Happy New Year!

Happy New Year all! 

Have a blessed Christmas all :The doctor never reported that the angels sang....!

One of my favourite books in the Bible is Gospel of Luke. Luke, as well as the Acts of the Apostles are supposed to have been written by the Greco-Syrian physician, Luke. Although not an eyewitness to the many of the events he reported on, he drew heavily on eye witness accounts about the life on Jesus as well as the events which took place around the early church. His accounts all carry the trademark attention to personal details and emotions.

His account of the night of Jesus birth has provided many of the inspirations for the celebration of Christmas. Unfortunately they have been pretty much distorted by romantic notions and more recent commercial interests.

"Hark!" The herald angels sang. Or did they? The romanticized accounts all have mass choir of angels celebrating proclaiming "Peace on earth, goodwill to men!". Fireworks in the sky even!

But careful reading of Luke's account actually shows us a very different reality. The angels appeared to shepherds in the darkness of the fields. Their appearance was not at all comforting. In fact they were a terrifying spectacle.The angels had to reassure the shepherds. They had a simple message. Luke documented that the angels spoke the message rather than sang. There was no musical performance in the sky. Yes, the angels were praising God, but praises can be uttered and not sang.

It was a terrifying spectacle. And an earthshaking message. There was to be a major paradigm shift in the affairs of men. Their Messiah had been born.

It is like that for other aspects of life, isn't it? Major paradigm shifts are often terrifying events. The mistake Management often makes is to ignore how unsettling and terrifying paradigm changes are to the workforce. There is often no peace on earth and goodwill to men, other than to those in political alignment. The angels did make it clear, "...and on earth, Peace to those on whom His favour rests."

Nonetheless, Gigamole would like to wish that you all have a very blessed Christmas.

We need a major rethink of our educational system.... and please do so outside of the box.

One of the areas that Singapore can be very proud of is how we have been able to make education so available to our kids, to the extent that we can say that no child will be denied a chance to go to school. In the previous generation there many capable people who had limited opportunities simply because they did not have access to education. But not anymore. Education has indeed been the great leveler for this generation. Because schooling is now accessible to every child regardless of his/her  socioeconomic background, career opportunities are limited more by abilities and skills rather than the individual's socioeconomic stratum. Likewise for gender and ethnicity.

But sadly this appears true only to a certain degree.

The Ministry of Education (MOE) should be congratulated for making examination data available to the public. One wishes though that they would put up more detailed data, and not only cherry picked information for public consumption.

The recent data is quite instructive. They are really quite similar to previous years' data and therefore really doesn't say anything new. True, there are some wiggly movements in percentages, but they are relatively small changes. Over a long period one can see that the performance data is relatively stable. Boringly stable. This stability is actually both comforting and alarming. Comforting because it means the MOE has done an excellent job in providing education. Not much more to do. Alarming because despite all this effort, fixed disparities in educational performances between ethnic groups are apparent.

If we look at the performance at the Primary School Leaving Examinations,we see more than 90% of students pass the exams. But only the Chinese outperform the national average. The Malay students, as a group, under-perform everyone else.

This ethnic ranking not only persist at the O-levels, but the differences are markedly accentuated. And this is for 5 O-level passes. I am quite sure if we set more stringent criteria, even greater differences can be demonstrated.

This is alarming because the data is not improving despite what the amount of resources the MOE has put into the school system. I am sure the MOE is aware of this problem. But I hope they are not ignoring it. Something drastic needs to be done because the current models are not working.

To an outsider, looking at the data, such 'fixed' differences suggest a number of possibilities:
a] Our delivery of education has ethnic biases;
b] Our way of assessing has ethnic biases;
c] Ethnic biases exist in both instruction and assessment; or
d] There are real ethnic related limitations in abilities.

Since I do not subscribe to there being biologically and ethnically related limitations in ability, it must be that the first three are valid.

The MOE must spare no effort to get to the bottom of this problem. It must not rest on the laurels of its past accomplishments. There are unintended ethnic biases in how education is delivered to the public as well as ethnic biases in how the examinations are set. It is not adequate to congratulate ourselves on the performance at a national level, because this is invariably defined by the performance of the largest and most successful ethnic group. This is unfair to the minority groups who may have unaddressed special needs and considerations.

We need to remodel our educational paradigm to level the playing field for all ethnic groups.

Should the finger be pointing at the CEO? A moleview of the SMRT saga....

image from here

All of sudden there seems to be deluge of bad news for SMRT. The latest involves a woman who fell and and sustained a head injury. Apparently she remains in coma. Gigamole wishes her well.

The public outcry against the SMRT is both understandable and justified. The hounds are now baying for the head of the CEO, Saw Phaik Hwa. The mass media has been particularly unkind, I think, and has dug up as many photos as they have on  file that portray her in the most unflattering light.

However, Gigamole somehow feels this antipathy against the CEO has been somewhat misplaced. Yes, because she heads the SMRT, the responsibility for all the mishaps falls squarely on her lap. Bt we should not forget that as CEO she acts upon the guidance of the SMRT Board. It was also the SMRT Board who examined her credentials and appointed her to the post. It was the SMRT Board who crafted up the directions and strategies for the CEO. By appointing Ms Saw to the post, the Board obviously prioritized the retail agenda above operational and service needs. Whether they did this as a conscious strategic  decision is unclear. It may well have been it seemed like an OK thing to do at that time, and only now shown to be inappropriate.

It seems clear at the moment that the SMRT CEO did all she could within her capabilities. Unfortunately though her experience was principally in retail and marketing. Was she someone who had a good insight into the technical/engineering and operation needs of the SMRT? Should we blame her for  lapses in areas outside her expertise. Yes, as she is CEO; but not entirely, as the Board should account for why they did not think operational/service skills were critically important for a train and transport company. Transport Minister Lui was spot on when he picked up the phone to speak with Chairman SMRT. This is a problem squarely shared by the Board and Management.

So for those who are happily shooting off arrows at Ms Saw, hold your fire a bit, and see if perhaps some of the arrows need to be redirected towards the SMRT Board.

The Singapore Medical Council Physician's Pledge - What motivates doctors nowadays?

Pointing the finger at the SMRT for their Freudian slip prodded me to think about what motivates our doctors nowadays. Or at least what should motivate our doctors nowadays.

It seems to me that many doctors nowadays are quite happy to regard their practice as a business. Quite understandably so since every other aspect of health care has become such a business. Ever since the mid 1980s in Singapore, when Medicine became defined as one of the pillars of our economic growth, the practice of medicine has become increasingly premised upon a business-like quid pro quo relationship between doctors and patients.

Yet the very ethos of Medicine is not built upon any kind of a business model. In fact the Hippocratic traditions de-emphasized the rights (pecuniary or otherwise) of the physician and instead focused on the duties of the physician. The Hippocratic Oath was really all about the duties of the physician. Likewise, our SMC Physician's Pledge is heavy on duties and does not even mention payments for services rendered.

In fact the very first line of the Pledge reads: "I solemnly pledge to dedicate my life to the service of humanity". Some will of course argue that this is wholly unrealistic, and that doctors do have to make a living, and perhaps even to live in the lap of luxury. But they forget that this was the pledge they took. Theirs was to dedicate their life to the service of humanity. If this was unrealistic, perhaps they should not have taken the pledge.

