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CONTENTS news Vol. 53 No. 3 2021 Editorial EDITORIAL 04 The Editors’ Musings BOARD Dr Tina Tan and Dr Toh Han Chong Editor Dr Tina Tan Feature Deputy Editor Dr Chie Zhi Ying 05 Medical Humanities: Editorial Advisors What Is Its Role in Medicine? A/Prof Daniel Fung Dr Ong Eng Koon and A/Prof Cuthbert Teo Dr Devanand Anantham Dr Toh Han Chong Members Dr Ganesh Kudva President's Forum Dr Lim Ing Haan 08 Remembering the Dr Jipson Quah Dr Tan Tze Lee Need for Kindness Dr Jimmy Teo Dr Tan Yia Swam Dr Alex Wong 18 The Mind of an Artist EX-OFFICIOS Council News Dr Chng Nai Wee Dr Tan Yia Swam Dr Ng Chew Lip 11 Highlights from the Honorary Secretary 20 Caring for Vulnerable Persons EDITORIAL Dr Ng Chew Lip – Understanding the Important OFFICE Protective and Legal Framework Senior Manager in Singapore Sarah Lim Interview Dr Giles Tan and Dr T Thirumoorthy Assistant Manager 12 The Hepatitis B Programme: Sylvia Thay Interview with Dr Gabriel Oon Editorial Executive Chong Jin, Pioneer Scientist 22 Tuberculosis Control Unit: Daryl Lai Reflections and Lessons Learnt Dr Joel Tan Jingxin ADVERTISING AND PARTNERSHIP Opinion Li Li Loy 16 On Movies and Medicine Tel: (65) 6540 9174 Dr David Teo Choon Liang Reflections Allan Kuek 24 A Centenarian’s Life of Art Tel: (65) 6540 9175 Dr Ng Chew Lip Email: [email protected]
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Dr Tina Tan Dr Toh Han Chong
Editor Guest Editor The night before my Membership of Dr Tan is a psychiatrist with the Better the Royal Colleges of Physicians of the Dr Toh is a senior consultant, clinician- Life Psychological Medicine Clinic, and United Kingdom (MRCP) Part 2B – now scientist and deputy director of the a visiting consultant at the Institute of called Practical Assessment of Clinical National Cancer Centre Singapore. He Mental Health. She is also an alumnus Examination Skills (PACES) – in Edinburgh, was a former Editor of SMA News. In his of Duke-NUS Medical School. Between Scotland, I took the local bus to a cineplex free time, Dr Toh enjoys eating durians work and family life, she squeezes time to watch the then newly released film and ice cream, reading, writing, rowing out for her favourite pastimes – reading Forrest Gump. It was an easy choice for and watching films. Thankfully, the a good (fiction) book and writing. me being a lifelong movie buff. While latter four are not fattening. terrified of the neurology station of this You’d think that as a psychiatrist, much feared clinical examination, whose preparation was a scary bottomless Gawande and Siddhartha Mukherjee I’d be more knowledgeable on the have dived into their professional topic of medical humanities. Movies? pit, I still felt a big dose of inspiration lives, their keen observations and Aren’t those films for unwinding and and buttered popcorn was the right sometimes personal pain to weave entertainment? Don’t make me ponder prescription. My good friend and bed too much, please. Art? Um... my children and breakfast roommate was burning amazing, deeply human writings know that Mummy is notorious for not the midnight oil mugging up for his on science, medicine, the joys, juice being able to draw, though I can hold paediatrics MRCP. Forrest Gump was soul- and absurdity of medical life, social my own in a game of Pictionary. lifting, magical realism at its finest – about ills and the human condition. It is an underdog with a disability who rose widely believed that exposure to the Which is why this issue is perfect for above pain and adversity, triumphed over humanities fine-tunes the medical someone like me. On an intuitive level, odds, found healing and true meaning, student and trainee to become most of us recognise the importance of and gets the girl in the end. And I passed a more empathetic, questioning, the humanities in medicine, but how the examination, phew. The arts have critical and ethical physician. Now many of us are conscious of it, or go always provided a life blood to medicine. the extra lengths to ensure we apply it that doctors are empowered with in our daily practice? It’s not just about Chinese physician-turned-writer Lu so much more technology to be our medical schools incorporating Xun (鲁迅), China’s greatest modern nearly trans-human, there is an even the humanities into their curriculum. writer, was revered by Mao Zedong. He greater need to balance this with It’s about making a deliberate and was hailed by Mao as the “willing ox” a return to the art, heart, soul and of the Party and “the saint of modern regular choice to expand our minds intuition of the profession. through the voices of others, who may China”, yet also paradoxically feared and not necessarily be our patients, using mistrusted for being a loud critic of This issue on humanities and different mediums like art and film. China’s policy and politics, its lack of medicine reflects the burning belief freedom of speech and expression. that medicine embraces a very deep, I’m grateful for the enthusiastic wide humanity and human-ness: contributions from my colleagues that English physician-turned-philosopher of the patient and their suffering, showcase what medical humanities are John Locke is the father of modern liberal about. I hope this inspires our readers thought, whose treatise became the families, society, health access and to go beyond what’s in this issue, and soul and foundation of the American equity, of right and wrong, of a social perhaps participate in some of the Declaration of Independence, of Life, compact rather than an overriding activities and programmes that were Liberty and the pursuit of Happiness. financial contract even in an highlighted in the various articles. You Modern physician writers AJ Cronin, increasingly complex transactional (and your patients) would probably Lewis Thomas, Samuel “The House of God” world, of life and death. And that benefit more than you realise. Shem, Oliver Sacks, Paul Kalanithi, Atul doctors are not bots.
04 MAR 2021 SMA News Medical FEATURE
Humanities What Is Its Role in Medicine? Text by Dr Ong Eng Koon and Dr Devanand Anantham Photos by Dr Devanand Anantham
The humanities, which include the we are paradoxically inundated with The gap in practice between treating wide-ranging fields of art, history, complaints about doctors not spending the disease and caring for the person literature, music, philosophy, and other enough time with patients or treating is what the medical humanities can performing arts, are ubiquitous and them as a collection of dysfunctional fill. It is an interdisciplinary field where impact us daily. We remember reading organs. “If we are interested in people’s concepts, content and methods from The Good Earth by Pearl S. Buck during well-being, we also need to take seriously art, history and literature are used to English literature class as impression- the implications of characteristics of investigate the experience of illness and to understand professional identity.2 able youths. It was an opportunity to ‘persons’… their subjectivity and ‘inner Experiences and perspectives depicted understand a different culture, and life’ including their capacity for suffering; through the humanities can help learn about relationships. The narratives their identities, histories and social develop observation skills and deep helped us connect with emotions like contexts, including the way these are reflective practice. Such transformative sadness, pity and bewilderment with embedded in both personal and social change is possible through an appraisal a consequent desire to get involved – relationships and social structures.” 1 of clinical experiences and examination components of what we now define as The framing of medicine within the of both personal and professional empathy. The power of literature is all narrow lens of natural sciences and values.3 While the science of medicine too apparent – to understand lives other evidence-based practice has been the continues to provide us with answers than our own. shortcoming of many a dissatisfied about facts of nature, it struggles to clinician. Medicine is about caring for provide all the answers to the important Filling the gap in medicine people as much as it is about treating question of value – what counts as good While reminiscing secondary school disease. “Without an active component of and what counts as bad. The COVID-19 pandemic has brought this into sharp literature, it is disheartening as clinicians eliciting patient values and preferences, focus. The vast range of national to realise that empathy levels of both then biomedical reasoning will fall responses to the same viral pathogen medical students and doctors have short: it can reasonably aim to make illustrates why there can be no value- been decreasing with correspondingly valid judgments about people’s bodies neutral health policy based on science. increasing rates of physician burnout. and what might happen to them, but The humanities generate knowledge Scientific and technological advances it cannot make valid claims about the about value through reflecting on have improved our ability to treat course of people’s lives and what should human experience and by sensitively disease and extend life expectancy, but be done.” 1 analysing these experiences.
