why people get burnout; if this is what you’ve been wanting to do since young, you are living the dream that you always had. 4. If someone would write a book about you, what would the title be? (Answered by Dr Natalie Koh) Green Eggs and Ham! Dr Lee is like the protagonist Sam in the book by Dr. Seuss, who helps others discover Wonder. 5. What is the favourite family activity? We go to church every Saturday evening and have dinner at our favourite places such as ramen at Novena Square. On Sunday the whole family goes for a swim together.


Natalie Koh 1. What is the best part of your job? Getting to work with my favourite people at NNI. It feels like school but with all the fun bits. The environment here is an ideal working environment, which balances work with academic pursuits. The seniors and my colleagues are wonderful. 2. What’s your favourite thing to do when you need a break from work? I love to read. I read all sorts of books and magazines, often several at the same time. My favourites are young adult fiction and biographies. Reading provides me with an escape into an alternate reality, and sometimes a window into someone else’s life. 3. What is the first thing you do when you wake up? Try not to go back to sleep! 4. If you could design a house for yourself, how would it look like? What a great question! I saw a picture of my dream house when I was 13 or 14. It was a glass house at the end of the world on the edge of a cliff overlooking the ocean, with lots of space, in the middle of nowhere. 5. If you could have dinner with a famous historical figure, who would it be? When I grew up I was a huge fan of Romanian gymnast Nadia Comăneci, who was the first to score a “Perfect 10” at the Olympics. I was drilled by Type A parents and strove for similar perfection. I would love to meet her and ask her how it felt to be deemed “perfect” in such a punishing sport. 26


Sight on Eye Research Two recent studies in SNEC have shed light on some unanswered questions about dry eye and distribution of eye diseases, and further studies stemming from them may just allow us keep our sights clear. By Monica Lim




ision can be said to be the most crucial of the human senses. Asked which of the five senses people fear losing most, most would probably answer the sense of sight. The most well-known culprits of vision impairment are eye diseases such as cataract and glaucoma. However, it might surprise many that one of the common eye diseases that impair vision is the seemingly innocuous dry eye disorder. Unlike age-related macular degeneration (AMD) and glaucoma, dry eye does not cause permanent blindness. However, dry eye patients experience eye irritation and episodic blurring of vision, making everyday activities seem like hurdles.

Dr Louis Tong Consultant, Cornea and External Eye Disease Service Singapore National Eye Centre; Head Ocular Surface Research Group Singapore Eye Research Institute As its name suggests, dry eye is related to the lack of tears in the eye. Researchers know that tears in dry eye patients are unstable and evaporate quickly, but they have been unable to find out why. Progress has finally been made in this area. In a recent study jointly undertaken by the Singapore Eye Research institute (SERI) and the National University of Singapore’s Lipidomics Institute, the lipid 28

profiles of meibomian gland secretions (meibum) collected from dry eye patients were studied and compared with those of normal volunteers. Meibum, secreted by glands at the rim of eyelids, prevents evaporation of the eye’s tear film. The study was the largest ever conducted on lipids in dry eye, comprising 256 lipid species from 12 major lipid classes. Results showed that some lipid classes, such as phosphatidylcholines, sphingomyelins and triacylglycerides were higher in meibum from dry eye patients as compared to normal volunteers. Detailed analysis even showed specific lipid classes to be increased, while others are decreased, and these changes are likely to disturb the microstructure of the oily layer causing tear film instability and

Normal cornea with no fluoresce in staining.

fast evaporation, making the patients eye dry more quickly. These findings, apart from allowing medical professionals to better understand dry eyes, have biotechnological and therapeutic implications. In the past, treatment for dry eye has largely been via the usage of eye drops, which are inconvenient and costly. It is also not ideal as there is no eyedrop that closely resembles natural tears.

Researchers know that tears in dry eye patients are unstable and evaporate quickly, but they have been unable to find out why. Progress has finally been made in this area through a recent study jointly undertaken by the SERI and NUS’ Lipidomics Institute.