The great Canadian physician Sir William Osler, made it equally clear - “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.”

In today's world, this calling is so easily brushed aside in favour of the allure of "Income Opportunities". I do not mean to belittle the sacrifices of many doctors who do have their hearts in the right place. Indeed there are many of them. Many I have had the privilege of knowing as teachers, friends and colleagues. But I think even they would not disagree that the practice of medicine in Singapore has to a large part, degenerated to a mere trade or business.

What is the purpose of the Physician's Pledge if we are not to take it seriously?

On another note, I wonder why hospital CEOs are not expected to take a similar pledge of service and duty to patients. After all, it is their management performance indicators that compel doctors to behave after a certain fashion. Can we expect a doctor bound in service to a hospital to put the patient's interest first, and disregard the clarion call to seize the hospital's "Income Opportunities"?

Can an organization such as the SMRT commit a Freudian slip? Of course...!

In psychology there is a term, parapraxis, that refers to the situation when you do something that was really not what was intended. In layman terms, this is often referred to as a 'slip of the tongue' when you say something unintended. We excuse ourselves through the maxim, 'a slip of the tongue is no fault of the mind'. This is of course quite untrue. Slips of the tongue often reflect a primary fault with the mind, and often betrays what the the speaker is covertly thinking, albeit subconsciously. At cocktail parties, we laugh at such Freudian slips when people chatter about meaningfully under the influence of alcohol. At other times, such Freudian slips occur when a persons guard is let down, or he/she is operating under duress.

So I was quite amused by the recent gaffe by SMRT when it sent out the message to taxi drivers during the breakdown of train services. "Income Opportunities" headed the message that the SMRT had trumpeted to taxi drivers. Quite insensitive and inappropriate. Of course the SMRT quickly came out and apologized for the message. It was a template message which had been wrongly used. Of course. In normal conversation, this is exactly what happens when someone says something unintended. He/she had used the wrong template message in his mind. It is nothing more than parapraxis. A slip of the tongue. A Freudian slip that revealed what the speaker had been thinking about.

So the SMRT really did have a Freudian slip. One could of course argue that an organization such as the SMRT, not being alive, does not really have a mind, and is incapable of committing a Freudian slip. But in reality it does have a corporate mind and a corporate consciousness. So the Freudian slip gave us a rare glimpse of the SMRT corporate mind. And the image is not at all attractive. "Income opportunities". Is that what it is all about? We know that SMRT has a duty to return shareholder value, but we should seriously question the SMRT about its raison d'etre.

At a broader level, we should be concerned that our society has become so preoccupied by "income opportunities". Sadly it seems like things are only worth doing if it has a clear potential for revenue generation. Tragically the practice of medicine seems to be rushing down that road too.

Congrats, Yasmin!

Topped the PSLE. Loving mixed-ethnicity family. Muslim. Neighbourhood school. What else can I say?

We are all superly happy and proud of you, Yasmin! And if this represents what Singapore is about, I can say I am damn proud to be a Singaporean!

But there is a flip side to this story.... we should ask ourselves (and the MoE), why it should be this way? Why should a Primary 6 examination, which is supposed to be nothing more than a competency exam to enter Secondary school, be an exam where we identify top students? It is about time we put a stop to this madness.

Curiouser and curiouser..... sharing the skeletons

Image from here

An independent investigation is not always the most intuitive thing to do when a problem arises. The management of an organization will always seek to retain control of the proceedings so that the damage can be contained should any wrong doing be uncovered. Yet we all know that a less than independent investigation will in the end prove to be the least beneficial for the organization in the long run.

A number of recent incidents locally highlight the need for external and independent invistigations or audits.

Late last year, an IVF mistake occured in Thomson Medical Centre. In response, the Ministry of Health held its own investigation rather than to leave it to the TMC to uncover and report its own lapses.

More recently, an accident occured in the Singapore Air Force. Apparent a technician ruptured his liver during an induction exercise. The internal Board of Inquiry, disclaimed any association with the activities during the induction. It was only after the coroner made its findings that the BOI backtracked and agreed to consider that the ruptured liver could have been related to the tunnel crawl during the induction activities.

Now there are allegations of publication fraud and self-plagiarisms at the NUS. One wonders if the NUS sees it as in their interest to keep the investigation 'in house' and secret. Should it not be in everybody's (including NUS's interest), to have an external party audit whatever happened? This is especially as senior members of the faculty are associated with the allegations. Even if the senior members are innocent of any wrongdoing, the perception that the investigations are less than independent is damaging to the credibility of the NUS.

Instead, there is this very bizarre situation where the lead investigator is a Director of Research Admin, in the Office of the Deputy President (Research&Technology) while his boss himself is the subject of certain allegations of self-plagiarism and is associated with two of the Melendez list of publications.

Curiouser and curiouser.

The graduate student squeeze

I am told the recent research fraud allegations flying around the Singapore biomedical research environment have produced some rather grim ashened faces. I don't blame them. The uncertainty about how the die will fall can be somewhat unsettling even if you are innocent.

It is likely however that the investigations will point to the guy (or gal) who occupies the lowest position of the food chain (usually the graduate student). This does not necessarily indicate some high level conspiracy, and merely point to the reality that he/she is the one who is in the position to generate the raw data and to output the findings. Often the supervisor is really unable to verify every bit of data generated as gospel truth.

In such situations people often overlook the weaknesses in the environment leading to the wrong doing. I am not trying to justify any wrong doing here.... but merely pointing out that a dysfunctional environment can predispose and even encourage such malpractices.

The graduate student does not have an easy lot in Singapore. Cost of living is high. And even though scholarships are quite generous, the tenure of of the scholarship is strictly limited to 3 .5 years with almost zero chance of extension. Students are well aware that at the end of this time, they are pretty much out on their own. And if they cannot get a job and convert perhaps to a part-time studentship, they are out of the programme. Which means really research and development for graduate students in Singapore is really about the predictable production of data for publication in high impact journals. It is really all about D rather than R&D. The problem is compounded by the reality that the support for graduate student research is funded through research grants, whose granting agencies also impose a very high expection on the promise of a translated product, as well as very tight constraints of the tenure of the grant. The flow of money is switched off as soon as the clock strikes twelve.

Under such conditions the students know that if they do not produce results before midnight, the golden carriage they ride in will be turned into a pumpkin and they will revert to being field mice.

Contrary to expectations, graduate students generally do not have any say in the shaping of their projects. How can they when the project is regulated so tightly by the terms of the research proposal designed by their supervisor even before they have been accepted as students. And since their supervisors had to inflate expectations in order to win grants, they are left in the unenviable position of having to meet unrealistic expectations in generating publishable results in high impact journals in the shortest possible time, even though the hypothesis may be flawed.

Under such conditions, one can understand if the student is tempted to 'generate' the results that their supervisors expect to see.

Plagiarism? It is easy to see how this often happens. The graduate students from other Asian countries do not often have the language skills to write their reports/theses. This is especially so for the introduction and discussion sections. It is very tempting to snip and paste from a source that has explained so well the concept you want to present. I am not refering to the student misrepresenting that new knowledge or ideas originate from him/her, but just that he/she repeats chunks that are already in the public domain, unfortunately without citation.