MAR 2021 SMA News 05 Medical humanities and share their thoughts and examine practice through what is affectionately its application their own values in order to strive called “bedside manner.” This includes The medical humanities can be towards more empathetic patient listening skills, non-verbal communication, care. These sessions received positive interpersonal approach and even how employed in all three areas of academic 4 medicine – medical education, patient feedback from the learners because we use touch to relate to each other. care and research. In medical education, the humanities are an excellent means Appreciating the narrative of a patient’s the humanities offer a diverse trove to deliver educational content. The life provides genuine appreciation for the of materials to teach topics like material engages the senses and fact that illness is as much a disruption communication skills and empathy. emotions, facilitating a connection of biography as it is of biology. Only Learners can observe realistic patient- between teacher and learner, and when we appreciate the depth of this doctor interactions depicted in movies between learner and content. The disruption can we as clinicians empower humanities also provide context and to appreciate non-verbal signs of distress patients to rewrite their biography. realism so that teaching is not done and how to respond appropriately. As the Narratives are about appreciating the in the abstract. Besides serving as a scenarios are hypothetical, psychological details of the illness experience and their safety is ensured to facilitate uninhibited modality to deliver medical content effectively, the humanities can operate impact. Narratives also help delineate sharing between students. Literary peripheral concerns from core values. works can also be used. For example, at as the content itself. Philosophy in the Division of Supportive and Palliative bioethics, observation skills in art The practical application of bioethics Care in the National Cancer Centre appreciation, listening skills in music occurs through discourses on patient’s Singapore, residents have been taught and interpretive abilities in narratives rights, standards of informed consent, empathy through close reading exercises are but some of the many examples. It professional accountability, boundaries of the book The Death of Ivan Ilyich. This is little wonder that many universities in of medicine and conflicts of interest. novel vividly describes the distress of North America have medical humanities an authoritative lawmaker Ivan, and built into the medical curriculum. how he struggles with severe pain on his deathbed, unable to comprehend Patient care how a life of personal discipline and In clinical practice, healthcare is as material prestige could be ending in such much about care as it is about health. existential misery. As one passage reads: Creative therapies such as music and “It occurred to him that what had art can be employed as interventions appeared perfectly impossible before, to reduce anxiety and stress. COVID- namely that he had not spent his life 19-related isolation measures have as he should have done, might after exacerbated the psychological distress all be true. It occurred to him that his of the illness experience. In response, scarcely perceptible attempts to struggle the humanities have also gone digital. against what was considered good by For example, at the Singapore General the most highly placed people, those Hospital (SGH), paintings of hope, tips scarcely noticeable impulses which he on coping with stress and verses of had immediately suppressed, might encouragement from healthcare teams have been the real thing, and all the rest have been provided for patients in some false. And his professional duties and isolation wards via bedside electronic the whole arrangement of his life and of tablets. Patients have expressed that his family, and all his social and official these platforms provide a sense of interests, might all have been false. He connection with the outside world and tried to defend all those things to himself alleviate what can be the cold and sterile and suddenly felt the weakness of what environment of an isolation room. A he was defending. There was nothing collaborative effort between the SGH to defend. ‘But if that is so,’ he said to art therapist, the SingHealth Duke-NUS himself, ‘and I am leaving this life with the Institute for Patient Safety and Quality, consciousness that I have lost all that was and the Care Collection of the National given me, and it is impossible to rectify Gallery Singapore and Singapore Art it — what then?’” Museum to offer an online art-as-therapy programme through a mobile phone Education app is also underway. The residents rotating through the Communication theory places 1 palliative care posting are asked to humanities at the heart of clinical
06 MAR 2021 SMA News act. It is an intuition which Legend 2 turns out to be reality at 1. Humanities content delivered to patients the end of it – and I see through bedside electronic tablets no difference between 2. Mobile phone app that facilitates art- a scientist developing a as-therapy marvellous discovery and an artist making a painting.” Besides the pioneering Dr Ong is a member of research pursued in the Medical Humanities medical education, at SingHealth Duke-NUS humanities research Medicine Academic Clinical often takes the form of Programme, and a consultant at the Division of Supportive narratives and critiques. and Palliative Care, National Narratives can contribute Cancer Centre Singapore. to the burgeoning range of qualitative analysis that Even when philosophical questions is being done to improve interpretative yield no definitive answers, healthcare understanding in medicine. Critiques professionals have to live out some offer fresh perspective often beyond the answers to these questions through confines of the biomedical paradigm. the clinical judgements made in daily In addition, the clinical effectiveness of practice. The SMA through the Centre creative therapies is being subject to for Medical Ethics and Professionalism more rigorous analysis. continues to serve as a beacon of these standards and as a forum to advance Dr Devanand is the director Concluding thoughts of the Medical Humanities such discourses. The medical humanities may be viewed at SingHealth Duke-NUS The humanities help us tackle as either a possible elixir to cure some Medicine Academic Clinical of the maladies of modern medicine, Programme and Council physician burnout by facilitating the Member of the SMA. expression of complex and difficult or as something that has always been emotions. We can find comfort in an integral part of clinical practice but uncertainties through perspective- somehow got lost along the way as we taking and develop a sense of focused on binary clinical outcomes and meaning at work through finding a technological advances. Either way, the common purpose. Examples of activities humanities ought to co-exist with the to tackle burnout include group art- science of medicine and in doing so, make making, chalkboard doodling and sharing medicine more whole. That promises of music and songs. These activities are to make medicine more meaningful for doctors and for patients. not only enjoyable in themselves, but help humanise each other by providing a glimpse of another aspect of our References colleagues beyond that of a fellow 1. Cribb A. Healthcare in Transition: Understanding co-worker. The humanities by being Key Ideas and Tensions in Contemporary Health interdisciplinary in nature can fuel inter- Policy. Policy Press, 2017. professional collaboration through insights 2. Shapiro J, Coulehan J, Wear D, Montello on change management, complexity M. Medical humanities and their discontents: theory, professional boundaries and definitions, critiques, and implications. Acad Med 2009; 84(2):192-8. alternative framing/perspectives. 3. Dennhardt S, Apramian T, Lingard L, Torabi N, Research Arntfield S. Rethinking research in the medical humanities: a scoping review and narrative In research, the humanities can be at the synthesis of qualitative outcome studies. Med Educ forefront of knowledge generation. As 2016; 50(3):285-99. the physics Nobel laureate Carlo Rubbia 4. Ong EK. HAPPE – A pilot programme using humanities to teach junior doctors empathy in claimed: “Science for me is very close to a palliative medicine posting. The Asia-Pacific art. Scientific discovery is an irrational Scholar 2021; 6(1):83-92. Remembering the need for PRESIDENT'S FORUM Kindness Text by Dr Tan Yia Swam
For those who were curious as to how our swearing-in and first Parliamentary Dr Tan is a mother to three kids, I became a Nominated Member of sitting on 1 February 2021. That started wife to a surgeon; a daughter Parliament (NMP), this was how it came at 12 pm and ended around 9 pm; and a daughter-in-law. She trained as a general surgeon, to be. followed by part two the following day, and entered private practice The public call for NMP nominations took from 12 pm to 6 pm! in mid-2019, focusing on place in late October 2020. The Academy breast surgery. She treasures of Medicine, Singapore was tasked to her friends and wishes to Speaking up for have more time for her diverse be the coordinator for the “Professions” healthcare issues Functional Group, which consists of 13 interests: cooking, eating, It was really fascinating witnessing the music, drawing, writing, professional bodies (PB). Out of eight debates, discussions on bills and motions. photography and comedy. names nominated by the different PBs, the two names which received the most votes Now that Parliament proceedings are by the respective representatives were live-streamed, I encourage everyone to submitted to the Parliamentary Clerk. tune in and see for yourself the different styles of speeches, delivery of content, The selection process involved and the demonstration of critical thinking preparing an updated CV, and an and analysis. essay of the issues I wanted to champion. Candidates were invited By the time this column is published, to an interview by the Selection I would have had the chance to speak Committee, comprising eight Members during the subsequent weeks of Budget of Parliament and Ministers. Imagine debates, including the Committee being seated across a grand wooden of Supply debates after the Budget table, speaking into a microphone Statement that was delivered on 16 while eight prominent figures scrutinise February. There is a very specific formality you. It was no joke; I found it more as to how to raise queries and how to stressful than the final exit examination speak. It is a whole new arena, and I viva. Hearing the Committee say “there have much to learn about navigating the is no right or wrong answer”, or “what system and representing the concerns of do you think I’m asking you?” really doctors and patients at a national level. induced some post-traumatic stress disorder flashbacks! It was not an easy decision to agree to Then we waited for results. The be nominated in the first place. The time newspapers announced the news on commitment needed is tremendous. I 14 January 2021: nine were selected am keenly aware of my other roles and out of the 61 candidates. The official responsibilities as a medical doctor, a appointment was conducted on 21 mother, a wife, a daughter and daughter- January 2021. The subsequent weeks in-law. Not to mention that my small were a whirlwind of orientation and private practice is still growing, and I also briefings by various ministries, with want time for myself and friends! However, this is a chance for me to would keep these private. They all have I thus have to explain to them in a practise what I preach and to step up their own reasons – they might feel way that they would understand (“It’s to serve when given the chance. After that it is not relevant to their care, not hot, it will burn you, like the sun”), or discussions with various friends and the doctor’s business to know, or be try out other ways like gamification or some soul-searching, I believe my embarrassed by it. having a reward system to achieve the roles as the SMA President and NMP This is when non-verbal cues, or our outcome I desire. If all else fails, we either are complementary. emotional intelligence, come in useful – have to let them proceed with their own The issues I will speak on are mainly to realise that there is something more plans and face the consequences (touch healthcare related: to bring up the and to hopefully be able to tease it it, get burnt and cry), or impose strict ground concerns on how changes in out. Some have psychiatric conditions punishments (time-out!). Otherwise, it insurance policies have affected private (whether diagnosed or not) which colour would be my failing as their parent. practice, and my strong belief that we their decision-making processes and need to reclaim the doctor-patient our interactions. Anxiety, depression, Taking care and reaching out relationship. Other issues close to simmering anger from chronic stresses, As the SMA President, I feel the same my heart include mental health and apathy, paranoia... I am sure most of us responsibility for those under my care. wellness, as well as striving for equality would have encountered patients with In representing our Members, and also in our society – starting from something these emotions at some point. Some thinking on behalf of all doctors and as simple as kindness. training and experience may be needed patients, it is a challenge to decide what for one to know how to stay objective, is best for the profession, even with Keeping the patient in focus and avoid countertransference! Think collective discussions. After which we need about it – how many patient complaints This issue’s focus on the medical humanities to consider how SMA can best present were due to these unhappy encounters, is a timely acknowledgement of how the options to our Members, and what rather than a real medical error? I know closely intertwined the mind and body would be a good way to disseminate the there are courses on how to manage information. Finally, how do we engage are. While medical advancements pride these incidents, but I am urging for themselves on good scientific methods Members effectively – to garner feedback something even simpler – to just be and have meaningful discussions? to push forward new discoveries and kinder and to place yourself in the treatments, the clinical practice of other party’s shoes. I am still exploring different ways – medicine involves more than that. through this column, various sporadic We have to keep the patient at the Applying lessons to oneself interactions on social media, and through heart of all that we do. personal interactions with those of you This is something I have been actively I know in real life. If you are reading this, While certain treatments may putting into practice in many aspects do drop us a note at [email protected], so I be shown to be the “best”, are they of my life as well. Take interactions may know that these words are read, and necessarily the most appropriate for the with my kids as an example – why don’t not just going to end up in some obscure patient? What are the patient’s ideals, they just follow my instructions? But I corner of cyberspace forever! concerns and expectations? While some realised that just telling my three-year- patients are forthcoming with their old, “Don’t touch the boiling kettle!” will concerns, including financial constraints not work. Mere instructions might not Legend and social deadlines (eg, waiting for make sense to young children (“Why 1. Dr Tan (first row, second from the left) at the Singapore Medical Society of Ireland, grandkids to return from overseas before not? Look at that smoke coming out, it’s Singapore Medical Society of the United proceeding with a major surgery), some so cool! And it whistles!”). Kingdom and SMA meet-up in 2019
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From the Honorary Secretary council news Report by Dr Ng Chew Lip
SMA face mask collection exercise
Dr Ng is an ENT consultant SMA is conducting a SMA face mask (SMAsk) collection in public service. After a day exercise in appreciation of our Members’ support. of doctoring and cajoling his two princesses at home Members in good standing are entitled to one SMAsk, to finish their food, his idea available in white, navy blue and grey, while stocks of relaxation is watching last. SMAsks can be collected from the SMA office a drama serial with his from 1 March 2021, between 9 am to 6 pm. As collection lovely wife and occasionally is on a first-come-first-served basis, reservations will throwing some paint on a canvas. not be possible.