Cornea of a dry eye patient after staining with topical fluorescein eyedrops. Dr Louis Tong, a Clinician Scientist at SNEC, believes that the study has given rise to new hope in this area. “By manipulating the lipids in the surface of the eye, we can hopefully one day, create an effective form of treatment for this disorder. There is a huge market to explore.” An Eye-Opening Study Another recent breakthrough finding in eye research is the distribution of eye diseases specific to ethnic groups. Vision loss is a major public health issue in Asia but the different problems across the various ethnic Asian groups have

not been well understood. That is, until recently, with the conclusion of the Singapore Malay Eye Study (SiMES-1). Performed on 3,280 randomly selected Malay adults living in the south western part of Singapore, SiMES-1 was a cross-sectional, population-based epidemiological study on eye diseases. Part of the study involved identifying the traditional factors that contribute to eye diseases and vision loss, such as high blood pressure and smoking, and also novel factors like genetics and inflammatory markers. This helps researchers better understand how eye problems develop. The results were eye-opening, to say the least. Half of the study population were

increases their chances of having vein occlusion and narrow blood vessels in their eyes. Smoking also doubles the risk of cataract and triples the risk of AMD, which is as common in Malays as in Caucasians. With such comprehensive data, medical practitioners and public health officials can now better understand the risk factors and etiology of major eye diseases, leading to more effective education and disease prevention programmes. SiMES is now recognised internationally as a landmark study in Asia, with some 100 articles published in journals worldwide. It has been of such value that a follow-up study, SiMES-2, has been launched in 2011. According to Prof Wong Tien Yin,

SiMEs-1 was a cross-sectional, population-based epidemiological study on eye diseases performed on Malay adults in Singapore.

found to have low vision in at least one eye. Of these, half were correctable by glasses. Cataract accounted for 60% of blindness in participants and among those with diabetic retinopathy and glaucoma, more than 80% and 90% respectively are unaware of their conditions.

Director of SERI and SiMES’ Principal Investigator, “A follow-up observation is the only way to gain information regarding the future number of individuals affected by the disease and associated healthcare costs. It will also add further insight on the complex interactions between certain genes, environments and eye diseases.”

The study also found that visual impairment is related to the individual’s socio-economic status as well as level of literacy. Various health problems were also found to affect visual impairment. For example, 70% of the study population had systemic hypertension which

Participants in SiMES-1 have been invited to take part in a thorough, follow-up checkup at no cost. This may lead to the early detection of eye conditions that may otherwise have led to vision loss. Looks like good news for all involved. 

The Singapore Malay Eye Study was a crosssectional, population-based epidemiological study on eye diseases…with such comprehensive data, medical practitioners and public health officials can now better understand the risk factors and etiology of major eye diseases, leading to more effective education and disease prevention programmes.

Prof Wong Tien Yin Director, Singapore Eye Research Institute Senior Consultant, Vitreo Retinal Service Singapore National Eye Centre

Singapore Eye Research Institute (SERI) serves as the research institute of the Singapore National Eye Centre. It is the national institute for ophthalmic and vision research.



Working Together to Make a Difference This is the first of a series of EPIC Hero stories by SingHealth Clinical Governance and Quality Management (CGQM) showcasing the teams behind outstanding quality improvement projects and how their care innovation has improved patient safety and outcome.


very job has its stresses. But for Violet Kwek, a Senior Staff Nurse at the Major Operating Theatre at SGH’s Orthopaedic and Hand Surgery Department, work stress was compounded by the fact that everyone was depending on her to prepare the arthroscope for surgery. Why was this seemingly simple task so stressful? Koh Ka Cheong, Technician at SGH’s Theatre Sterile Supplies Unit explained, “The arthroscope is a long, thin, delicate instrument made of hairthin, glass fibre optic fibres that are delicate and fragile and can be easily damaged.” This means that even after Violet has checked the instrument, miniscule irregularities may still be found during surgery, making it unsuitable for use. This happened as frequently as once a week, and with the patient already prepped for surgery, Violet would have to make a mad dash for a replacement arthroscope while the entire operating


By Monica Lim

theatre waited. “Everyone would be stressed when this happens,” she recalled. Apart from the stressful situation, the faulty arthroscopes were costing the department dearly. In 2008, S$35,860 was incurred in arthroscope repairs. In 2009, it surged to S$70,180. Taking Action Vexed by the situation, staff who worked with the arthroscope, 10 members in all including Violet, decided to take an active approach. They assembled a team and initiated a Quality Improvement project, aimed at reducing the number of arthroscope repairs. Working around their different shifts and schedules, the group members met every week for a month for brainstorms to determine the causes and solutions. The team determined that because of the fragile material the arthroscope was made of, it was particularly vulnerable

Compared to 2009, fewer faulty arthroscopes make their way to the OT and the number of arthroscope repairs has been reduced to about half by end of September 2011. Repair costs have also plunged by more than half to S$30,460. to damage during handling and use. Since no changes could be made to the material and structure of the arthroscope, the way forward was to reduce the chances of mishandling it. Over the next 12 months, the team tirelessly tried out different solutions and came up with several successful measures. First, pictorial guidelines