I don't think that the situation here in Singapore is very different from many other high performance univeristies. But I do think that it is quite a bit more exaggerated because of the impatience in the system to compete and achieve blobal recognition almost at all costs.

Early history of hospitals ... Happy Deepavilli!

Historically the care for the sick tended to occur within temples and other religious establishments. This I believe was largely related to the tendency to associate illness and healing with spiritual events. Thus the early concept of hospitals in Europe was nothing like what we encounter nowadays.

The earliest evidence of a specially constructed facility for the care of sick was apparently in Sri Lanka. This was early as the 3rd to 4th Century BC. According Wikipedia, the Carakasamhita (Compendium of Caraka) and descriptions by the travelling monk Fa Xian, India probably had the first "organized cosmopolitan system of institutionally-based medical provision" in the world. This was approximately at the turn of the first millenium. Europe continued to develop their hospital concept largely as part of the religious establishment, the modern hospital concept seen in Asia and Persia never really took root until the social and civic reforms following the French Revolution.

This perspective is important to have as we look at the continued evolution of health care provision. The usually eurocentric portrayal of medical history tends to convey the fallacious idea that all things good flowed out of Europe. This is only true to a certain extent because of the renaissance and the industrial revolution. But it is important to recognize that that renaissance was deeply rooted in wisdom that had originally flowed westwards from Asia.

This is a good account to read:
Medicine and Society in the Medieval Hospital by Tatjana Buklijaš (2008)

India was very much where the action was in the development of the modern hospital concept. And they were more than half a millenium ahead of Europe.

Nice to know that....especially as we head towards the Deepavalli celebrations.

Happy Deepavalli all!

The culture of bandwagons, whale-ariums and the authorship mass-graves

Bandwagons are great things to have in the neighbourhood, but they are not something that Singaporeans are very familiar with. The closest we have to bandwagons would be the floats that used to be paraded across the grandstand during National Day parades. These floats would generally profile the organization and trumpet its most recent achievements. But few personalities ever get to reap any reflected fame by jumping on these bandwagons. Another version of the bandwagon is the local 歌台 ge tai's. Here's where aspiring politicians sometimes flaunt themselves during 'hungry ghosts' season hoping for some public attention.

The version of the bandwagon seen in academic circles is that associated with 'successful' and high profile researchers (or research). If you have one in the neghbourhood, you'd be very blessed indeed. By jumping on such a bandwagon, aspiring wannabe researchers collect instant fame and fortune. In the past, when few bandwagons were apparent in the local scene, we used to have to send aspiring researchers to high profile universities or research insitutes where they get access to high profile bandwagons. These researchers then return covered with reflected glory and certainty of an equivalently high profile career.

Nowadays of course, there's is a lot more money floating around and we can afford to bring in some of the bandwagons instead of sending our novice researchers out to them. Net benefit to us, as not only our young researchers but Singapore gets to bask in the limelight of these bandwagons. In order to not look so crass and obvious, the bandwagons have been camoflaged as travelling whales, as if we were recruiting for an oceanarium in Resorts World Sentosa.

It is of course, nice to have whales in the neighbourhood. Up to a certain point.

It's unfortunately been somewhat overdone. Nevermind that the rest of world also play this game. But the game of cultivating whale-ariums has taken on a life of its own, complete with its own set of KPIs. Senior management of universities, research institutes and other high profile research establishments spend enormous sums of money bidding for top performers for their whale-ariums. These senior management KPIs are based on how many whale Michael Jacksons (or Lady Gaga) they can attract. Don't worry about whether there is real transfer of technology or not, just make sure the whales perform, and as many as possible get to ride the whale.

Too cynical Gigamole is being?

Well, look at our grant agencies, and see how they look disdainfully down on local content. Woe betide your chances should you not have a significant performing whale leashed to your proposal, and are not part of one of these existing whale-ariums. Your career on the other hand, is pretty much secured for life if you can convince the grant agencies to advance you enough credit for you to lease your own whale-arium (otherwise called a programmatic grant) with at least one performing whale on board. All you need to is to sit back and collect the gate fees (otherwise known as research credits).

Correspondingly an entire culture has grown around the bandwagon/whale-arium 'ge tai'. The output of such whale-ariums has become a major KPI. Hence chalking up such research credits through being involved in publications can make or break a young scientist's career. Publication authorship lists have grown exponentially over the years. Endorsements of major performing whales become essential in providing gravitas to these publications. This gravitas is important because it provides better odds in getting your publication into major journals. Such heavy publications are referred to as having 'high impact' and secure much credit for the authors on these publications.

The university actually encourages the formation and farming of these whale-ariums.

Academic staff performances are graded according to their abilities in securing funding to lease a whale-arium or a significant bandwagon. Individual local efforts are frowned upon, regardless on whether they are meritorius (in fact a medical school Dean has been famously quoted as having disparaged his staff "How good can you be?"), or not. Involvement in journal publications are extremely important in the KPIs of academic staff. Here again the university/medical school also encourages long authorship lists to develop. It's a no brainer. Everybody stands to gain from long authorship lists. It's just a mathematical reality. More people benefit from a single publication. Young staff without an established reputation gets ahead on the (coat) tails of senior and more prominent whales. Senior academics without much research output get free rides on the backs of their more energetic and younger colleagues. The university glows with pride as all this light gets reflected back and forth. Of course the university ranking gets to climb a few notches.

Too cynical Gigamole is being?

Well, look at how the medical school computes research performance credits of it staff. Performance credits get elevated disportionately of the actual impact factors of the journals. These credits are freely awarded to co-authors without the main authors losing out on their own personal credits, resulting in total credit inflation. Hence total credits often exceed 100% of the expected credit score of any publication. Co-authorships are tacitly encouraged even if real participation is minimal. In fact, mathematically, it makes more sense to be a nominal participant on these bandwagons than trying to develop your own ideas and independant research.

Journals are supposed to require authors to decalre their actual involvement in any publication. But they seldom do. According to Wikipedia:
"In the medical field, authorship is defined very narrowly. According to the Uniform Requirements for Manuscripts Submitted to Biomedical Journals, in order to be considered an author, one must have satisfied all three conditions:
Contributed substantially to the conception and design of the study, the acquisition of data, or the analysis and interpretation
Drafting or providing critical revision of the article,and
Provided final approval of the version to be published
The acquisition of funding, or general supervision of the research group alone does not constitute authorship. Many medical journals have abandoned the strict notion of author, with the flexible notion of contributor."

I have never seen these criteria being applied.

Wikipedia further elaborates:
"the U.S. National Academies specify 'an author who is willing to take credit for a paper must also bear responsibility for its contents. Thus, unless a footnote or the text of the paper explicitly assigns responsibility for different parts of the paper to different authors, the authors whose names appear on a paper must share responsibility for all of it.' "

Really?

Let's watch the Alirio Melendez story unfold as the investigations continue. The Straits Times recently reported on another investigation of a prominent whale-arium.

These whale-ariums have lives of their own. Time to re-boot the system?