StartSAFE Workplace Safety and Health programme
The Workplace Safety and Health Council has initiated StartSAFE, a free programme that helps Small and Medium Enterprises identify and manage workplace safety and health risks. Through StartSAFE, participants will be able to: • Understand their legal obligations under the Workplace Safety and Health (WSH) Act; • Receive professional advice and hands-on guidance on how to improve WSH lapses; • Receive advice on the implementation of Safe Management Measures; and • Receive a WSH report that includes Total WSH recommendations to improve their employees’ safety and health. Participants will be awarded a bizSAFE Level 2 Certificate upon successful completion of the programme. We encourage Members who own clinics to consider participating in this programme. Details of StartSAFE can be found at https://bit.ly/3avCXHA.
No parking at Alumni Medical Centre
Please note that with effect from 1 June 2006, the Alumni Association has implemented a vehicle wheel-clamp penalty for unauthorised parking of vehicles at the Alumni Medical Centre carpark. The wheel-clamp release fee is $200. This is a gentle reminder: SMA Members are not eligible to park their vehicles at the Alumni Medical Centre carpark. The SMA office has relocated to the following address since 3 August 2018: 2985 Jalan Bukit Merah #02-2C, SMF Building Singapore 159457
MAR 2021 SMA News 11 INTERVIEW THE HEPATITIS B PROGRAMME
Interview with Dr Gabriel Oon Chong Jin, Pioneer Scientist
Dr Gabriel Oon is a pioneer in primary liver cancer research, and has played a key role in Singapore’s hepatitis B vaccination programme. SMA News speaks with him on his involvement in the vaccine project and the challenges his team faced, his sporting glory in his youth and running the Apex Harmony Lodge for dementia patients with his aunt Dr Oon Chiew Seng, who recently received the National University of Singapore (NUS) Honorary Doctor of Letters at 104 years old.
Tell us a bit about yourself and Through food histories, it was found present in them and humans. From how you became involved with that 4% of volunteers had ingested it different parts of the world, we identified primary liver cancer research and through fried food, satay and exposed various human subtypes: “ady”, “adr”, the hepatitis B vaccine. rice. They had the highest numbers of “adw”, “ayr” and “ayw”, but all had the same epitope “a” for which the vaccine I returned to Singapore in June 1975, aflatoxin exposure then, followed by was made to target. soon after obtaining my Cambridge some medical staff and laboratory staff. University MD in cancer immunology. Singapore then was a free port and Hepatitis B research was conducted Profs Seah Cheng Siang (head of very porous with importing medicines in three prongs: vaccine manufacture, Medical Unit I, Singapore General and goods. Legislation banning finding a treatment for HBV carriers, Hospital [SGH]), Khoo Oon Teik (my importation of food containing aflatoxin and early detection of liver cancer. boss) and K Shanmugaratnam (head of was brought in, marking the start Wellferon, a natural lymphoblastoid the Singapore Cancer Registry) asked of stricter enforcement of food and alpha interferon, was the first drug used. me to conduct research on liver cancer, medicines entry into Singapore. It was able to prevent recurrence of liver then the number one killer in Singapore cancer in high-risk HBV resected cases The hepatitis B virus (HBV) was an via three monthly interferon treatments, and the Asia Pacific region, and to start ancient killer, killing millions since the oncology and immunology research. and it inhibited or reduced liver fibrosis. time of the Bronze Age where 4,500 Later we developed the HBV DNA I was given a small attic room years old human remains were found to assay. The first ultrasound machine for a laboratory, which was called have HBV. The virus was not identified was brought in to screen for early liver the Ransome Research Laboratory, until Baruch Blumberg discovered disease and cancer, and I worked with named after Prof Gordon Ransome. it in 1963 and named it Australia the late Prof Lenny Tan on diagnosis and With a $10,000 donation from the antigen (Au). In 1976, WHO named transarterial chemoembolisation, and Lee Foundation, the laboratory soon this DNA virus the hepatitis B virus – a with Dr Felix Sundram on radioisotopes. brought in a laboratory technician and parenteral transmitted virus in contrast There were no well-established a research scientist. We were intricately to the orally transmitted hepatitis A. biomedical manufacturing industries linked to the International Agency for There were many sick children in the in Singapore then, but our team dared Research on Cancer (IARC) and the paediatric wards suffering from fever, to proceed with manufacturing. With a World Health Organization (WHO), diarrhoea and jaundice; among adults, grant of S$1.3 million from the Ministry which provided regular advice. many were dying from bleeding varices of Trade and Industry, we worked with One of the research projects then and terminal liver failure. It was sad to both NUS and Ministry of Health (MOH) was to look into aflatoxin, a potent liver see so many weeping families. teams and made a vaccine to the level of carcinogen. We were curious about how HBV is ubiquitous, not only among animal testing. The team felt that if we much aflatoxin there was and where humans but also in the animal kingdom. succeeded, it would be the inspiration it was commonly found in Singapore. The key antigen was the “a” epitope for a local medical industry.
12 MAR 2021 SMA News 1
A lifelong adventure Meng, Chairman of the Shaw with vaccines Foundation for his long-term financial funding. You were appointed the Principal In treating hepatitis B, Investigator by the WHO and IARC we explored adoptive for Singapore’s hepatitis B vaccination immunotherapy, using project. What were the events leading immune leucocytes from up to this appointment? family members who were In 1978, as the Secretary General of negative for hepatitis B the Asia Pacific Association for the surface antigen (HBsAg) Study of the Liver, I gathered scientists but had hepatitis B surface from the region and requested for antibodies (anti-HBs), hoping that immunity could be transferred help from WHO regional advisor Dr Ransome Laboratory was designated to the carrier. It reduced the titre of Shoichi Endo. Alan Linsell, IARC/WHO the WHO Collaborating Centre for HBV the virus but did not eradicate it. Later, regional representative, saw our work vaccines. Lacking industry experience, in progress and put us in contact with we discovered that this was due to we sought WHO’s help to choose the WHO Geneva. I persuaded Dr Lorenzo integrated HBV in the nucleus of the best manufacturers to train our staff in Tomatis, director of IARC/WHO, and hepatocyte, and only removal of the vaccine manufacture technology, and infected liver by liver transplant would the IARC Council in 1982, that one to select the technology which would remove the HBV. Experimentally, we country was needed to prove that the help us to leapfrog to future vaccine found that HBV grew and fed voraciously HBV vaccine works in preventing liver technologies. With their advice, we on cultured human liver tissue but died chose Merck Sharp & Dohme. cancer. It would be the first vaccine to when these were removed. prevent a major cancer. We looked at Additionally, due to some difficulties every country for feasibility. Singapore Treatment with Wellferon in 1985 had within my department, MOH appointed had a small population of 2.5 million good success in preventing recurrences me as Principal Investigator in their new at the time, a national cancer registry in the resected cases within the first five Department of Clinical Research in 1986 years, and thereafter for some 20 years. linked with IARC, good academic and to monitor the vaccine project safely Government support, and a method to In manufacturing the HBV vaccine and to continue my research on liver trace every vaccination delivered and from the blood of carriers, there was the cancer and hepatitis. received. Singapore was thus chosen danger of being infected as we had no and I was appointed the Principal immunity. We had to get huge volumes How did you come to vaccinate Investigator in 1983, with US$25,000 of high titre HBsAg, and these would yourself and your family with the to start the project. come mostly from the HBsAg- and then-untested hepatitis B vaccine? hepatitis B e-antigen-positive carriers. When our hepatoma research team The commitment to this project and In closely monitoring all vaccinations decided to make the vaccine, I then-Prime Minister Lee Kuan Yew’s in the clinical trials serologically, we pondered, “Are we too gung-ho?” We expectation of “300% safety” would noticed an unusual persistence of had no backups of industrial experience require me to monitor it for almost anti-HBc IgG in some individuals which nor any local biopharma industries, but a lifetime. On 4 July 2019, with the were expected to have disappeared we decided to try and get WHO to help. help of MOH, the Singapore Cancer within three months. The sera of these Our French colleagues were kind Registry, and through publications in persons were isolated, the nucleic acid and offered us a few vials of plasma- the Singapore Epidemiological Bulletin, it sequenced, and we discovered that derived vaccines which they had been was officially announced at a Duke-NUS these were molecular new viruses. We using. Then-Permanent Secretary of Medical School public lecture that HBV brought some samples to Prof Arie Health Dr Andrew Chew, who oversaw and liver cancer had been eliminated in Zuckerman in London who oversaw the project and who was one of my all those vaccinated and under the age the WHO Collaborating Laboratories mentors said: “Chong Jin, you and of 40 years, with no major disasters. for HBV, and he confirmed them as your team should have it first as you vaccine escape mutants. These were are continuously handling dangerous dangerous, as they were not picked up What were some of the challenges infected materials daily. ” you and your team encountered by conventional immunoassays, and not Dr Aw Swee Eng, laboratory during the project? killed by natural nor vaccine-induced anti-HBs. Subsequently, it was found to technicians and myself were the first to There was a constant need for funding be due to zealous use of urea, pepsin be vaccinated, followed by the rest of the and getting the best clinicians and and formaldehyde in sterilising, which laboratory staff. When we were well after scientists to join us. Our group was damaged the epitope of the plasma a month, and more plasma vaccines were called the Hepatoma Research Group, in vaccine. With the onset of the yeast available, volunteer nursing, medical and the University Department of Medicine recombinant vaccine, there were no laboratory attendants at SGH received in SGH. I am grateful to Dr Shaw Vee more problems. the vaccine, and all remained well.