Today, Operating Theatre (OT) nurses no longer have to race to get replacement arthroscopes, fewer faulty arthroscopes get delivered to the OT and repair costs for faulty scopes are drastically reduced. All thanks to a Quality Improvement project by Ms Violet Kwek and her team at SGH Major OT.

clearly instructing users on the right way to handle and transport the arthroscope were developed. These were displayed on walls at the work stations of the decontamination and packing area of the Theatre Sterile Supplies Unit, as well as the Operating Theatre disposal rooms. “We took our own pictures and made our own pictograms because we didn’t want to use any copyrighted material,” explained Violet. Next, staff were trained on the proper handling and use of the arthroscope via internal lectures. A computer software was developed to track the repair history of arthroscopes so that the situation could be monitored and a steady supply of functional, quality arthroscopes could be constantly made available. Perseverance Bears Fruit Today, OT nurses like Violet no longer have to race to get replacement arthroscopes. Compared to 2009, fewer

faulty arthroscopes make their way to the OT and the number of arthroscopes’ repairs has been reduced to about half by end of September 2011. Repair costs have also plunged by more than half to S$30,460. The amount of time wasted to get replacement arthroscopes has also dropped by 70% and, overall, everyone is happier and less stressed. Work is even being done to create a permanent skills laboratory for doctors to undergo simulated skills training in arthroscopic surgery using simulated training models of limbs. “The work process has improved and we don’t have to keep running to get replacement arthroscopes before surgeries,” said fellow colleague, Senior Staff Nurse, Eileen Seah. Working together to make things better for the patients and colleagues has also yielded other personal benefits.

“The team has also become friends. Before the project, engineers and doctors don’t really meet and we only knew each other in passing. But the project brought people from different parts of the department together. Now, when we have to work together, the relationship is much better,” smiled Violet. 

About EPIC SingHealth Enhancing Performance, Improving Care (EPIC) is a multipronged programme aimed to rapidly accelerate understanding and adoption of improvement and creative thinking principles through SingHealth. Get yourself involved in an EPIC programme: http://mysinghealth/singhealth/ corporateoffice/qm/epic/epicnews



Artist’s impression of The Academia

THE ACADEMIA OPENING NEW POSSIBILITIES FOR DISCOVERY AND DIAGNOSTICS A year to its completion, SingHealth marked an important milestone for The Academia with a topping out ceremony on 2 April 2012. Health Minister Mr Gan Kim Yong graced the event as Guest of Honour.

The two towers will house SGH Department of Pathology and SingHealth research, education and training facilities

A specially commissioned mosaic art piece which depicts The Academia’s façade was unveiled during the topping out ceremony

The 13-storey twin tower facility, which is located at the heart of SGH Campus, will house the Diagnostics Tower for SGH Department of Pathology and Discovery Tower for SingHealth research, education and training facilities. The architectural design of The Academia promotes interconnectivity and collaboration between pathologists, clinician-scientists, researchers, academics, educators as well as medical students. Group CEO Professor Ivy Ng, said, “This is an important milestone in the transformation of SingHealth in academic medicine. On completion, The Academia will offer a vibrant and stimulating environment where research, scholarly work and education contribute to the advancement of better diagnosis, treatments and cures for our patients.” The SingHealth Infrastructure Advisory Group presented the vision for the model of care, SingHealth 2020 at the recent SingHealth Board Retreat. The topping out ceremony of The Academia marked the first phase of development on SGH Campus. Its opening in 2013 will be followed by the opening of the new National Heart Centre Building later in the year, along with plans on KKH Campus redevelopment and expansion of our Polyclinics. By 2018, the Sengkang General Hospital with an attached community hospital will commence operations, followed by the opening of a community hospital on SGH Campus in 2020.


SingHealth and partners celebrate the topping out with a sake barrelbreaking ceremony

These new facilities aim to seamlessly integrate care across the continuum from primary to acute, and on to intermediate and long-term care to deliver patient-centric care, with two key priorities – Outcomes first and Patients first.

SinghealthREVIEW Academic Medicine Update Many steps forward for Academic Medicine Our last issue touched on the introduction of the ACPs and covered some of the overlying concerns that we’ve heard from the ground. In this issue, we went further into our academic culture and looked at what Academic Medicine means to our medical professions and how they’ve been involved from the beginning.