Bandwagons, clowns, whales and massgraves - perspecting the Alirio Melendez story

The Alirio Melendez story broke sometime last week. In fact the story had for some time, apparently already been quietly whispered about along selected corridors of the YLL Medical School campus. There have been accusations about fabrication of data, and major scientific papers have been withdrawn and investigated. I really don't want to presume I know too much about the case, nor about Professor Melendez's guilt or innocance. But certain things are interesting to reflect upon.

The phrase 'jumping onto the bandwagon', comes readily to mind. The phrase, according to my fav source for info, Wikipedia, apparently came about because of activities related to a less than famous clown-politician in early American history. Apparently he had been extremely successful in exploiting the mass media technology platform of his time, the bandwagon, to exhibit his political ambitions. Soon every other politician wanted to jump onto his bandwagon to share his spotlight. Thus arose the disparaging phrase 'jumping onto the bandwagon'.

What's all that got to do with us?

Well, observers of the Singapore approach towards biomedical research excellence cannot fail to notice that we spend a lot (in fact massive) amounts of money on bandwagons. Some have disguised these bandwagons as whales so as not to be too obvious. Bandwagons are obviously quite useful when you want instant fame and recognition, but it is not based on reality or substance. Coming from our Singaporean success on planting instant trees there is a fallacious thinking among some that there is an 'instant success' equivalent for biomedical research. So we rush about frantically planting those instant whales.... sorry, I meant trees.

Research bandwagons have however been extremely successful in transforming the Singapore research reputation. Suddenly we have a Nobel Prize laureate among us (transplanted, of course). Lots of whales (recently some apparently in migratory mode). And suddenly our local researchers look good, and get to cavort on the world stage. Can't complain too much....since as local guppies we've had many covert opportunities to grow fat off some of the crumbs falling from the mouths of whales.

But the problem is fame gotten from being on bandwagons is not necessarily real, and can be fleeting. And when the bandwagon topples - voila, you have an instant mass grave.

It was an interesting exercising looking up the Melendez publications generated in Sinapore. Anyone can do it. Just go to Pubmed and search for 'Alirio' 'Melendez' 'Singapore'. Or if you are lazy, just click here. You will find a listing of 50 publications generated during his time in Singapore. These publication date between 2002 and 2010.

It was very interesting going through this publication list because you find a lot of research associations in the authorship lists. Apparently all these papers are now under investigation. And all these authors now become somewhat tarnished by their association with Melendez because of these accusations of academic dishonesty. Again, I don't want to presume the outcome of the investigations, and I do hope that it will not uncover any widely endemic dishonesty within the scientific community. But the authorship list for Melendez papers reads almost like a Who's Who in the medical school, and includes heads of departments, Vice Deans and prominent individuals in the office of the NUS Vice President. Interestingly Prof Barry Halliwell, who is NUS Deputy President (Research and Technology), and who has been cited as fronting the investigation into the Melendez publications is himself associated with at least 2 Melendez publications.

Mass graves? These tend to develop when over-populated bandwagons fall over. But more about this in another post.

The Singapore Medical Council Physician's Pledge - respect for teachers

Upon graduation, all newly minted doctors in Singapore have to take the SMC Physician's Pledge. The pledge is our local adaptation of the Hippocratic Oath and the similarities are obvious if you lay them out side by side.

In the original Hippocratic Oath, the very first para addresses the issue of respecting your teachers. It reads :

"TO RECHON him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look up his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according the law of medicine, but to none others."

I guess it was something very important to Hippocrates, or at least to the Hippocratic School.

Our SMC Physician's Pledge more succinctly states "give due respect and gratitude to my teachers". That it is placed second only to "dedicate my life to service of humanity" but before all the other practice related oaths also indicates the relative importance of such a value.

Unfortunately though, as undergraduate medical teachers, few of us observe the expression of this in the hallowed halls of learning. In fact a common refrain among medical teachers is that medical student behaviour is arguably the worst among the undergraduate population. They come late for class, talk, send text messages, surf the net, and play with their smart phones during lectures. And generally are somewhat lacking with respect to respecting their teachers. I do have to qualify that the above probably applies to only a section, and perhaps only a very visible minority of the medical student population. Yet it is a significant enough segment to create the impression that there is very little respect in the class for the teacher who is in front of them trying to start a lecture.

I have always wondered why this is so. Perhaps it is because the students have not yet been exposed to these noble values as articulated in the Physician's Pledge. It does seem a bit late to take an oath to respect your teachers only after you have graduated, and after having spent 5 years abusing your teachers. Perhaps the medical students ought to take a earlier version of the Physician's Pledge, a Physician's Pledge Lite, for example, that might encourage them to consider value systems they need to cultivate and express during their undergraduate years.

Some shrug their shoulders, capitulating to the idea that this bad behaviour is really just our local manifestion of the global modern 'Gen Z plus' university student phenotype. But I disagree. I have been to universities in Japan, Korea and even Taiwan where University and Medical School teachers are held in high respect and where students are appropriately deferential to their seniors and their professors. And it seems like the non-medical student classes in the NUS are somewhat better behaved.

Please do not get me wrong. I am not arguing here for blind submissiveness. I am all for a fiercely independantly thinking medical students. Students who can be clear minded and innovative enough to challenge traditional professional paradigms. But our students need to be taught that the development of independent and creative thinking does not mean a jettisoning of responsibility and respect for others.... especially their teachers.

So Minister Heng Swee Keat, please have a look at our universities and medical schools as well.

The new educational focus on values and character - a long overdue initiative

It was certainly refreshing to read of the new Education Minister Heng Swee Keat's take on the future strategic educational mission. Apparently the new mission will focus on values and character.

Great stuff! I hope this is not one of those empty promises that serve no other purpose than to look good in annual reports and glossy brochures.

For too long our educational system had fostered this mindless ultracompetitiveness to excel academically. It seemed like all that mattered was getting those As and distinctions. Those that couldn't fell by the wayside, as did the noble values of respect, integrity, discipline and selflessness. We have seen this precipitous moral erosion among the undergraduate and medical student population. It seemed clear to many that this decline in values among the university student population was largely due values and behaviours inculcated during the preceding 12 years of schooling. Many have been dismayed by the apparent lack of concern shown by the school and ministry leaders,many of whom were clearly motivated by chasing after those elusive academic KPIs.

Fancy pedagological approaches such as 'student centred learning' and 'the student as the customer' became cliched excuses for spoiling students and fostering negative student attitudes and behaviour.

So Minister Heng's position is to be applauded. Not only is it timely, but in my opinion, long overdue. But it is a difficult task and there will be many who will resist him. I certainly wish him and his Ministry well, and will certainly go all out to support his initiatives. We have too much to lose if he does not succeed.

The great Islamic physician Muhammad ibn Zakariya al-Razi

Modern medicine owes a great debt of gratitude to the great physicians who populated the medical world during the Islamic golden age. For while Europe languished in darkness, it was the Islamic physicians who systematically collected, archived, translated, studied and innovated upon the classical medical texts from the Greeks and Romans before them. It was this vast corpus of knowledge that eventually fueled the developments during the European renaissance.