MAR 2021 SMA News 13 2
You and your brothers ten different medications. Residents were talented badminton were often discarded because their players, each winning loved ones had died, and no one else many international could care for them. titles. Tell us about how Being on the medical committee you started playing which oversees medical and nursing badminton. care, my duties include ward rounds, Our uncle, the legendary chatting with residents, and watching badminton world champion their activities which include drawing, Wong Peng Soon, used gardening, mahjong and drumming. to stay with us when he Those doing better can have outings. prepared for the Thomas It is a training ground for nurses and is Cup. He said to us, “Be the best. Be humble” very professionally run by experienced Three months later, we looked at and this has been my motto in life – to administrative staff. My aunt, who founded vaccinating all high-risk babies born to always try to be the best in whatever I do. it in 1995 and was its first chairperson till HBV-positive mothers. Before vaccinating I won the All England Junior Singles 2012, set up the Oon Chiew Seng Visiting them, I felt I should vaccinate my two at the age of 16 years, and as many as Fellowship at the NUS Yong Loo Lin School sons first, aged six and eight years. When 30 trophies in championships in the of Medicine and now we are forming a I mentioned this to my wife Susie, she British Isles and Europe between 1956 Department of Dementia, which would said: “Then you must vaccinate me too. If use the Apex Harmony Lodge as a hands- we die, we all die together.” And so, our and 1965. My last championship was on training ground for future medical and entire family were among the first in the the All England Men’s Doubles in 1965. nursing students. region to be vaccinated. Badminton was not yet in the Olympics nor world championships, and the All Personal thoughts Life journey England was the equivalent of a world championship then. I was recalled to help We understand that you have just You studied medicine at Cambridge defend the Thomas Cup in 1964 – a very retired from active medical practice. University, attained your MD there distinguished honour – but I had to turn Given your extensive experience and stayed on in the UK to further it down as it was three months before in medicine, do you have any words your career. What made you decide to my Cambridge MB examinations, and of advice for medical students return to Singapore? qualifying as a doctor was my priority. and doctors? I was in the UK from 1954 to 1975. I did The next year, I reached the All England I give this same advice to all doctors, my “O” and “A” Levels in the Perse School Doubles Men’s Finals and it was the scientists, writers and missionaries. Cambridge, and then proceeded to pinnacle of my badminton career. I retired Integrity, honesty, kindness and study medicine. after that to concentrate on medicine. compassion are key values to embrace. I used to travel to give lectures in Be humble and do whatever you can Singapore, Hong Kong and China. You are currently the Board Chairman even for those who cannot repay you. Three eminent persons, Prof Seah CS, and Chairman of the Medical Treat them as you would treat yourself. Prof David Todd (Head, Department Committee at the Apex Harmony of Medicine, Queen Mary Hospital, Lodge for dementia residents, If you are a prayerful person, Hong Kong) and Mr Song Zhiguang established in 1995 by your aunt Dr a prayer is soothing when facing (Chinese Ambassador to UK) said to Oon Chiew Seng. How and why did enormous obstacles and difficulties in me separately in 1973, soon after I had you decide to join in the running of accomplishing your mission. passed my Cambridge MD, to go back the lodge in 2007? “Lord… It is your Will… let your Will East and help our people. I pondered I am a Catholic and in 2003 was invested be done.” about where to go and what to do, into the Order of Malta. It is a chivalrous though I had a yearning to go back to and noble Order which defends the faith This prayer gives you the comfort the East with Susie. My aunt Dr Oon and carries out many missions of mercy that God is with you in overcoming Chiew Seng advised me on the benefits to help devastated areas of the world. I the obstacles. of coming back to Singapore and have helped in several rescue medical offered to put us up at her place. missions since. Legend The decision was further affirmed So, in 2007, when I was asked by a because I felt the need to return and psychiatric colleague to help oversee 1. Visit of Prof Baruch S Blumberg, the Lee Kuan Yew Distinguished Visitor, to the Department of serve my homeland. Here, I implore the care of some 200 residents of Apex Clinical Research, Singapore General Hospital readers to consider this question: “ Harmony Lodge, I agreed. It was a sad on 24 August 1992 When your country calls upon you, scene as many of them had multiple 2. Dr Oon at age 17 with the badminton will you answer the call to serve?” medical conditions, and were on at least challenge trophies won between 1957 and 1958
14 MAR 2021 SMA News SMA CLINIC ASSISTANT PLACE AND TRAIN PROGRAMME
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Organised by: Supported by: OPINION On MOVIESand MEDICINE Text by Dr David Teo Choon Liang
In all human perceptual experience, explore ethical conundrums and the They open the door to a world of exciting nothing surpasses the ability of our complex dynamics of the doctor-patient possibilities for reflection about humanity, visual sense to convey information and relationship – issues concerned with the morality and mortality – all issues at the evoke emotions. Filmmakers masterfully humanistic aspects or the art of medicine. heart of medicine. Movies also provide harness the richness of the visual sense a stimulus for doctors to introspectively and couple it with auditory stimuli Why should we bother about the reflect on our humanness – our feelings, to create the ultimate storytelling medical humanities? vulnerabilities and self-doubts – and how experience – the movie. Modern medicine has been increasingly we relate to our patients. Across the world, movies are enjoyed dominated by a biomedical approach. It by people from all walks of life. No other is often practised within the constraints of Movies that influenced my art form pervades the consciousness of increasingly corporatised systems driven practice as a doctor a person with such power and extent as by performance metrics. Clinical pathways From Hollywood to Bollywood to Korean cinema. During a movie, we are instantly designed to improve efficiency and dramas, movies have played an integral transported into a dream-like state where promote evidence-based practice seldom role in my professional development first we magically become connected with its adequately promote person-centred care. as a student, then a junior doctor, and characters, and the world they live in. A growing disconnect between what our now a psychiatrist. Due to their powerful visual impact, patients seek and the care we provide calls movies captivate the hearts and minds for us to reconnect with the humanistic A Beautiful Mind is a movie that left an of viewers and exert greater influence roots of medicine and the art of healing indelible impression on me as a young than many other art forms. Movies the person behind the illness. junior college student and then-aspiring doctor. This biographical drama portrays are a mirror that reflects our everyday Humanism has been at the heart of the how mathematician John Nash overcame life experiences. They transcend age, medical profession since its establishment. schizophrenia to win the Nobel Prize for gender, culture, time, geographical Humanistic values such as compassion his revolutionary work on game theory. and professional boundaries. In a short and respect for others form the basis of It transported me into the world of a hour or two, viewers are immersed in a the therapeutic relationship and integrate cornucopia of social, cultural, and political the psychosocial and biomedical aspects schizophrenic patient – one far detached themes, experiences and perspectives. of care. The medical humanities draw from reality, ravaged by hallucinations Movies thus have the power to shape our on the arts to stimulate deep reflection and paranoia – and allowed me to attitudes and behaviours. about complex issues in healthcare. witness the anguish that it wreaks on They imbue in us professional attitudes patients and their loved ones. Despite What do medicine and movies and behaviours which demonstrate an witnessing the risk Nash’s illness posed have in common? authentic interest in and respect for our to others and himself, his wife Alicia stays patients as human beings. by his side and supports his decision Medicine and movies are both art forms to reject antipsychotic medications that involve stories. Medical practice is and work out a way of coping with his a series of interactions with successive How can movies improve medical practice? psychotic symptoms. In a poignant final patients. Each patient brings a problem scene, showing his victory over the illness that is framed in the context of a In the face of the escalating threat of which derailed his life, Nash delivers his unique life story. The doctor-patient dehumanisation of medicine, movies acceptance speech for the Nobel Prize relationship involves narratives of illness can foster empathy and compassion in while still hallucinating. He integrates and suffering as well as the collaborative clinicians, helping us reconnect with the his identities as a mathematician and search for healing, relief and comfort. heart and soul of medicine – treating the schizophrenic patient and delivers Through the stories they tell, medically person, not just the disease. a moving tribute to his wife for her themed movies portray patients’ Movies provide an evocative window unwavering support throughout his experiences with illness and suffering, into the realities of medical practice. journey of recovery.
