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World’s hardest working ophthalmic team in Singapore
Many U.S. physicians can learn from this bustling, highly efficient and cohesive practice in Southeast Asia.
 John B. Pinto |
Like every other kid growing up in the 1960s, I often heard my parents say to us at dinnertime, “Be sure to clean your plate — just remember the starving kids in the Orient.” How the dining room tables have turned.
I recently returned from a week on assignment in Singapore, the guest of eye surgeon Jerry Tan, MD, his wife/administrator, Suan Choo, and their simply brilliant practice staff.
Although the two-way jet lag is finally waning, I am still having many of the same disoriented feelings that Marco Polo must have felt about 700 years ago, traveling on the Silk Road to China, puffed up about the cleverness of his 14th century Venetian culture until he, too, came face to face with an unexpected level of both technical and human sophistication.
Right about now, on behalf of my American colleagues, I am feeling a little barbaric and behind the times. Here is why.
Singapore is an amazingly compact island nation, only about 16 miles by 16 miles, with a little less than 5 million densely packed people. That is about the size and scale and populace of Chicago plus a few of its suburbs. From the early 1800s, control of the country has bounced from Britain to Japan, then back to Britain, then Malaysia and finally onward to independence in the early 1970s.
Today, Singapore is a tax haven and a hub for wealth management. It enjoys an overwhelmingly positive trade balance with the world. Seemingly, there is a Rolex or Louis Vuitton outlet on every block to cater to the millions of voracious shoppers who visit every year. The average man-in-the-street makes nearly as much as the average American, and the upper crust is in abundance. Most people own their own flat or house, in a country where an average home (that would sell for $250,000 in America) can go for upward of a couple of million dollars. The sidewalks and streets are almost eerily spic and span, and the people are courteous beyond description.
Strict policies, hard workers
At first appearance, the national rules that Singapore has applied to achieve all of this are harsh. Drug dealers are executed with dispatch. You may remember the furor over an American youth some years ago who was convicted of spray painting graffiti and sentenced to be caned. The punishment for littering is steep fines plus a free trip to the beach — to pick up litter. If your right hand is cut off in a workplace injury, then you had better learn a trade that only requires use of your left hand because there is only a minimal social safety net. Welfare checks are distributed only in the direst of circumstances, and then at a level that slows the pace of starvation, nothing more. Military service is compulsory for young men (and has the salutary effect of helping to harmoniously integrate a culture as diverse and prone to racial discord than our own).
These national policies have resulted in a country that works. And Singapore really works, both in the societal sense, and even more in the kinetic-commercial sense.
Singapore has the world’s busiest and hardest-working seaport. Its economy is growing 8% a year (more than four times the pace of our own). And as you are about to learn, Singapore probably also has one of the hardest working ophthalmic teams in the world.
This gushing about Singapore’s obvious attributes is meant to be more than a travelogue. It is a send-up for some practical comparisons between Dr. Tan’s highly efficient and cohesive practice and perhaps your own setting in Anytown, U.S.A. Given the expected pace of health payment reforms in the United States, the falling dollar, $100-a-barrel oil and rising inflation, there is much to be learned from what Dr. Tan and his team have created on the far side of the world.
Let us start with some numbers.
Abundance of patients
On the surface, Singapore is not under-doctored. With about 130 ophthalmologists and 600 optometrists, Singapore has an eye care provider for about every 6,200 people. How does that compare to the United States? We also have about 6,200 people per eye doctor (MD + OD); so on paper, Singaporean doctors have about the same competition to worry about compared with their American colleagues.
But that is not entirely correct, because in Singapore, the optometry profession is still developmentally at the stage America was at two generations ago. Optometrists, who receive little more than a baccalaureate degree, can diagnose but not treat; they have no therapeutic dispensing privileges. They are really, for the present moment, on par with COT-level technicians. So if we were to normalize for the extremely limited current scope of optometry in Singapore, Dr. Tan and his 130 or so MD colleagues really have something like 35,000 people per fully licensed provider — a sixfold advantage over American eye surgeons. For the sake of a wider international comparison, that is a little better than twice the patient-to-provider ratios we see in Europe today.
As a result, patients are in abundance. You can imagine how doctors in Singapore have to double-time it up and down the clinic floor. And that is precisely what I saw in Dr. Tan’s clinic. The go-go pace of Singapore’s street life is duplicated in the eye clinic, with staff, patients and doctors literally on the run much of the day. Indeed, any patients who move a bit too slowly are whisked along, dragged by the arm or pushed from behind (and I mean this quite literally) to keep up with the blur of events. The result? Dr. Tan personally sees more than 1,100 patients per month using just two exam rooms (and the widest battery of specialty testing I have ever seen).
Doctors who can keep up this brisk tempo are well-rewarded. The typical cataract surgery fee is nearly three times the professional fee paid in America. Practice costs charged against the resulting high cash flows are less in some respects, and much higher in others, than here in the states. The typical clerical or clinical support staffer in Singapore costs about 60% of their American peers to hire, but office space can be four times more costly.
As a visiting consultant, it felt for me like a trip back to an American practice 25 years ago, when patients could wait for months to see the doctor, and profit margins were once routinely 50+% compared with current levels of 35% or less.