One of the great physicians of this period was the Persian physician, Muhammad ibn Zakariya al-Razi, also known by the Latin form of his name Rhazes. Al-Razi was not just a physician, but also a great thinker, philosopher and rationalist. That he not only survived, but flourished during this period was a testament to how open minded and tolerant the Islamic society of those days were to non-conformist ideas.

He was known for a great many innovations and discoveries in medical practice. He identified for example, allergic asthma, and was the first to distinguish smallpox from measles (a great achievement considering the state of ignorance at that time of the microbial world). He was also the guy who pioneered the distillation of alcohol.

After his death, a compilation of his writings became a widely regarded classic of medical science and philosophy, The Virtuous Life (Kitab al-Hawi الحاوي).

Widely remembered as arguably one of the greatest physicians of that period, and possibly the Father of Paediatrics (having written the first ever treatise on Paediatrics,The Diseases of Children), he was not only a great mind, but also an ethical and compassionate physician.

"The doctor's aim is to do good, even to our enemies, so much more to our friends, and my profession forbids us to do harm to our kindred, as it is instituted for the benefit and welfare of the human race, and God imposed on physicians the oath not to compose mortiferous remedies."

Selamat Hari Raya Aidilfitri!

To my Muslim friends everywhere, "Selamat Hari Raya Aidilfitri"! Please forgive me if I have wronged you in any way.

The elected President will have considerable moral authority but should not aspire to be our moral authority.

So we will have our Presidential Elections today. Very exciting because it is a very significant milestone in our political development. I like the political awakening I see yet I remain somewhat concerned that this new political energy has been too enthusiastically injected into this presidential contest. Wasn't it supposed to have been a non-partisan affair? But then, I suppose, any kind of election will inevitably be 'political'. By this logic then, the very act of creating the elected presidency had already begun politicization the highest office in our country. Even though it was not intended to be, it has become the new reality.

Instead of being a purely ceremonial position, the Presidency has now become a lightning rod for all kinds of things. Because of the political energy that has been vested into electing the President, regardless of what the Constitution tries to curtail, the elected President will receive a considerable moral authority to do and say things. This authority must come with responsibility. The elected President must realize that notwithstanding the electioneering and promises made in the heat of the moment, the Presidency is a position that must chiefly unify and inspire. He must try and embody all the noble values that will bring us together as a united citizenry.

But should he speak up for all kinds of perceived wrongs and champion pet causes? Though we may wish it to be, I believe he should not. This is not to say he cannot support community based projects and causes. But that he should be careful not be a social activist for causes which may be controversial and divide the society. Can the President be the standard bearer for justice and morality in our society? To be the heart....or voice ....of the people? I don't think so. Because, how is he to decide what is just and unjust,what is moral and what not? The election does not confer upon him the supernatural ability to make those judgements for the rest of us. So inevitably, to place himself on a pedestal to champion a particular position in such causes will cause him to elevate some ... and in the process, decrease some. And make the position open to all kinds of political lobbying. He should therefore ask himself if such activities serve to unite or to divide.

When we elect the President, we willingly confer upon him the moral authority to assume the highest position in our land, but this does not make him eligible to be the authority for our morals.

Why I find it difficult to support Tan Jee Say for President

He would seem to be the ideal candidate for President.... scholar, humble origins, family man, and very personable. Someone who can comfortably be at the wet market, engage academics in scholarly discussions and also hobnob with world leaders.

But I have reservations.

There is something in his past that I have not been able to understand. Here is a guy who worked his way up the admin service for 11 years and then served for 5 years as the PPS for the then DPM Goh Chok Tong. Now, I know some out there will deny this vehemently, but to my reckoning, nobody goes through this kind of career trajectory without first conforming and then succumbing to a certain degree of political and admin group think. But somewhere along this trajectory TJS appears to have experienced an epiphany of sorts to suddenly become a highly political animal of the opposition sort. But not only an opposition figure but a key figure of the most vehemently anti-PAP and anti-government opposition parties out there.

Now I may be way off course here, but common sense tells me that something happened in TJS's life. Something which we do not know about. He is not saying. And obviously neither is the government. This is important gap in our understanding of the man, because it will give us a better idea of his true drives in seeking out the presidency.

The other reservation is linked to the first. TJS has come across as a bit to combative, and rather too willing to confront the government on too many populist issues. I think this goes beyond just electioneering. I think these are pet opposition issues that an opposition party should confront the PAP government about. But these should not be issues taken up by the President. By all means debate these in Parliament but these should not form the contentious bickering backdrop for the relationship between the President and the government. I certainly do not want an opposition party to usurp the post of President. And although TJS has stepped down as a member of the SDP, it is clear from the rabid and almost exclusive support given him by Temasek Review Emeritus that he remains very much their man. To what extent he can maintain a position free of SDP influence if he does become President remains to be seen. But I am doubtful.

To this latter ends, I would like to suggest the the criteria for eligibility for President must be non-association with any political party for a period of at least 5 years. Otherwise the criteria of not belonging to a political party is meaningless.

So TJS, sorry, no support from me. I suppose this would only leave two options for me on Saturday.

Why I find it hard to support Tony Tan for President.

Much has been made of his dead fish handshake. Sadly, I have been at the wrong end of that dreaded handshake with presidential hopeful Tony Tan, so I can vouch for the veracity of those allegations. For me it had been a significant turn-off.

But a limp and damp handshake is too frivolous a reason for rejecting a presidential candidate.

In 1991 when the elected presidency was introduced, its purpose was to act as a check against a profligate government. The custodial powers of the elected president would include powers to check governmental abuse of power as well as to have custodial powers against governmental raiding of our national reserves. It seems clear that the PAP introduced this scheme not to check itself but to protect against a freak election result which allowed an opposition group to take over government, and therefore be in a position to 'raid' the reserves.

Increasingly though, the people are now coming round to the idea that the national reserves as well as public service appointments are actually assets belonging to the nation and should be managed in a non-partisan way. The elected president should therefore have custodial powers over the reserves and public service appointments, regardless of which political party is in power. Previous President Ong Teng Cheong had tried unsuccessfully to exercise these powers. But the shabby way he was treated as the people's President because he had the audacity to do his job remains deeply etched many people's minds. I have to confess I still harbour deep resentment for his being denied a state funeral when he passed away.

So never again.

Logically therefore, the uber establishment Tony Tan should automatically be disqualified from the job as he is just too deeply enmeshed with the PAP leadership and the GIC management of our national reserves. How can he be the second key for the reserves when he has been such an integral part of the first key? The increasing litany of endorsements from leaders of unions and establishment groups just continue to flag him out as being so ultra-establishment and so pro-status quo that I find it harder and harder to consider his legitimacy for the elected presidency position. In fact I find it increasingly difficult not to see him as a desperate attempt by the government to stem the growing movement towards greater expectation of a higher level of transparency of government and of the management of our reserves.

It does not help also that he has not 'come clean' about the allegations of preferential NS deferment for his son Dr Patrick Tan. From what I have read of the incident and of his early rebuttals, the whole thing seemed somewhat irregular. And if he as a very senior political leader, cannot see that it was irregular and should not have happened, then I am more than concerned. So be it if it was a lapse in judgement. I can accept that. But if it remains unaddressed, it sets an awful precedence for all our subsequent generations of leaders that such 'white horse' decisions are acceptable and defensible. That's not the road I want our country to go down.