16 MAR 2021 SMA News On MOVIESand Movies are not entertainment. They “ “ are a kind of language and reflection. MEDICINE – Peter Greenaway, British film director, screenwriter and artist. Text by Dr David Teo Choon Liang As a psychiatrist, I would not suggest Using movies in medical education our patients, we could well use some that sheer willpower and family support help to bridge the growing chasm of Wit, a movie about an English literature alone can overcome a severe and misunderstanding between them and us. persistent mental illness such as Nash’s professor’s struggle with and eventual Movies offer far more than mere schizophrenia. However, an important demise from metastatic ovarian cancer, entertainment. Through portraying lesson I learnt from this movie is how has been used as a tool to teach humanistic values such as empathy empathy in several medical schools. medical themes ranging from illness and respect for a patient’s autonomy in As Vivian becomes increasingly ill and death to hope and recovery, rejecting our best and well-intentioned and undergoes more experimental movies provide an evocative lens medical advice can also facilitate the treatments, she perceives that her through which we can consider the healing of the whole person. doctors see her more as an object of different perspectives of patients, experimentation and an illness to treat, healthcare workers, caregivers and Many other excellent movies and rather than a person to save. The only society at large. By promoting deep drama series which hold valuable one who seems to care for her as a thinking and reflection about complex lessons for doctors have impacted me in person is one of the nurses on the team. practice-related issues, movies challenge my professional growth as a physician paradigms, enhance self-awareness and medical educator. The Health Wellness Programme (Assessment and Shared Care Team), and shape our practice attitudes and Munna Bhai M.B.B.S and Patch behaviours, and in so doing encourage Adams, both movies set in medical one of Changi General Hospital’s community mental health programmes, us to become more humanistic, person- schools in different parts of the world, centred doctors. ask hard-hitting questions about organises “Psychiatry in the Movies” whether physicians should be cold, events as a training and engagement platform to facilitate primary care detached master technicians of our Dr Teo is a consultant psychiatrist at craft, and the extent to which time- physicians’ and other community Changi General Hospital where he leads honoured professional boundaries can partners’ learning about mental health the Health Wellness Programme and be crossed to provide compassionate conditions and associated practice- medical humanities initiative. His interests care to our patients. related issues. Manchester by the Sea (grief and depression), Silver Linings are in adolescent psychiatry, mood and Doctor Stranger is a Korean drama Playbook (bipolar disorder), and Still Alice anxiety disorders and psychosomatic series about a genius cardiothoracic medicine. He believes that humanistic surgeon. As a child, Park Hoon and his (Alzheimer’s disease) are some titles that have been screened. Following the doctoring involves endeavouring to father, a cardiothoracic surgeon himself, understand the person behind the were tricked into North Korea and movie, the audience is invited to share reflections on the conditions portrayed illness and holistically addressing the prevented from returning to the South bio-psycho-social and spiritual aspects of as part of a political plot to prevent the and the attendant professional, ethical and social issues. Participants regularly illness. Outside of work, he relishes good latter from testifying in a malpractice movies and pondering the deep questions feedback that this is a relaxing yet suit. Park’s father trains him to become of life that they pose. a doctor, inculcating in him the value impactful learning experience. of always putting the patient first. After his father was killed, Park flees to the Concluding words South and begins working in a top In her classic novel To Kill a Mockingbird, hospital where his values are put to the Harper Lee penned perhaps one of the test in the face of professional rivalry, most fitting definitions of empathy: “You political horse-trading and conflicts of never really understand a person until interest. This drama presents a sobering you consider things from his point of reminder that as doctors we are equally view... until you climb into his skin and human as our patients with problems, needs, dreams and aspirations of our walk around in it.” own. However, serving our patients’ best It is a tall order to even begin under- interests must always be our foremost standing how another thinks, feels and priority and motivation. behaves. As we strive to empathise with
MAR 2021 SMA News 17 1
OPINION TheThe MindMind ofof an an
ArtistArtistText and photos by Dr Chng Nai Wee
videos and drug lists at our fingertips acquired in one field will in time be Dr Chng Nai Wee is an ophthalmologist through apps, web and cloud, we are translatable and transplantable in practising at Mount Alvernia Hospital supercharged with data. While the another. A healthy dose of inquis- and the Parkway group of hospitals. memorisation of diagnostic criteria, itiveness and gumption in testing He is a multi-disciplinary artist whose clinical algorithms and step-by-step the assumptions of convention and work is part of the National Collection. A recipient of the National Arts Council procedures consumed the bulk of our establishment is to be celebrated. Young Artist Award, he currently advises mental powers before, we are now able For it is in all things non-linear and on the implementation of the Business to be more observationally receptive, speculative, with all parts seemingly Times Budding Young Artist Fund. cognitively critical, imaginatively creative nonsensical and jarring, that the holistic and linguistically communicative. fitness of sensibility and beauty will Traditionally, these mental faculties have emerge. Perhaps nothing save that been the stronghold of the artistic mind, which is wholly utilitarian and discretely whose inculcation has been unfairly measurable can be completely mastered relegated to an afterthought by doctors. by the artificial mind. But with AI threatening to supplant us, by sheer computing supremacy in linear For medicine to remain a noble algorithm processing, brute data recall profession, doctors must manifest the To me, the realms of science and art and chilling calculatedness in probability best of the human spirit. In empathy and are not separate islands in isolation, permutation, it is necessary for all compassion, passion and love, faith and but polar ends of a continuum. Though doctors to distinguish their minds to belief – we hold true to the inspiriting medicine revolves around the sciences of retain existential relevance. They cannot qualities of our soul. Through the arts, the human body, we also recognise the remain complacent, for they could soon we appreciate these same qualities that impact of psychological and sociological be facing the challenges posed by an would come to define us: the heroism factors in clinical practice. autonomous machine that functions of the persistent man, the tragedy of Not that illnesses are primarily with eerie unerring precision. the man who gives his all yet fails, and psychosomatic, or that there is no the dash and deployment of humour, Evidently, the acquisition of an artistic irony, sarcasm and hyperbole in art. The veritable truth in science, but clinical mindset is no longer a Hamletesque medicine is in reality the artistic practice poignancy of these narrative archetypes choice but a resolution we must and artistic accoutrements are only of an applied science, and is fraught undertake for our survival. with the inexactness of estimation, the palpable and appreciable against our incompleteness of data, the constraints of background of inevitable mortality and scarcity and the unknowns of unknowns. Machinations of the artistic mind of traditions and cultures honed over a Qualitatively, the healing arts are coloured Of an artistic mind, in addition to that millennium of blood, sweat and tears. by the lenses of subjective interpretation listed above, we refer unreservedly by both clinicians and patients alike. to the development of intuition and Blending medicine and art instinct, sensitivity and awareness, As a doctor I found the clinical practice and a preference for more design and The influence of technology of medicine, though engaging in parts, aesthetics over mere utility and function. The arrival of the information age and the Worshipped as much in symphony is insufficiently nourishing for my soul. concomitant rise of artificial intelligence cacophony, equilibrium and chaos, There were big questions relating to (AI) are two of the most transformational perpetuity and disruption – the artistic the world, life and myself that needed forces shaping our training and practice orientation is opening your mind to all answering. Managing patients where life of medicine. diverse domains, learning everything and death was a stroke away was serious With the trove of research papers, from the simple to the complex, and business. Clinical practice demanded my guidelines, practice manuals, surgical trusting that the knowledge and skill presence of mind to ensure that the best
18 MAR 2021 SMA News was done for the patient, with no room familial characteristics, and the societal aptness of proportion, balance and line for grave error. implications of infinite life extension. – has lifted the outcome of functional eyelid surgeries to be aesthetically The arts – visual, literary and its Moleculux – Luminescent Bodies in heavenly, and traumatic wound repairs interdisciplinary domains – was the Hyperspace was a vast outdoor assembly to be cosmetically acceptable. My perfect avenue for me to tap into the of scalable, mutable light structures that well of human consciousness and query I fabricated for Sculpture Square in 2002. deference to first principles and tireless my at times inspiriting and devastating Autofluorescence, additive synthesis of questioning of assumptions have emotional fragmentations. Every piece coloured light and concave reflectivity in enabled me to reason better in the of work that I create is an expression in the generation of virtual imaginary were running of my private practice. my own voice by my own hand. Through among the optical and ophthalmological Without the artistic mindset, I would the frame of my work, the audience can principles that I employed in the work. not have strayed from my comfort see through my eyes. Art-making – its Around 2003, I was appointed the zone, charging into areas that would process from inspirational inception, arts consultant for Biopolis and was have arrested a dilettante of lesser exhaustive execution, to infusion of commissioned the work Pantheon conviction and purpose. I would not public consciousness – was altogether a – Innards of Consciousness, where I have devised the Doctors Online portal relatively riskless activity that was non- illustrated the human body on multiple for Sembawang Media or conceived the judgemental but open to interpretation. overlays of suspended transparent LifeMedic emergency medical records Provided I sidestep from politically sheets in poses that displayed the in the nascent days of the internet. provocative issues, I was safe in my contemplative and the spiritual man. The Assisi Hospice would not have crafted personae as a doctor and an The tiny spacing between the sheets, seen my opined contributions to the artist, which were mutually exclusive or each in barely perceptible motion, development committee’s evaluation insufferably inseparable, depending on rendered a depth of stereopsis to of its architectural design and oversight how one chooses to view it. the viewer. Understanding the visual of its construction. Medicine and its clinical practice sciences, and how perception was hard- were, of course, a fertile ground for wired and influenced by surroundings Revealing the hidden philosophical inquiry and artistic and context, sharpened my edge in artist within artistic practice. questioning. Trained as a licentiate and Learning from the revelations of my a fellow at the venerated Royal College Whether the life of the artist and/or journey as both a clinician and artist, of Surgeons of England, I bore the halo the clinician is akin to the fate of it would not be exaggerative for me to of an esteemed expert in the biological conjoined twins or the tall tale of state categorically that doctors are all and pathological workings of the human two-faced Janus, it depends on which somewhat conceptual and performance body. What better way to uniquely of the duo is momentarily ascendant artists. The artistic mindset, and its position myself in a saturated field of or complementarily subsumed in the bond with the human spirit, can no professional artists than as