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Image: Pinto JB |
Subspecialties
There are only about 16 retinal specialists in the country, so each one has about 40% more work to do than their American counterpart, and everyone has more than a full schedule.
One of the most interesting points of divergence between the patient base in America vs. Singapore is that, in the latter country, myopia affects about 85% of the population compared with about 25% here. Even so, the pace at which Singaporean myopes are seeking out LASIK — at least thus far — is only about one-third the pace at which American patients are coming forward. Part of this is due to the diminished role of marketing. As in Europe, until recently, it was frowned on for doctors to advertise. This is liberalizing rapidly (although patients are still not allowed to provide testimonials).
The average fee for LASIK in Singapore is about the same as the fee in America, but it is common to still charge $300 or more for a consultation (which is now typically provided on a courtesy basis in America). Discount centers are beginning to emerge. I would forecast that better communication and falling fees will all lead to much higher case volumes in the next few years.
In many respects, I suspect that the business of ophthalmology in Singapore and America will converge, as is happening in other First World countries, but with at least three critical differences: work ethic, team cohesion and customer service. I wish we could import the splendid traits that I observed in Dr. Tan’s practice and deliver them in a tidy box to American surgeons and their patients. Let us cover each in turn.
Traits
First, work ethic; the “standard” nongovernmental workweek in Singapore is 44 hours. But that is just a warm-up for staff in Dr. Tan’s company and in similar entrepreneurial settings. Laboring long and hard (remember they run between exam rooms) is simply a way of life, an embedded part of the culture in Singapore. Pushing through 50 hours without complaint is common; working 60 hours in a week is not uncommon. Indeed, the typical junior associate I saw in Singapore worked at least as hard as the average practice manager or owner in America.
Turning to teamwork and staff cohesion; here is just one small example of the commendable difference between “here” and “there.” Every day, most of Dr. Tan and Suan’s staff ring down for a hot meal (abundant, delicious and low cost) from a nearby takeout — nothing fancy. They spread old newspapers on the table in a cozy staff room and lay out a feast that puts our fast-food-on-the-fly-lunch to shame. Then they sit down for the better part of an hour, shoulder to shoulder, and actually talk to each other, chopsticks clicking and soup slurping. Compare that to the typical ophthalmic break room where the staff will sit as far apart as they can from each other, munch their stale sandwich or power bar, and privately read a magazine or watch a soap opera until the afternoon shift commences.
A very high level of customer service, “six star” as Jerry and Suan call it, is the mandate at Tan Eye Center. But remember that five-star is the expected baseline norm for courtesy in Singapore. This is extended to patients and vendors and visitors alike. I could point out scores of social rituals that I observed. Here is just one. Take the way they exchange business cards in the Orient. The routine is to present your card with two hands, your card facing the recipient so he can read it. The recipient in turn is expected to pay attention to the card, read a line or two, and then comment favorably — “Ah, Mr. Chan, vice president of development, excellent.”
While working at the Tan Eye Center for a week, Dr. Tan’s staff spontaneously competed to bring me no fewer than two lunches, four snacks, six coffees and glass after glass of water each day. (Sincere thanks to Cindy, Eileen, Joyce, Shareen, Audrey, Mr. Yong, Dawn, Kerina, Jasmine, Kenny, Fanny and Collin.)
Here’s one more remarkable thing about Dr. Tan’s LASIK practice — his enhancement rate over the past 2 years has averaged just 1.7%. Dr. Tan attributes this low enhancement rate to 100% custom treatments, 99% IntraLase (Advanced Medical Optics) and performing surgery on one eye at a time. He operates the fellow eye at least 1 week later with adjustment of the refractive correction depending on the first eye’s response. He uses optical coherence tomography to measure flap thickness and has the patient wait up to 60 minutes before lasering the bed, using corneal wavefront with Q (aspheric) adjustment and ultrathin flaps. Without enhancements, Dr. Tan reports that 100% of his patients achieve 20/40 or better vision and 53% achieve 20/15 or better vision.
Apply these lessons
Please take this little virtual tour of Singapore to heart. Apply the lessons that Dr. Tan and his staff so kindly afforded me. Although you cannot personally hope to change the culture in all of America, perhaps in reading this you can shift the culture of your practice just a little bit.
And meanwhile, as you are reading this, imagine a scene 16 or more time zones away, where everyone is sitting around Dr. Tan and Suan’s family dinner table. After their orientation to our practice life here in America, when their kids (Michelle, Bryan, Andrew and Nicholas) do not quite clean their plates, I am sure Mom and Dad are saying, “Eat up! Eat up! Just remember the starving ophthalmologists in America!”
For more information:
- John B. Pinto is president of J. Pinto & Associates, Inc., an ophthalmic practice management consulting firm established in 1979. Mr. Pinto is the country’s most-published author on ophthalmology management topics. He is the author of John Pinto’s Little Green Book of Ophthalmology, Turnaround: 21 Weeks to Ophthalmic Practice Survival and Permanent Improvement, Cashflow: The Practical Art of Earning More From Your Ophthalmology Practice, The Efficient Ophthalmologist: How to See More Patients, Provide Better Care and Prosper in an Era of Falling Fees and a new book, The Women of Ophthalmology. He can be reached at 619-223-2233; e-mail: pintoinc@aol.com; Web site: www.pintoinc.com.