I have actually tried very hard to avoid commenting on the presidential election, but I find it very difficult because it continues to grate upon my conscience. I want my President to represent my country and to function correctly as the custodian of the reserves and a guard against a profligate government. And I am not sure Tony Tan is the man for the job. Sadly though, he may still end up getting the job because of the continued silliness of the other candiates in not wanting to coordinate their efforts for Singapore's sake.

Which of the other three candiates would I vote for? I am not telling you. But two of the three appear to be too driven by their egos for my liking.

Happy National Day !! Majulah Singapura!

Assoc Professor Paul Ananth Tambyah's speech

Reprinted from Temasek Review Emeritus

Ladies and Gentlemen,

My name is Paul Ananth Tambyah, I am an academic infectious diseases physician working at a major teaching hospital. I would like to state from the outset that I am speaking entirely in my personal capacity.

Historically, Singaporeans, especially those in public sector jobs have been very reluctant to speak at major political events except for those organized by the ruling party for fear that it would adversely affect their careers. I am pleased to share that after speaking at the SDP rallies at Boat Quay and Sembawang, my career has not taken a dive, I am not in exile on some island feeding seagulls off Pedra Branca and I am not walking the corridors of Mt Elizabeth Hospital looking for a job.

Since the SDP rallies at Sembawang and Boat Quay, I have received countless messages from all ends of the healthcare spectrum. Allow me to share a few of these actual quotes:

“I am a current Houseman. I just wanted to thank you for speaking out for our state of healthcare in Singapore. Many of us echo your sentiments, but are too timid or too selfish to speak out for our patients. As Singaporeans, we have often been taught to take the pragmatic approach and very often that means to be silent and let the underprivileged fend for themselves, I pray that the day will come when the sole aim of our healthcare system is to serve our people and not fill the coffers.“

From a cancer specialist, “I saw your impassioned speech on the internet and I would like to thank you for voicing the concerns of thousands of doctors in the public sector. I often see patients making treatment decisions based on whether or not they can afford them. This one patient I am looking after decided to stop cancer treatment the moment his medisave account ran dry. He did not want to burden his children. He knew that he was not eligible for additional funding as he had dependents. The only way for him to continue treatment was to tap on his daughter’s medisave accounts. I ask myself if there is indeed fairness in the world. I worry for my 11 month old child’s future. I need to think hard this elections, not for myself, my career but for his future”

From a SPH journalist, “I read your rally speech online, agree with you on many points. Healthcare and education are two major areas that need seriously to be re-looked if we want to build a truly inclusive society. Also, our social safety net…”

These are just a sample of the heartfelt feedback that I have received after the SDP rally speech. It has been very heart warming and encouraging to me to recognize that not all Singaporeans care only about making money.

On the other hand, there have been rumors going around that I was sacked or demoted or reprimanded. I would like to state categorically that this is NOT true. In fact, in the last few weeks, I have received nominations for awards and important administrative appointments.

More importantly from a pragmatic Singaporean point of view, I received my bonus letter last week telling me that I got a thousand dollars more than last year. I also received a letter from NS PC telling me that I was now eligible for a responsibility allowance and I received an award from MINDEF for my service as a volunteer.

Although I have enjoyed working with the SAF in research, education and clinical care in my field of Infectious Diseases, I am also still serving with an infantry brigade as a BMO. In fact, last week, I broke my elbow walking out of the cookhouse to a bus en route to a training visit!

Many in authority in Singapore are trapped in a system which says “Do not rock the boat”. Like the SPH journalists who privately support alternative points of view while publicly producing official spin, many in public sector institutions set aside their own personal beliefs and convictions to “toe the party line”, make minor tweaks to official policies without really addressing the fundamental flaws or unintended consequences of policies which come from above.

I believe that the fundamental flaw in our current system lies in the corporatization of our country and society. In healthcare, we have seen how restructured hospitals are expected to recover costs as far as possible.

I have tried to explain to many in authority that I do not believe that anyone chooses to get sick. There is always the fear of abuse when subsidies are provided liberally. I once asked a panel of senior parliamentarians, which individual would say “Aha, the government is providing free healthcare for children with leukemia – let my child get leukemia so I can enjoy that benefit”.

Healthcare, like education, public transport and defence and security are public goods. Singapore has an outstanding record in maternal and child mortality. That is the result of a massive investment in maternal and child care from the 1950s onwards.

My generation are beneficiaries of that investment, today’s parents are often afraid to have children in case the medical costs bankrupt them especially since the state health insurance policy specifically excludes congenital illnesses.

A corporation is concerned about the bottom line, about maximizing shareholder value while on the other hand, a country or a society is concerned primarily about the wellbeing of the people. The key indicator should not be GDP growth, it should be whether all people – young and old, rich or poor, able bodied or disabled are allowed to reach their fullest potential. There are corporations like Google which believe in “Doing No Evil” and perhaps we can start by being less of a Microsoft and more of a Google!

Investments are based on trust. Singaporeans do have a high degree of trust in the government although recently there have been many questions raised about policies and practices. It is time for the government to trust the people. Philip Yeo who is one of the most outspoken voices of the establishment has said “My greatest fear now is that the Government is terrified of the people.”

That is a fantastic position to be in. The ministers need to recognize that the only reason that they are in their jobs is because we the people put them there. We can dismiss them if we think that they are not performing. Singaporeans are an educated people, a first world society who are savvy enough to know what we want rather than being told what is best for us.

The fundamentals of a society can be changed from the ground up and the online social activism that has demonstrated its vibrancy during the elections is a good start. My rally speech was ignored by the mainstream English media and rebutted partially in the Zaobao but it was widely circulated online among the medical and healthcare community.

The internet has provided an unprecedented level of accountability with ministers being forced to justify to their employers – that is us – the citizens why they have implemented various policies. This is good for Singapore. But change can also come from above.

The highest office in the land is the Presidency of Singapore. The President and his wife look down on us from every school and government office. That is an extraordinary position for someone with moral courage and leadership like Mr Tan Jee Say or someone with guts and an independent mind like Mr Tan Kin Lian. Jee Say sees himself as the conscience of the nation. Kin Lian is someone who will speak for the people. Both, like the SDP, have a clear stand on the issues that matter – on how our money should be spent and how our citizens should be valued.

One person who speaks up can be safely ignored. I think that perhaps is what many hope will happen to me. Ten thousand people speaking up at many different fora, at different times and in different places cannot be ignored.

This is the new era in Singapore politics when more and more citizens start asking questions about justice and equality, about our reserves and about our jobs, about our healthcare and our education. We cannot “sit down and shut up”. We will be heard. Start by choosing a President who puts the people first. Vote for either of them.

Happy National Day. Majulah Singapore!

Who cares about the f***ing F-word?

NTU does it again!
http://news.asiaone.com/News/AsiaOne%2BNews/Singapore/Story/A1Story20110801-292019.html
But who really cares about the f***ing F-word nowadays, apparently?