one who eternal cycle of yin and yang. longer stay hidden in the inner recesses would investigate the particularities and Nonetheless, the influence of the of our minds. It is every doctor’s tool peculiarities of the human condition artist in me is irrepressible, even if I in daily clinical practice and our best in diseased and high-performance were to remain incarcerated in the offence against the looming threat settings? To say I was opportunistic windowless cell that is my clinic. of redundancy brought on by the would be missing the mark, for I had impending singularity of AI and the found the natural genesis of the human inexorable march of robots. body too marvellous to disregard Artistically influenced and the discourse of the post-human medical practice Only with the artist in us can we condition too inflammatory to ignore. How positively a surgical outcome is be masters of technology, and not its viewed by patients is relative to their unwitting slaves. Only with the human Making art out of medicine expectations, which I skilfully set. How spirit in force can we have a better satisfactory a consultation is perceived tomorrow, for the best is yet to come For the 1995 work Biotics, I arrayed by patients is imbued by the pleasantness in the brave new world beyond. pharmaceutical bottles of steroids and of the interaction which I control. antibiotics in a sculptural aluminium Legend cast installation evocative of military I cannot recall how often the 1. Yearning – a three- armamentarium, in postulation of a soft whisper of clinical acumen has dimensional photo work future when we would have ready access nudged me to save the day. The 2. The Contemplative to enhancements. In 1996, I created a times when I only had the sixth sense Man – from Pantheon – Swift digital work, Biotechnoethics, that of feeling to guide my hands in the Innards of Consciousness manifested and dematerialised axioms fog of surgery testify to the utility of on plexiglass sheets in a screen of darkness. The Robot Thinks artistry. My halcyon student days spent drawing and doodling aimlessly on Therefore He is, Matching Programs 2 Exchange Their Code, and Immortality white margins of textbooks, amid the Makes Hoarding Power Worthwhile teacher’s monotonous monologue, have were among the texts that questioned surprisingly (or unsurprisingly) drilled the parallels between sentience of a hand that is calibrated for the fine art artificial and human intelligences, of microsurgery. And blessedly, my eye the procreativity of machines with for beauty – that perceptive sense of OPINION
Text by Dr Giles Tan and Dr T Thirumoorthy
Introduction This Act applies to vulnerable persons (“the donor”) can appoint a proxy (“the donee”) to act or make decisions on his A famous quote from Mahatma Gandhi who are mentally ill and pose significant or her behalf for matters relating to goes, “The true measure of any society psychiatric risks but who decline voluntary personal welfare and/or property and can be found in how it treats its most treatment for their mental illness. The Act financial affairs when the person loses vulnerable members”. Our society has also provides for protection of a mentally mental capacity. become more mature and complex and unwell person against ill treatment by as such, vulnerable groups within society healthcare professionals. It also allows the court to appoint a have higher needs which may not always There are several processes and Deputy to make decisions on behalf of a be adequately met. Various groups have stages to ensure checks and balances person who has been determined to lack been identified as vulnerable, including in the detention of a person under this mental capacity. The Office of the Public those with mental illness and disabilities statute. The police may, under s.7 of Guardian (OPG) oversees the functions including intellectual disabilities, and the Act, apprehend and take someone of donees of an LPA and court-appointed those who are elderly and frail. This has who, due to a mental disorder, poses a Deputies to ensure that they act in the best implications on health and social care danger to themselves or others for further interests of the person lacking capacity. services as they strive to meet the needs assessment by a medical practitioner Medical practitioners with concerns in this of the vulnerable in our society. or to a psychiatric institution. A medical regard may contact the OPG. Reflecting these changing societal practitioner may under s.9 of the Act send The five statutory guiding principles of needs are the enactment of laws to allow a person under their care who is mentally the Act are that: disordered or requires psychiatric appropriate care and protection to be (i) There is a presumption of capacity provided to the vulnerable in our society: treatment to a designated medical practitioner at a psychiatric institution. and that everyone possesses the (i) The Mental Health (Care & Treatment) capacity to make a decision, unless Act 2008 (MHCTA) A designated medical practitioner proven otherwise; (DMP) at a gazette site (Institute of (ii) A person cannot be assumed to lack (ii) The Mental Capacity Act 2008 (MCA) Mental Health [IMH] or Changi Prison) capacity unless all reasonable steps may sign Form 1, which allows the (iii) The Vulnerable Adults Act 2018 (VAA) have been taken to help the person involuntary admission of an individual The concept of vulnerability underpins make the decision; suffering from mental disorder into these three statutes. Each are meant to IMH for treatment, for up to 72 hours. (iii) A person cannot be assumed to lack empower society to protect and care Form 2 is signed by a different DMP, for mental capacity merely because the for the different vulnerable groups: the up to one month and Form 3 by two person makes an unwise decision; MHCTA for those suffering from mental independent DMPs for up to six months illness; the MCA for those lacking mental (iv) Any decision made on behalf of a if the criteria for detention under the Act person who lacks mental capacity must capacity; and the VAA for those with continues to be met. impairments rendering them vulnerable be in the person’s best interest; and to self-neglect, neglect or abuse by Beyond that, Form 4 is an application (v) The decision made on behalf of a others. It is important for medical to the courts for an order under Form 5 person who lacks capacity must be practitioners who are involved in the care for longer term detention, subject to least restrictive to the person’s rights. periodic review by the Visitor’s Board of the vulnerable to be aware of these When assessing the mental capacity important statutes. which has the power to discharge patients from the Form. of a person, it must be determined firstly, that the person suffers from an Mental Health (Care & impairment in the functioning of the Treatment) Act 2008 Mental Capacity Act 2008 mind or brain; and secondly, that if an 2 The Singapore MHCTA1 supersedes The MCA safeguards vulnerable impairment is present, it affects the the Mental Disorders and Treatment members of the society who lack person’s ability to make specific decisions. Act 1965 and provides for the admission, mental capacity. A person lacks mental capacity if unable detention, care and treatment of The Act allows a person 21 years to (i) understand the information relevant mentally disordered persons in or older to make a lasting power of to the decision-making; (ii) retain specific designated psychiatric institutions. attorney (LPA). Under the LPA, a person information required for decision-making;
20 MAR 2021 SMA News (iii) use or weigh relevant information as (ii) Vulnerable adults with mental capacity Conclusion part of the decision-making process; and are generally best placed to decide Clinicians working with vulnerable (iv) communicate that decision by any how they wish to live and whether or groups in our society should be familiar means. It is worth bearing in mind that not to accept any assistance; with the purpose and application of the mental capacity is decision specific and (iii) Vulnerable adults lacking mental time sensitive. statutes mentioned here. In this direction, capacity must have their views the SMA Centre for Medical Ethics and Where a person is determined to lack (whether past or present), wishes, Professionalism, in collaboration with feelings, values and beliefs considered; mental capacity, then the person who the College of Psychiatrists, Academy of needs the decision taken must make (iv) Regard must be had as to whether Medicine, Singapore will be organising a the decision in the best interests of the actions taken can be achieved in a webinar on 17 April 2021, Saturday from incapacitated person and must take into way that is less restrictive of the 1 pm to 4.30 pm. consideration the past wishes, beliefs and vulnerable adult’s rights and freedom 3 values of the person. of action; and (v) The welfare and best interests of the Vulnerable Adults Act 2018 References vulnerable adult must be the first The VAA4 seeks to safeguard vulnerable and paramount consideration. 1. Mental Health (Care and Treatment) Act (Cap 178A, adults from abuse, neglect or self- 2012 Rev. Ed.). Available at: https://bit.ly/37e8BbZ. Under this Act, the State, in the form neglect, and allows the State to 2. Mental Capacity Act (Cap 177A, 2010 Rev. Ed.). of the director-general of social welfare, intervene so as to assist and protect Available at: https://bit.ly/3rYAfSf. has the power to remove a vulnerable the vulnerable adult when earlier 3. Ho RC, Ho CS, Khan N, Kua EH. An overview of adult from their place of residence if interventions have been unsuccessful. mental health legislation in Singapore. BJPsych Int there are reasonable grounds to suspect 2015; 12(2):42-4. The Act defines a vulnerable adult as that he or she is experiencing or at risk of 4. Vulnerable Adults Act 2018. Available at: any individual aged 18 years and above abuse, neglect or self-neglect and commit https://bit.ly/3jNYeQY. with mental or physical disabilities, and them to a place of temporary care and 5. Ministry of Social and Family Development. 5 who is unable to protect himself/herself protection or to the care of a fit person. Protection for Vulnerable Adults. Available at: from abuse, neglect, or self-neglect The Act also allows the vulnerable adult, https://bit.ly/2ZkJvU8. because of these disabilities. The Act their family and/or the State to apply for 6. The Law Society of Singapore. Understanding defines these key terms as follows: various court orders for their protection the Vulnerable Adults Act. Available at: (i) Abuse includes physical, emotional including the following Protective Orders: https://bit.ly/3qq30XE. or psychological abuse. It is also (i) Restraining the perpetrator from defined as controlling or dominating (further) abusing the vulnerable adult; behaviour which causes the Dr Tan is the honorary secretary of (ii) Prohibiting the perpetrator from individual to fear for his or her the College of Psychiatrists, Academy entering the vulnerable adult’s safety or well-being, or behaviour of Medicine, Singapore. He is a senior home (or parts of it); that unreasonably deprives or consultant in the Department of (iii) Prohibiting the perpetrator from Developmental Psychiatry at the threatens to unreasonably deprive Institute of Mental Health. the vulnerable adult’s freedom of entering or remaining in a specified movement or well-being. area frequented by the vulnerable adult for a specified period; and (ii) Neglect means the lack of provision of essential care, such as food, (iv) Prohibiting the perpetrator from clothing, medical aid and lodging, communicating with or visiting the to an individual that causes personal vulnerable adult. injury, physical pain or injury to These applications should be made physical and mental health. with the vulnerable adult’s consent, (iii) Self-neglect occurs where an unless he or she lacks the mental Dr Thirumoorthy has been with the individual fails to perform essential capacity to provide that consent. In cases SMA Centre for Medical Ethics and tasks of daily living (including not where the vulnerable adult is suspected Professionalism (SMA CMEP) since its seeking medical aid) to care for or known to lack mental capacity to founding in 2000 and most recently himself/herself. This results in the consent to the application, a mental been given the responsibility of being individual living in grossly unsanitary capacity assessment by a registered the SMA CMEP Academic Director. or hazardous conditions, suffering medical practitioner, psychiatrist or from malnutrition or dehydration, psychologist needs to be undertaken from an untreated physical or mental and their report included as part of the illness, or injury. court application.6 Medical practitioners who have concerns regarding a The Guiding Principles of the VAA are: vulnerable adult may contact the Adult (i) Protect vulnerable adults from abuse, Protective Service under the Ministry neglect and self-neglect; of Social and Family Development.