“The best organisation and planning would be defeated without the right culture” – Prof R Sanders Williams

We take a look now at the most recent developments in Academic Medicine, starting with a visit by our Academic Medicine Advisory Council (AMAC) from 3-4 April 2012.

Members of the SingHealth Academic Medicine Executive Committee (AM EXCO) welcomed the esteemed AMAC where they shared their invaluable insights on the building and running of an Academic Campus. In their two-day visit, the AMAC brought their wealth of experience in Academic Medical Centres and engaged various members of the AM EXCO in in-depth dialogues to evaluate and improve on our Academic Medicine structure. The Academic Medicine Advisory Council Prof R Sanders Williams (Chairman) Founding Dean, Duke-NUS President of J. David Gladstone Institutes Prof Sir Keith Peters Emeritus Regius Professor of Physic, University of Cambridge Prof Sir Sabaratnam Arulkumaran Head of Obstetrics and Gynecology, St George’s University of London President Elect, International Federation of Gynecology & Obstetrics

SingHealth welcomes the addition of three new Academic Clinical Programs (ACPs), bringing our total number of ACPs to six. Surgery ACP Academic Chair: Prof London Lucien Ooi Vice-Chair, Research: Prof Low Wong Kein Vice-Chair, Education: Prof Wong Wai Keong Vice-Chairs, Clinical: Prof Christopher Goh (SGH Campus) Dr Kevin Lim Boon Leong (KKH Campus) Neuroscience ACP (NNI) Academic Chair: Prof Lee Wei Ling Vice-Chair, Research: Assoc Prof Tan Eng King Vice-Chair(s), Education: Assoc Prof Nigel Tan & Prof Lim Shih Hui Vice-Chair, Clinical: Dr Francis Hui Opththalmology ACP (SNEC) Academic Chair: Prof Donald Tan Vice-Chair, Research: Prof Wong Tien Yin Vice-Chair, Education: Dr Ian Yeo

Prof Eugene Braunwald Eminent Cardiologist and Distinguished Hersey Professor of Medicine, Harvard Medical School

Vice-Chair, Clinical: Prof Donald Tan

Session 1 Session 2 Session 3 Session 4 Session 5

We would also like to introduce the Academic Vice-Chairs for the phase 1 ACPs:

Partnership between SingHealth and Duke-NUS Dialogues with ACPs Dialogue with AM Research Institute and AM Education Institute Dialogue with Education Group Dialogue with Research Group

Also here to share their expertise in the managing and operation of an academic campus were Gordon D. Williams, former Chief of Operations and Senior Associate Vice President for Administration at the University of Iowa Healthcare, and John Glier, President and Chief Executive Officer for GG+A Consultants in Philanthropic Management.

Medicine ACP (SGH) Assoc Prof Chow Wan Cheng Assoc Prof Chan Choong Meng Paediatrics ACP (SGH & KKH) Assoc Prof Ng Kee Chong (KKH) Prof Ho Lai Yun (SGH) Obstetrics and Gynaecology ACP (SGH & KKH) Assoc Prof Bernard Chern (KKH) Prof Tan Hak Koon (SGH) Information accurate as of date of publication, pending ARC approval.


SinghealthREVIEW AWARDING EXCELLENCE Allied Health Community Day & Innovative Practice Award Our Allied Health Professionals play an important role in our Academic Medicine journey, and for this they work very hard to improve care to their patients. Every year, we show our appreciation for their dedication by organising the Allied Health Community Day. This year’s celebration let our hardworking AHPs unwind with a night at St James Power Station, with Group CEO Prof Ivy Ng letting her hair down and partying the night away together. The winners of the Allied Health Innovative Practice Award were also announced. See pages 12-13 to find out more about the winning projects.

Singapore Health Quality Service Awards The Singapore Health Quality Service Award 2012 (SHQSA) on 13 January honoured 2,694 healthcare professionals who have demonstrated commitment to delivering quality care and excellent service. The SHQSA is also a platform for collective celebration of quality service achievements by individuals and teams from public, community and private healthcare institutions in appreciation of the industry’s unsung heroes and heroines.

2nd SingHealth Excellence Award 23 March was a night where the best in their field gathered to be honoured for their contributions in building the Academic Culture we’ve read about in the pages of this issue. Forty-six Individuals from SingHealth and its institutions were awarded for their tireless efforts in their respective fields. View the complete list of winners on the SingHealth Desktop Portal.

