Speech by Minister Indranee Rajah at the Duke NUS Class of 2023 Graduation & Hooding Ceremony

Triaging the Future

Professor Eugene Washington, Chancellor for Health Affairs, Duke University and President and CEO, Duke University Health System

Professor Ivy Ng, Group CEO, SingHealth

Chairman and Members of the Duke-NUS Governing Board

Professor Thomas Coffman, Dean, Duke-NUS Medical School

Graduands

Parents, Family Members, and Guests

Good afternoon. I’m delighted to join you all today to mark this important milestone as the 89 members of the Class of 2023 graduate and enter the ranks of our medical and research professions. I remember what it was like to graduate a long time ago, probably before many of the graduands today were born. It’s a fairly special feeling.

To these graduands, yours has been a uniquely challenging journey. While there are no pandemic restrictions for today’s event, we shouldn’t forget that the bulk of your medical school experience took place under unprecedented conditions.

The Importance of Triage

Even as the COVID-19 pandemic appears to be behind us though, we need to continue to prepare for challenges on the horizon. To do so will require us to triage situations well and channel our resources wisely, and we have to be proactive to ensure that we are prepared.

So as doctors, you will all be familiar with the importance of triage. It ensures patients receive the appropriate care given the current resources. It also requires a balance between optimising for efficiency and buffering for resilience at the systems level.

So let me attempt to triage several challenges on the horizon that are closely related to healthcare. This is important because these challenges are going to take place in your time as doctors. So when you’re in the wards, when you’re doing your clinical work, these are the challenges that you will be facing in very real terms. But we certainly hope that you’ll be able to work with the Government to address these challenges because really, it’s by putting our minds together and having people on the ground like yourselves that we will be able to have better outcomes.

Emergency – Preparing our response to future emergencies.

So first, the highest category in the World Health Organisation’s Emergency Triage Assessment and Treatment, or (ETAT) model, is “Emergency”, referring to cases that demand immediate treatment. From a national perspective, the COVID-19 pandemic is an example of one such emergency. The pandemic brought about an extraordinary impact on human health, society, and economy.

Each of you experienced the impact of the pandemic first-hand, both as students and as future healthcare professionals. COVID-19 struck just six months after you embarked on your first year at Duke-NUS.

As Dean Coffman said, each of you had to adapt to multiple changes in health and safety regulations, including modifications to the curriculum and tests. You have all demonstrated significant resolve.

When clinical wards were out of bounds and your cohort had to undertake research experiences earlier, many of you pivoted quickly and managed to make an impact through research even before being immersed in a hospital setting.

I’m also heartened that many of you rallied together to overcome the risk of social isolation, including through online interclass bonding events, check-ins by your class presidents Michelle and Derek, and enjoying welfare care packs provided by your student council.

Despite the elevated risks of being in the healthcare profession amidst a pandemic, you began your clinical training in April 2021 and persevered both in caring for your patients and in furthering your own education.

You too are our healthcare heroes. Let’s hear it for them everyone, please give them a big hand. While Singapore weathered the COVID-19 storm relatively well thanks to the tenacity and resilience of our healthcare system and our healthcare professionals and people, we have to be prepared for the next pandemic, and the pandemics after that.

The global deterioration in biodiversity will almost certainly lead to further spill overs of zoonotic pathogens, which will lead to future pandemics. It is not a question of if, but a question of when, where, and how bad.

Climate change will only accelerate these trends and sharpen their impact on human health.

Preparing our response to future emergencies will require marshalling our best ideas to advance creative solutions while strengthening our healthcare capabilities and responses.

On the research front, I’m pleased that Duke and Duke-NUS have launched a Research Collaboration Pilot Project Grant which will nurture new collaborations between researchers in Singapore and Durham, enabling Duke-NUS to develop innovative community health interventions.

On the capabilities front, the “Clinician First, Clinician Plus” curriculum at Duke-NUS is strengthening our pipeline of healthcare practitioners who are committed to improving healthcare delivery.

Championing additional elements such as an emphasis on patient safety, quality improvement, systems thinking, and healthcare leadership, will ensure that our healthcare professionals are adaptable and nimble, no matter the circumstances.

Priority – Addressing an ageing population

The next category in the WHO triage model is “Priority”, which refers to cases that need to be prioritised for rapid assessment and treatment.

We must be intentional in addressing these priority issues consistently, lest they become emergencies of tomorrow.

Ageing is one such priority issue. At the Committee of Supply debate earlier this year in parliament, I spoke about building a future that all Singaporeans can aspire to. One area that we will need to address relates to key population trends that are affecting us: both our declining total fertility rate and, on the other hand, longer life expectancies.

10 years ago, around 11% of Singapore Citizens were aged 65 and above. Today, this proportion has increased to 18%, and by the end of this decade one in four, or 25%, will be aged 65 or above.

This will require us to rethink society in quite a fundamental way, particularly our healthcare sector.

I currently co-chair the Care Pillar of Forward Singapore or Forward SG, with my parliamentary colleagues, Minister Ong Ye Kung, and Minister Masagos. One of the key moves under the Care Pillar is a renewed focus on population health over healthcare provision.

We have developed a Healthier SG strategy to shift the centre of gravity of our healthcare sector from acute care to preventive care.

Under Healthier SG, we want Singaporeans to think of their family clinics as the first stop for their care needs, rather than hospitals. We want Singaporeans to work with their family doctors and community partners to consider how they can choose health and healthy living before they need healthcare.

For the healthcare profession, doctors will be key to building relationships with their patients. This will require knowing patients well and having a good overview of their health status to develop plans for them to stay healthy.