MAR 2021 SMA News 21 OPINION
Tuberculosis Control Unit: Reflections and Lessons Learnt Text by Dr Joel Tan Jingxin
World Tuberculosis (TB) day falls from the routine of ward work and resistance within hours. These on 24 March every year, on the overnight calls that had been the are essential for the initiation of anniversary of the discovery of norm in our careers. Fortuitously, appropriate treatment in a timely Mycobacterium tuberculosis by our request was granted and we manner. Patients undergoing Robert Koch as the causative had the chance to work in TBCU treatment are regularly reviewed pathogen of tuberculosis. In for 15 months. Our time there gave and treatment responses are monitored using subsequent Singapore, the incidence of TB has us opportunities to participate in sputum tests and chest X-rays. We fallen drastically with the advent inpatient and outpatient care of TB also manage comorbidities that of improved sanitation, medical patients, as well as gain exposure to aspects of microbiology, public can affect treatment response (eg, services and reduced overcrowding diabetes), as well as side effects of since the 1960s. However, since health and epidemiology. In this article, I hope to share my treatment (eg, cutaneous reactions the late 1990s, it has plateaued at experiences working at TBCU along and drug-induced hepatitis). approximately 40 cases per 100,000 with some key reflections. The other main aspect of our population. To address this, the work is in the Contact Clinic, where Singapore Tuberculosis Elimination Functions of the TBCU we evaluate contacts of diagnosed Programme (STEP) was launched TB cases who have been identified in 1997. Its main aims include The two main clinics at TBCU are the through a rigorous tracing process. the early detection and effective Diagnostic Clinic and the Contact These contacts undergo an treatment of active TB cases, as Clinic. In the Diagnostic Clinic, interferon-gamma release assay well as identification and screening we evaluate suspected TB cases, (IGRA) blood test or Mantoux test of contacts. Housed in a quaint start newly diagnosed TB patients (if they are under two years old). If heritage building along Moulmein on treatment and follow up with a positive result is detected, clinical Road, the TB control unit (TBCU) them until completion. Diagnostic examination and a chest X-ray are is an integral part of this effort, evaluation usually involves detailed performed to exclude active TB. If serving as the national referral history-taking, physical examination, these are unremarkable, a diagnosis chest X-rays and sputum tests. One centre and handling all contact of latent TB infection is made and of the key advances in recent years the patient is usually commenced investigations for TB cases. is the availability of an in-house TB on a four- to six-month course My wife and I had applied for a polymerase chain reaction assay, of preventive treatment with an posting at TBCU because we wanted which enables rapid diagnosis of anti-TB drug (usually Rifampicin to experience something different TB and detection of Rifampicin or Isoniazid).
22 MAR 2021 SMA News Treatment of active TB comprises presenting to multiple doctors and settings like emergency medicine, an intensive phase of daily medi- receiving courses of antibiotics where patients with undiagnosed cations for two months, followed by with no significant improvement TB might require urgent procedures a continuation phase lasting four to before finally being diagnosed with risk of exposing healthcare seven months where medications with TB. In her case, she could have workers to aerosolised secretions. can be taken three times a week for exposed dozens of vulnerable Our experiences at TBCU have greater convenience to patients. The children before being diagnosed. taught us much about TB and its majority of TB patients in Singapore It is critical for all doctors to have public health implications. Even as are treated under directly observed a high index of suspicion for we have moved on to postings in therapy (DOT). TB medications are TB, particularly in patients who primary care, the lessons and skills fully subsidised by the Government are immunocompromised, live learnt continue to serve us well. for all patients on DOT. It is available in communal settings, work in With so much attention and at TBCU and all polyclinics, where occupations with higher risk of resources rightly diverted to fighting specially trained nurses observe exposure to TB or interaction with the spread of COVID-19, I hope that the consumption of medications vulnerable contacts, or hail from I have provided a useful insight and assess patients for side effects countries with high TB incidence into the often overlooked public or other issues that may affect rates. Early referral of suspect cases health threat of TB in Singapore and compliance. DOT is a cornerstone of for evaluation will improve rates of the work that goes on at TBCU to effective TB treatment and has been detection and successful treatment, safeguard Singapore from TB. It is my shown to decrease the chances of and prevent community spread. hope that all medical practitioners treatment failure, relapse and the rally behind and share the mission development of drug-resistance Reflecting on my of STEP and TBCU through early resulting from non-compliance. TBCU experience detection, effective treatment and The usual response I received early contact tracing. Lessons learnt at TBCU from peers when I told them that Most of the patients I encountered I was working at TBCU would be: were appreciative of the care they “Aren’t you worried that you might get infected?” During the second received at TBCU and compliant to Dr Tan and his wife were posted DOT. However, some like Mr M half of our posting, we found out to TBCU from July 2019 to October (a 53-year-old delivery driver that my wife was pregnant, which 2020. They are currently serving as with strongly smear positive led to even greater concern from medical officers at polyclinics and family and friends. These fears pursuing Graduate Diplomas in pulmonary TB) were angry at Family Medicine. the inconvenience of having to stem from the assumption that all attend DOT daily. Addressing his TB patients are highly infectious. frustrations, I educated him on the In reality, airborne precautions are nature and transmissibility of TB, only required when seeing suspect emphasising the importance of or newly diagnosed cases of DOT for his recovery, so that he can pulmonary TB. Once patients begin continue to protect his family from treatment, their infectiousness TB and continue working to earn declines rapidly and only standard a living. I also referred him to our precautions are needed when they social worker for enrolment in the return for a follow-up after two DOT-and-Shop programme, which weeks (we only started wearing rewards him with grocery vouchers surgical masks due to COVID-19 for continued compliance to DOT. precautions). TBCU staff also have annual IGRA blood testing as an A key learning point was that additional safeguard. cases of TB are often asymptomatic or have minimal symptoms. Often, During our time at TBCU, we these patients are referred due to never worried about getting TB abnormal chest X-ray screenings because we adopted appropriate for work permit or vocational precautions and were confident driving license applications. Some that the patients were receiving patients, like Ms L (a 24-year-old effective treatment through DOT. preschool teacher) reported In this regard, working at TBCU low-grade symptoms for years, was probably safer than in other
MAR 2021 SMA News 23 REFLECTIONS A Centenarian’s Life of Art
Text and photos by Dr Ng Chew Lip
Mr Lim Tze Peng turned 100 in September 2020. A celebrated Singaporean artist and calligrapher, Mr Lim was awarded the Cultural Medallion Award in 2003 and the Meritorious Service Medal in 2016 for his outstanding contributions to Singapore’s arts and cultural scene. He is one of the most well-known Singaporean Chinese ink painters today, known especially for painting the Singapore River and Chinatown, and for his unique style of Chinese calligraphy. One of Mr Lim’s most iconic and celebrated themes in his artwork is the scene of shophouses and bumboats along the Singapore River, a record of a bygone era in Singapore. I acquired one of Mr Lim’s paintings from Mr Terence Teo, owner of the Cape of Good Hope Gallery at Bras Basah. An accomplished artist and President of the Singapore Art Society, Mr Teo has been a friend of Mr Lim’s for many years, and his gallery has represented Mr Lim for decades. Having heard and read about Mr Lim, I was inspired by the master’s dedication to his craft and asked if Mr Teo could help arrange for an interview with Mr Lim, which he kindly agreed to. I visited Mr Lim at his home studio for this interview.