SingHealth Inspirational Patient and Caregiver Award The SingHealth Inspirational Patient and Caregiver Award 2012 on 15 March recognised and honoured patients and caregivers who have shown exemplary qualities such as courage, generosity of spirit and a zest for life that all of us can learn from. Said Group CEO Prof Ivy Ng, “Courage, strength, resilience and a positive outlook – these are the qualities that inspire healthcare professionals like me to give all that we can to improve the care that we administer.” Visit the SingHealth website to read the stories on our winners.


SinghealthREVIEW Coming UP SingHealth Duke-NUS Scientific Congress 2012

Defining Tomorrow’s Medicine, 3-4 August, Raffles City Convention Centre

Pushing the frontiers of healthcare and biomedical sciences, the SingHealth Duke-NUS Scientific Congress 2012 is a highlyanticipated event for healthcare professionals. Join us at this bi-annual meeting and benefit from the rich scientific programme that features a distinguished line-up of more than 55 international and local speakers. Book a seat at the Congress now! To register or view the full scientific programme, visit




On 1 March, Assoc Prof Lim Swee Hia passed her leadership baton of Group Director of Nursing, SingHealth to Dr Tracy Carol Ayre.

Starting 1 February for a term of 3 years:

Dr Edwin Low has been appointed Senior Associate Dean for Academic Medicine at DukeNUS with effect from 1 January, concurrent with his SingHealth portfolios as Group Director, Office of Academic Medicine and Group Director, Strategic Human Resource.

Prof Lim will continue to play key roles in SingHealth as Senior Director of the SingHealth Alice Lee Institute of Advanced Nursing and Director, Special Projects, SGH. She also extends her appointment as Director of Nursing, NHCS until August 2012. Dr Tracy Carol Ayre, was appointed the new SingHealth Group Director, Nursing and concurrently Director of Nursing, SGH. (take waterfall photo for thumbnail) Ms Tan Soh Chin, Director of Nursing, KKH took on the concurrent appointment of Deputy Group Director of Nursing, SingHealth. On 10 February, Assoc Prof Lim Swee Hia was conferred the award of Honorary Doctor of Science by Curtin University. She is the first nursing professional from Singapore to be conferred the prestigious award.

Prof London Lucien Ooi, SGH Division Chairman, Surgery, has been reappointed Director. Prof Donald Tan, Medical Director, SNEC, was appointed as Co-Director.

Assoc Prof Tan Chee Kiat, Senior Consultant, SGH Department of Gastroenterology and Hepatology; and Director of the Liver Transplant Service was appointed Deputy Director (Solid Organ Transplant). Dr William Hwang, Head, Department of Haematology and current Director of the Haematopoietic Stem Cell Transplant Programme in SGH was appointed Deputy Director (Tissue & Cell Transplant).

Mr Tan Wei Ming joined SingHealth Corporate Office on 3 February as Director, Education.

SECONDMENT OF CMB Prof Tay Boon Keng, currently SingHealth’s Chairman Medical Board (International) and Emeritus Consultant in the Department of Orthopaedic Surgery in SGH, was seconded to the Ministry of Health on 1 April 2012 as Senior Consultant Director (Hospital Services) on a part-time basis.



Lights Through The Glass Ceiling At a time when doctors were unquestionably male and female health professionals were typically nurses, two exceptional women shattered the glass ceiling to shine at the very top. The late Professor Elaine Field and 96-year-old Dr Oon Chiew Seng achieved stellar successes in their medical careers, paving the way for other women in the field of Medicine – and across Singapore By Debbie Chia


hen Elaine Field obtained her Doctorate in Medicine from the University of London in 1937, the right for women to vote in the United Kingdom was barely 20 years old. Her achievement was surely a feat in its own right, but the ambitious and bright young lady was only just getting started.

Prof Field became a one-woman machine, pioneering child health services across Malaysia, Singapore and Hong Kong. Her arrival in Singapore heralded the start of a new era in medicine locally, with SGH opening a spanking new Paediatrics wing soon after that.


Prof Elaine Field pioneered child health services accross Asia

Building a rock-solid resume around the burgeoning field of paediatrics, she gained recognition for her work in childhood bronchiectasis, as well as her

unwavering devotion to the cause of sick children. By 1962, she was elected a Fellow of the Royal College of Physicians, taking her place alongside a sea of titans in Medicine.

other children in a cramped flat, she would escape to the rooftop to read by kerosene lamp.