Another strategy that complements our population health approach is to transform our aged care infrastructure so that seniors can age well within their homes and communities. The aim is to delay frailty and reduce social isolation, so that we can further prevent institutionalisation of seniors in nursing homes and hospitals.

In fact, my constituency is just opposite, many of you probably go for lunch at the Silat area, you can see that the residents there have been ageing quite rapidly over the years, and it’s a matter of priority for me to make sure that they stay out of your facilities as long as possible. Because that is the test, really, of having them age in place and be healthy. So that’s the goal.

For these strategies to succeed, we need effective implementation, robust research, and bold innovation.

Duke-NUS is at the heart of this. The graduating cohort of Duke-NUS students has done meaningful work to advance our understanding and responses to ageing.

Gabriel Chew, who will be graduating with an MD-PhD, examined the brain for clues to tackle Alzheimer’s disease which causes dementia. This is a condition expected to affect 80,000 seniors aged 60 and above in Singapore by 2030. From his research, Gabriel discovered key changes in the gene expression patterns in certain cells in the brain associated with the disease, which enables us to better understand the mechanisms underlying disease development.

Besides research, another way in which new healthcare innovations can improve the lives of our seniors is through therapeutic inventions.

I am glad that Duke-NUS is preparing to nurture future generations of clinician-innovators through the launch of programmes like the Duke-NUS Health Innovator Programme or DHIP, an initiative spearheaded by alumni Dr. Rena Dharmawan.

The DHIP provides an immersive experience in innovation for third-year medical students.

I hear from the Dean that this year’s cohort focused on coming up with solutions to tackle women’s health issues, partnering with KK Women’s and Children’s Hospital and other business partners.

The winning team developed a device that prevents vaginal tears during childbirth.

The team has filed a provisional patent and is working closely with their clinician mentor and industry mentors to plan user testing and development which will pave the way for small batch manufacturing and clinical studies.

Should this device make it to the maternity wards, I’m certain that many mothers will welcome it.

I encourage the team, along with any others with good ideas, to take full advantage of resources such as innovation grants from SingHealth to translate your ideas into reality.

As we venture into preventive care, we will have to tackle issues in broader settings beyond hospitals and clinics. This includes introducing interventions in the community that are not purely medical, but in the social and lifestyle dimensions.

Such interventions could benefit long-term psychological outcomes of young patients at higher risk of developing stress related disorders following paediatric intensive care unit admission, an issue that class speaker Michelle Ko published a research paper on.

With the introduction of “social prescribing”[1] in the first-year MD curriculum last year, I’m hopeful that Duke-NUS’ graduates will be well-prepared to tackle issues at these new frontiers in healthcare.

Non-urgent – Continue to take a long-term view to reimagine the future of medical work

The lowest category in the WHO triaging model is “non-urgent”, which refers to cases that can wait their turn for assessment and treatment. But these are nonetheless important, and we should reserve some mindshare for these issues.

Non-urgent issues typically relate to the longer-term institutional building work that is necessary both to keep the system going and to make it better. Efforts on this front are oftentimes thankless and hidden.

Singapore has an established tradition of taking a long-term view and investing in these non-urgent issues. We must continue to do so, lest they do become urgent.

If we think back to the genesis of Duke-NUS as Singapore’s first graduate-level medical school, there may not have been an urgent need for such an institution. Nonetheless, we pressed on, and the school has since cultivated many healthcare professionals with a wide range of backgrounds, a diversity which is reflected in this graduation cohort:

Cassandra Chan is a banker by training and chose to pursue medicine to tackle issues like the surging costs of healthcare technology and equipment. She is keen to develop solutions that creatively overcome time constraints caused by manual, administrative tasks to increase facetime with patients.

Loh Xinpeng who was trained in biological sciences hopes to identify deficiencies in current therapies and develop targeted improvements in clinical management. Progress on these fronts would allow her to enhance patient care.

There would be no Duke-NUS and no graduate medical school pathway in Singapore for Cassandra or Xinpeng if we did not choose to invest in the non-Urgent issues of that time.

My challenge to all of you today is for each of you to reserve some space to address the non-urgent issues of our day.

For a start, we should continue challenging ourselves to reimagine the future of medical education and rethink how our healthcare professionals can address existing and emerging care gaps in and beyond Singapore.

Ultimately, our responses to non-urgent issues of the present will set us up for the big successes of the future, just like Duke-NUS.

Triaging the Future

I have spoken about emergency, priority, and non-urgent issues that are likely to lie ahead of us. But triaging the future is a difficult art.

The reality is that no matter how hard we triage, we will face the very human instinct of not wanting to make trade-offs. It is quite natural to want it all.

While we can continue adjusting our triaging approach and assessment to ensure that the most pressing issues are taken care of, we must not forget the important but not-yet pressing matters. It is this long-termism that will position Singapore well for the future.

Forward Singapore is part of our broader effort to build a healthy and thriving society and we will continue to partner with you and with all Singaporeans as we forge ahead.

As you embark on different pathways after graduation, I have every confidence that you will contribute to the medical and scientific community, no matter what emergency, priority, and non-urgent issues come your way.

You will identify opportunities to transform the practice and delivery of medicine and improve the lives of patients as future clinicians and researchers.

You will do so in the excellent company of those who have supported you thus far and will continue adding wind to your sails, including your peers, professors, families, and friends.

So let me close by offering my heartiest congratulations to the Class of 2023 on your graduation. I wish you every success for a fulfilling career.

Thank you all very much.

[1] In social prescribing, the focus goes beyond treating patients when they are ill. This nascent area of family medicine seeks to encourage patients to live healthier lives by empowering them to manage their illnesses well and use the resources around them, such as Senior Activity Centres, to improve their overall wellbeing.