Into the artist’s studio The first impression of Mr Lim was for 20 minutes. She loved the portrait! that of a friendly, elderly gentleman with After she passed away, her children framed A studio is a special place to an artist, a kindly smile. He strode into the studio and hung the portrait up in memory of much like the operating theatre is to a with a surprisingly sprightly gait for a her. In those days, ordinary folks did not surgeon. It is the place where the magic take photographs. That portrait became happens, where plain canvases transform centenarian. He had some friends over that day and after some banter, we something her family could remember her into beautiful works of art. Mr Lim’s home by. After that, I started doing more portraits. studio is a large room in his house. He launched into the interview, which was paints on large pieces of Xuan paper conducted in Mandarin. I also began painting by the Singapore clipped up on walls. His collection of River when I was schooling. I liked the brushes range from little to massive ones Portrait of the artist as a scenes of the shophouses, and the hustle and bustle of the area. Today I still paint that measure almost a metre in length. young man the Singapore River of my teenhood, His cabinets are stacked with rolls of Dr Ng Chew Lip (NCL): Can you tell us much of it from memory. completed works. Mr Lim shares that he about your youth and how you became keeps many of his best paintings and an artist? Aside from painting, I enjoyed and was calligraphy as he cannot bear good at calligraphy. We had a calligraphy Mr Lim Tze Peng (LTP): I have loved to part with them. competition in school every year. The drawing since I was a child. From school would invite external calligraphy the age of ten, I would walk around experts to judge the submissions, and the kampong with a notebook in I won the first prize every year. That hand whenever I had time, drawing gave me tremendous encouragement plants, animals, birds, people and and affirmation. To me, calligraphy is houses. I loved the colours of the the core and essence of the Chinese art freshly laundered sarongs which form. Chinese characters are essentially my neighbours hung out to dry and drawings, because they were derived from often painted those! I also loved to graphical depictions of physical objects, paint scenes like houses and people like mountain (山), bird (鳥) and horse (馬). going about their daily lives. My teachers recognised my early talent Living a long and fulfilling life and were very encouraging. NCL: You have lived for a century. Not When I was 15, I painted a portrait many artists have that time to mature of one of my neighbours, an elderly and evolve in their techniques. How have 1 Malay lady who doted on me. She your techniques and approaches in art stood by the wall while I painted changed over the decades?
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3 As the arts scene continues to improve, I believe we can expect to see more talented Singaporeans taking on art as a profession, and perhaps more collaborations between art and medicine. One such collaboration is the National University of Singapore’s new Mind Art Experiential Lab at Alexandra Hospital, which aims to explore the link between the arts and the human mind, and explores mindfulness and art therapy by immersing visitors and patients in the various forms of art. Mr Lim’s longevity certainly seems to suggest an association between art and health! Let us take a leaf LTP: It changes every day! I try to do LTP: I think so. I couldn’t tolerate fatty from the centenarian’s book and see the something new and different each day. meat since childhood. I eat plainly, beauty in everyday life. You may just live I get very excited by my work in art, and in moderation, and I don’t have a big longer and healthier. I never get tired of it! I have tried different appetite. In fact, I seldom eat till I am media and styles over the years and have full. I exercise daily through painting. For more anecdotes and wisdom from Mr developed my own style since. By moving my brushes all over the Lim as well as Dr Ng’s thoughts, read the paper, my whole body shifts vigorously NCL: As the readers of this interview are full transcript at https://bit.ly/3qaeLR3. as I paint and often, I am drenched in mostly doctors, could you share your sweat after a painting session. My mind secrets to longevity? We would love to Legend and body are kept active, and I have share your secrets with our patients! 1. An iconic masterpiece of shophouses by the something to endeavour towards daily. Singapore River by Mr Lim, his masterful use of LTP: That’s a tough one but let me share Chinese ink in full display with the contrast and what I think may help people live a good Notes for the next generation overlap of tones life. As artists, we are constantly looking 2. Array of really big brushes at beautiful things. Our perception of NCL: What advice do you have for younger artists? 3. Bowls containing an assortment of paint beauty is different from non-artists. I see that Mr Lim uses beauty everywhere! There was once my LTP: Learn to be a good person with 4. Author and Mr Lim in his studio wife asked why I kept staring at an old good morals. Be dedicated to your work, tree stump. That’s because I thought it and be diligent. There are no shortcuts in was beautiful! I see beauty in the cracks art and life. Dr Ng is an ENT consultant in public of old walls, foot prints on the pavement, service. After a day of doctoring and NCL: As a former educator, what lessons cajoling his two princesses at home to even dirt and litter in the alleyway. do you have for medical educators? finish their food, his idea of relaxation There is so much beauty in the world LTP: Educators must have a loving heart. is watching a drama serial with his that we can’t paint them all! I don’t see lovely wife and occasionally throwing If students do badly, or make mistakes, some paint on a canvas. the ugliness in things. That is why I am we have to guide them patiently and so happy! with love. There is no point in criticising One other factor is calligraphy – them harshly. They have to feel your calligraphers have long lifespans. That’s love and concern before they will 4 because when we write, we are mobilising listen to you. I still keep in contact with our qi, and not merely moving our arms my students and they invite me to a or using our strength (写字是写气，不是 gathering once a year. 写力). NCL: Thank you for your time today and NCL: So you are transferring your qi onto for sharing your insights with our readers. the paper when you are writing? Concluding thoughts LTP: Yes, essentially! The words must have dynamism and life force in them, so they I was privileged to hear in person Mr evoke emotions in people. The words Lim’s thoughts on his journey through art and life, and was inspired by his cannot be dead. dedication and passion for his work NCL: Could you share your dietary habits and his positive outlook on life. We are and physical activities with us? Do you very fortunate to have passionate and think these contributed to your longevity? talented artists in Singapore.
MAR 2021 SMA News 25 INDULGE SojournSuzhou to Text and photos by Dr Jimmy Teo, Editorial Board Member
Following a visit to Nanjing (https://bit. through the manual checkpoints, as self- Suzhou used to house many wealthy ly/5205-Indulge), I took a high-speed scanning turnstiles are only for travellers salt and silk merchants, and the billionaires rail trip to Suzhou. Being a foreigner, it with Chinese identity cards. Do note that of those days built magnificent gardens was difficult to book tickets online as a many cities have several train stations and residences. Of the many Classical passport is required for purchase and and you should select your destination Gardens of Suzhou, nine of them are most websites are in Chinese. I thus took station based on your schedule and designated UNESCO World Heritage Sites. the easy way out by going to the train where you intend to stay. The Humble Administrator’s Garden (拙 station about one hour before my desired 政园, Zhuo Zheng Yuan) is one of these departure time to book my trip at the Sights and sounds of Suzhou nine gardens, and also the largest. Built ticket office. Often, there are counters The old city centre of Suzhou is close by Wang Xianchen, a Ming dynasty that cater to foreigners, but once the to the Suzhou train station (the other official in the sixteenth century, it is window for online booking has closed, being Suzhou North station). Through located north of Lindun Road. The the lines may be long due to locals Booking.com, I made my booking tour guide helped us appreciate the booking in person. Security is tight at the with the Hotel Soul Suzhou, which is train stations and taking trains is akin to located close to the area framed by taking a flight. You need to give yourself the north-south roads of Lindun Road additional time to put your baggage and Pingjiang Road. Many shops and through security checks and pass restaurants are located in this area.
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2 many ideas and imageries used in the construction of these gardens. A part of the garden (Central Garden) even used the Beisi Pagoda located many miles away to complete the view, and the city authorities have restricted the heights of the buildings around the area to preserve the framed view. Next to the garden is one of the most visited museums in the world, the Suzhou Museum, which houses ancient Chinese paintings, calligraphy and handmade crafts. Close by is another garden known as 4 the Lion Grove Garden (狮子林, Shi Zi Lin), also one of the nine UNESCO World 3 Heritage Sites. This garden features many multi-storey rock mazes. It is said that Emperor Qianlong of the Qing In many parts of China, the wearing of is also easy and convenient. Suzhou is dynasty visited it six times, and was so Han-style clothing (Hanfu) has come into connected to Nanjing, Hangzhou and enamoured with the garden that he vogue, especially in the older city areas. Shanghai by high-speed rail trains, and spent hours in it and even reproduced Locals and tourists add much colour and soon I was away on my next adventure one in the imperial palace in Beijing. excitement to the city when they don in another part of China. traditional Chinese clothes. The cuisine
of Suzhou is similar to other styles in the A vibrant culture Disclaimer: The author took this trip in Jiangsu province, though every place end‐2019, shortly before the COVID-19 Suzhou is also known as the Venice of would have their own unique take and travel restrictions were in place. the East with its many canals. Many dishes. Here, I tried the squirrel fish – a of them are well preserved and the deep-fried fish cut such that the meat Legend neighbourhoods are being revitalised stands up like the bushy tail of a squirrel, 1. Canal with new investments and tourist and drenched with sweet and sour sauce. 2. Humble Administrator’s Garden attractions. You can enjoy boat rides in Besides seeing the older city centre 3. Pavilion in Lion Grove Garden the waterways, or take a stroll down the and gardens, other places worth 4. Lion Grove Garden quaint alleyways and walk over the many visiting include the new Suzhou city 5. Lindun Road shops bridges. If you’re looking to sample some areas built outside the old city walls 6. Squirrel fish snacks, you can savour local sweets and and the Suzhou Silk Museum – China’s confectioneries, and shop for silk clothes first museum specialising in silk. A day as well along the canals. trip to nearby water towns like Tongli Dr Teo is an associate professor in the Department of Medicine, NUS Yong Loo Lin School of Medicine, and senior consultant in the Division of Nephrology at National University Hospital. He is the Division of Nephrology Research 6 Director and an active member of the Singapore Society of Nephrology.
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