What we care about is the education of an elite crop of graduates who feel that vulgarities are a way of life, and whose vocabulary is so limited that joy and exhilaration is best expressed with a profanity.

So what if she apologises. Shame on you, NTU!

Hoisted by the presidential petard

The petard was apparently a small bomb that the French used in the 16th century to blow up fortifications etc. The problem is that, like many such munitions, they can behave quite tempermentally and blow up at unexpected moments. Much like the situation of the terrorist who blows himself up accidentally in the comfort of his bomb factory. So one can easily be "hoisted by his own petard". Funnily, a related word to petard is 'peter' or 'petar' meaning 'to break wind', or fart. Seen in the light of this alternative meaning, one conjures up the comical imagery of someone being 'hoisted' by his own fart. For a guy, I suppose, it's like trying to pee against the wind.

Several years ago, the PAP, in a rare pique of insecurity, suddenly recognized that there could actually be a freak election result giving rise to an unintended opposition-led government. Quite an oxymoron here since all election results actually do reflect real decisions of the electorate, and if the opposition wins, it must be the decision of the electorate, and cannot be a freak result. Nevertheless, the PAP then petulantly declared that there should be second key to the national reserves that was to be held by an elected president; effectively the creation of a petard to be used against the opposition, should they be ever so freakish as to be voted into government. It was obviously never ever intended that the petard could be used against the PAP itself since any ruling party could easily engineer into position a pro-ruling party president.

How times have changed. Likewise the wind direction. Now, more than ever before, the possibility is very real that the opposition could swing enough votes to topple the PAP from its throne. Not only that, the sentiment among the electorate is very much in favour of a truly non-partisan elected president, who can actually serve as a check against the PAP itself. Under these conditions, there could be a very significant swing in support against any candidate viewed to be remotely linked to the PAP. In fact the support could likely swing in favour of any candidate who is capable of expressing some anti-PAP rhetoric.

So we see now the presidential petard dangerously being hoisted against the inventor of the petard. Will it actually detonate? We'll see. In any case, it is not a good time to be sitting downwind.

Black swans in Singapore?

The black swan metaphor was introduced to us by Naseem Nicholas Taleb to describe a high impact outlier phenomenon that no body expects and one that takes everyone by surprise. The recent global recession related to the collapse of Lehman Brothers was such a black swan event. And like all black swans it can be rationalized after the event, when everyone kicks themselves in the backside and wonders why they never recognized it coming.

Although not global in magnitude, there have been a number of black swans seen in Singapore recently. The GE2011 results for example, caught many people in the PAP by surprise. The flooding in Orchard Road was another such event. In retrospect however, these events could have been easily predicted, and now we have the unusual situation where many people in the gahment are kicking themselves wondering how they missed the picture.

Often therefore the black swans are not the result of extra-ordinary events but of a lack of foresight, and the reluctance to think outside of mainstream and traditional ideologies. The GE2011 black swanlette was I believe, very much a consequence the failure to really look at the signs, which in retrospect, was everywhere. There was much reluctance to listen to naysayers, and everyone was happy to fuel the emperor's vanity. The flooding story hasn't quite unfolded fully, but I believe the picture will emerge that the black swan really came about because of the reluctance to deal with changing weather patterns as a result of global warming. There was I believe, too much discomfort in wanting to move outside of traditional models looking at weather and flood patterns. After all, to do so would have been to abandon painstakingly collected historical rainfall and flooding data. Yet the world has changed, and these models need to change as well.

The increasingly recognized hospital "bed-crunch" is perhaps not unlike the flooding black swan. Caught everyone by surprise, did it? What absolute crock! The numbers were there for everyone to see. The population was growing at a phenomenal rate. People were aging. Medical tourism was being encouraged. But no one appeared to want to look seriously at the numbers. Either that or there was an absolutely wrong prioritization of healthcare resources to cater for medical tourism instead of community needs.

Singapore hospital bed crunch....again....and again and again

So Singapore is suffering from a hospital bed crunch? Again? Rightly it has been described as a perennial problem. Dr Jeremy Lim last year alluded to it being a 'systems problem'. Of course it is. Like the floods hitting us nowadays, it is a systems problem. When rainfall exceeds a certain rate, the drains must overflow. Likewise, if there are more patients needing beds than there a beds, there will be a crunch. And patients get to sleep in corridors.

When I was a houseofficer, this was a fairly common occurence during every admitting day.

The question is why has this problem not been solved? It is not as if the problem is unknown. Or cannot be predicted. At least for the flood problem we can always blame the vagaries of weather .... global warming etc. But patient bed demands are fairly predictable through the year. Population growth numbers are very well known...at least to government departments. Surely bed demands can be computed and modelled. To me, a bed crunch is a sad indictment of the lack of MoH resolve in tackling this problem.

There was once a model that promised to deliver at least 80% of capacity for local patients, and only 20% was to be for the servicing of medical tourists. Yet the current figures suggest that medical tourists now occupy 30% of bed capacity. Surely this discrepancy can be modelled and provided for. The problem did not spring up overnight!

Another problem relates to the unbalanced provision of beds. Bed occupancies differ in the different hospitals. SGH and NUH has much lower occupancies than TTSH and CGH, and the latter therefore suffer worse bed crunches. Has the MoH over provided for the premier hospitals and inadequately for those servicing residents.

I think MoH owes us an explanation.

Population issues....

Last year when I did the facile estimates of our population breakdown, it was more for fun than anything else. I did not realize then how important it was going to be.

The 2010 census results confirmed that in 2010 there were a total of 3.23 million Singapore citizens, out of a total population size of about 5.08 million, i.e. roughly for every 3 people walking around the streets of Singapore, only 1 would be a non-citizen. That's really not so bad. But these computations do not make a distinction between local born Singaporeans and immigrants. In my previous estimates, in 2009, there could have been as much as 500,000 immigrant Singaporeans since 2000.

But how many of the 3.23 million citizens can vote? The census is not really clear about how many are above 21 years of age, but a reasonable estimate from their data might be about 75%. So that would give approximately 2.4 million. If we consider the PAP's electoral performance of about 60%, PAP supporters number only about 1.4 million, and have an electoral advantage of only about 500,000.

That's really a remarkable coincidence isn't it? Could it really be that the PAP's electoral advantage is essentially comprised of immigrants? This would not be far from the truth if we accept the argument that immigrants tend to vote conservatively for the ruling party. If that is really true, then the reality is quite horrifying. Has the PAP support among native Singaporeans eroded so substantially - that only 1 in 2 native born Singaporeans support the PAP?

If the above is true, it will only mean that the PAP's hand will only strengthen in time as our population growth for this coming electoral cycle will primarily come from immigration. Unless their popular support among native born Singaporeans continue to erode. Even so, it would be hard to see the erosion of support among native Singaporeans exceed the growth of immigrant support.

I am not at all suggesting that the PAP has adopted a cynical electoral strategy of propping up their flagging support through rapid immigration. But the reality of our population changes do suggest that the opposition cannot keep playing to the fears of native Singaporeans against the growing size of the immigrant population. It will be a losing cause. To survive and succeed they will have to reach out to and represent ALL Singaporeans, native or immigrant.