Her best work was performed when she came to Asia in 1949. At a time when most Britons were headed back to the British Isles, moving to the Far East to become the Child Health Specialist was a dramatic and surprising gesture. But the United Kingdom’s loss was South East Asia’s gain. Professor Elaine Field became a onewoman machine, pioneering child health services across Malaysia, Singapore and Hong Kong. Her arrival in Singapore heralded the start of a new era in medicine locally, with SGH opening a spanking new Paediatrics wing soon after that. Hong Kong was not spared from her passion either. She fought to establish the Department of Paediatrics there, leaving behind a legacy that most doctors can only dream about. Going against the perception that paediatrics was basically child’s play was easy for a woman who was used to breaking stereotypes. Through the newly-founded Paediatric Society, she established and promoted good child health practices to be disseminated across the board. For a woman who pioneered paediatric education while championing the cause of underprivileged children, Prof Field will remain in the annals of medical history as a woman who made her mark in Asia. But she is not the only one. Dr Oon Chiew Seng spent her early years as a nurse before it struck her that being a doctor would enable her to serve the sick much more meaningfully. Armed with her convictions and the support of both her loving older brothers who pushed for her to continue her studies and enter the profession, she left nursing to study Medicine. The road ahead was fraught with difficulties. Within six months of starting her studies, World War II broke out and she had to be evacuated to India to continue her studies. Living with 16

Dr Oon Chiew Seng’s track record has been breathtaking with achievements that impacts many lives. But she persevered. By 1946, she was back in Singapore – and back on track to finish her studies, having leapfrogged over the local students through sheer determination. Post graduation, her housemanship took her straight to KKH, with which she maintains a lifelong association. The prestigious Queen’s Fellowship in 1953 saw her leaving for England to do postgraduate studies where she gained a wealth of expertise. Complemented with her extensive hands-on experience in a Singaporean clinical setting, it is not hard to see why Dr Oon would soon become a powerhouse in the life-and-death universe of obstetrics and gynaecology (O&G). Since then, Dr Oon’s track record has been nothing short of breathtaking. As Chairman of the Committee appointed to study nursing services in 1963, and President of the Obstetrics and Gynaecology Society over the years, her contributions to the medical sector are undeniable. As Chairman of the Building Fund of the Sree Narayanan Mission Home for the Aged and Sick, as well as a Member of the Singapore Family Planning and Population Board in 1971, her impact on society has literally been felt by millions. Balancing multiple roles in both the public and private sector has always been

an integral part of her career. Besides setting up a successful private clinical practice, the lady with boundless energy also initiated the groundwork to build a nursing home for dementia patients here. Today, Apex Harmony Lodge continues to cater to their needs, with Dr Oon playing a pivotal role in its management and operation until recently. Now, the independent and self-assured Dr Oon can look back on an entire timeline of commendations and awards, including the Honorary FRCOG and Honorary Fellow of the Asia Oceania Federation of O&G, Honorary Member and Gold Medallist of the Alumni Association, and the PBM by the Government of Singapore. Not forgetting her latest, an Honorary Membership to the Singapore Medical Association awarded in 2005. Through the Dr Oon Chiew Seng Fellowship and Distinguished Visitor Programme conducted under the auspices of her alma mater, she has sponsored programmes in dementia, memory, woman’s health and antiaging science. Giving back to society - and building a brighter future - comes naturally, as she feels grateful for the generosity of generations before.

Now, the independent and self-assured Dr Oon can look back on an entire timeline of commendations and awards. Passionate, courageous, and driven to succeed in the face of insurmountable obstacles - these qualities have enabled both women to succeed in what used to be a man’s world of Medicine. Their lights continue to shine on female medical professionals today, in a world where doctorates and dresses are no longer a surprising combination. 

We thank Toby Huynh, Curator of SGH Museum, for her ideas and contribution in researching for this article. Visit the SGH Museum at SGH Campus’ Bowyer Block to learn about the rich history of SGH and development of medical specialties and medical education in Singapore. sgh-museum 37

issue 02/2012 Translating the Academic Medicine Vision

In the vibrant healthcare system in our One Campus, synergies are being built among all our healthcare professionals to further our pursuit of Academic medicine and improve care for our patients. Our staff are shining champions of improvements to care, delving deeper their involvement in teaching, research and care innovation. This issue, we look at the bustling Academic Culture that makes our campuses come alive – from the clinicians behind the Academic Clinical Programs (ACP) to Nurses – the pride of Singhealth and our many-talented Allied Health Professionals. Pg 3-19

Tomorrow's Medicine Issue 02 - 2012  

Find out about our vibrant Academic Culture in our second issue!

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