And what of the native Singaporeans? I am afraid all indications are that we will go the way of the dodo bird. We are a shrinking and disappearing entity. The new orang asli. Just like the peranakans before us who have all but disappeared, and only kept alive by 'acting cute', and support from the tourism industry.

Perhaps Singapore needs a bumiputra policy?

The problem with giraffes....

For more discussions of giraffes.... see here

The unbalanced development of the giraffe's anatomy led paradoxically to a situation where his neck became too long for his legs. Although the long neck enabled better reach of the high leaves, his neck became too long to enable easy reach of the low lying water. Bizarre but true.

This tends to happen also in organizations where there is an unbalanced over-fixation on certain parts of the KPI, and and losing sight of the original mission. It's just too easy to chase after certain KPIs. People become comfortable and predictable.

George Yeo was spot on in his observation that from time to time, it is necessary to shake the box.

The PAP's new clothes......

Although Hans Christian Anderson popularized the story of the Emperor's New Clothes, the story actually did not originated from him. The story was rather, adapted from a Spanish original in the El Conde Lucanor (1335). Anderson's creative input was apparently to alter the punchline of the story to that of an innocent child blurting out the awesome truth: "But he isn't wearing anything at all!"

I couldn't help thinking of this as I read Mrs Lim Hwee Hua's comments of the recent elections:"We had spent the last five years working hard, trying to understand - in the areas where there are gaps - what the problems were, what the deficiencies were, and to address those," she recalled. "We have also, of course, been trying to engage the residents on some of the current issues."

"It is a surprise for us that the resentment is so deep and the unhappiness is so deep." In fact, it was only during the campaign, that "we began to fully appreciate the extent of the unhappiness and resentment towards the Government, hence the pledge by the PAP team led by Mr George Yeo for us to have a strong role in the transformation of the PAP itself."

One cannot really deny that the PAP MPs do work hard. And they are generally very good at what they do. But for Mrs Lim to admit so candidly they were caught by surprise at the level of resentment and unhappiness on the ground is indicative of how badly they had been betrayed by the people they surrounded themselves with. With their huge machinery and wide range of grassroot organizations, feedback channels, how can they not know?

They are not and will not be the only emperors who get be caught out by the sycophantic crowd. There will always be self-serving sucker-uppers who seek only to further their own fortunes by selectively telling their masters the 'truth' they want to hear.

Perhaps the first step in the transformation of the PAP is to weed out these self serving elements from within.

Doing the right operation..... ala Dr Vivian Balakrishnan

Dr Vivian Balakrishnan provided an interesting analogy of the consultative approach he advocated for the PAP in the future.

Stressing the value of communication, he said: "It's not good enough just to do the right operation ... It's very, very important to talk to the patient - to explain these choices and the different trade-offs and make sure the people of Singapore understand this and participate more actively in the decision-making process."

Words of wisdom. Lessons learnt .... apparently.... until you note the first part of what he actually said: "....It's not good enough just to do the RIGHT operation".

So what he actually meant was that the PAP was right all along, and that the electorate had misunderstood all along. The PAP only failed in so far as it did not persuade the electorate of its 'rightness'. Informed consent to him, is to persuade the patient to agree to the correctness of the solution administered. Really?

Sodesne !.... And all the while I thought they were going to be truly more consultative.

To be fair, his boss, PM Lee had in the post-election press conference hinted at a future more inclusive relationship with the electorate: "And that means not only the Government working hard on its own with a population of passive but engaging Singaporeans in the more difficult decisions and trade-offs which governing Singapore involves. There are often no easy choices and the more we can appreciate this and grapple with the dilemmas and the trade-offs together, I think the better the answers we'll come up with, and the more we'll be able to have workable solutions."

I for one am truly hopeful that there will be a reformed PAP that will seek to lead rather than rule. They have done a magnificent job thus far as rulers, but I want much more than that. I really want to see them enter into a new social contract with Singaporeans, one that includes a greater degree of engagement and involvement in decision making with respect to critical problems. But the real deal-breaker is whether they trust Singaporeans enough to be transparent in their decision making processes. Or whether they will just continue to pretend to be consultative, but secretly (well, not so secret...) go on believing they have the only truth and only real solution, and just work harder to convince Singaporeans to be compliant.

I think that would be a disaster.

I am proud of you, Singapore

For the first time in many years, I can say I am proud to be a Singaporean. Not just happy to be a beneficiary of GDP growth, but actually proud to be witnessing this exciting political awakening in Singapore, and this spontaneous outpouring of passion and nationalism around GE2011. True, the nationalism at times sounded somewhat xenophobic, but I don't believe the true emotions behind all that bluster about foreigners truly stems from xenophobism.

Specifically, I am so pleased to see

a] the relatively "clean" campaigns that all the parties have been running. True, the ruling party has had more than a moderate excess of campaign advantages on their side, but I think this has been relatively 'muted' (or not as effective) during these elections. Certainly there has been a minimum of personal attacks launched;

b] the PAP come to terms with the heart behind the cold rationality of their otherwise effective policies. True, this has been more forced upon them by the strong opposition showing than spontaneous development from with the party, but it is better this than not at all. I just hope that this is a true indication of changes within the party logic so that we will see a more wholesome PAP in the future;

c] the ability of the opposition to attract better qualified people into their fold. Particularly surprised and impressed by the ability of the SDP to re-engineer itself away from the self-destructive unnecessarily combative antics of their leader.

d] the emergence of a true-blue Singapore folk hero from the ranks of the opposition parties, such as Mr Chiam See Tong. He has so much love and respect from us all, and he will be so much missed when he finally retires. The sad reality is that he has run out of time, but this should not detract from his immense achievements on behalf of all Singaporeans;

e] the increasing confirmation and acceptability of Mr Low Thia Khiang, also Ms Sylvia Lim as clear definitive opposition voices on behalf of us all. He is another hero in the making, but not yet;

f] the public participation of professionals such as Assoc Professor Tambyah on the opposition platform. There had always been constraints for professionals within gov and quasi-gov institutions to be seen publicly consorting with the opposition, so Assoc Professor Tambyah's very visible participation in opposition politics is a significant milestone and very much welcomed. I truly hope that MoH will not be reactive and start to clip his wings. That would be a a monumental mistake, I think. Certainly the public will watch and pass judgement on such vindictiveness.

g] the emergence of online The Temasek Review and The Online Citizen as alternative voices for the mainstream media. Thank you guys. Please soldier on and do not give up.

h] and most heartwarming of all was the demonstration that the pledge taking can be such a stirring and emotional event as seen at the opposition rallies. Thank you so much to the opposition parties for making use of the pledge in that way (yes, they were making use of it, but thanks anyway). For too long, pledge taking had come across as formal, dead and uninspiring. Almost as if we were being punished.

So it is truly a watershed event, this GE2011. Congratulations Singapore. I am so proud, whatever the outcome.

The Singapore Pledge, as never heard or witnessed before

The Singapore Pledge

One of the amazing and most memorable things about this GE - seeing the Pledge taken as passionately and so committedly as never witnessed before in all the years since independence.

And this coming from an opposition rally.

Where and how did the PAP get it all so wrong?