Interview with KK Women's and Children's Chong Pik Wan

David E. Williams: Hello, this is David E. Williams, CEO MedTripInfo. Today I toured KK Women's and Children's Hospital, a 900-bed tertiary care facility in Singapore. After a tour of the facility, which matches anything I've seen in the US in terms of physical plant and creature comforts, I sat down to speak with Chong Pik Wan, the hospital's Director of International Medical Services, in order to learn more about KK's OB and fertility services, and their relevance for medical travelers.

What's the purpose of having women's and children's hospital together instead of just having one dedicated to women and one dedicated to children?

Pik Wan: Having a women's and children's hospital together allows us to meet the needs of women and children a lot more effectively. For instance our high risk pregnancies, all right, in some cases the children will be born with congenital deformities and would need special clinical care.

Therefore what happens is that very early on in the women's pregnancy once we identify that the child is going to have particular difficulties, our obstetricians and pediatric surgeons start working together very closely. This allows parents to be informed of their options, to get advice on their treatment that needs to happen when the child is born and then for us to try and therefore create as good a clinical outcome as possible for their child and plan for this outcome even before the child is born.

David: What are some of the differences in how obstetrics is practiced in Singapore compared to Europe or the United States? Are there any meaningful differences like natural child birth or vaginal birth after Cesarean? Any different approaches?

Pik Wan: I don't think that there are serious differences between childbirth practices in Singapore and Europe or in the US. I think where we may be right now is that probably at KK Women's and Children's hospital we tend to be a little bit more careful in terms of deliveries. Now a large part of that is because we are a tertiary referral center and for high risk pregnancies. And therefore you would find at this point of time we do not have water birth.

So we are very particular in that sense because we haven't seen clearly documented evidence that water births actually have a better outcome and so on. So you will find out that in the KK Hospital we do not do water birth at this point in time. So in that sense, doctors will actually want to see the evidence before they go into this method of childbirth.

Apart from that I see very global differences in terms of average length of stay. Clinical outcomes are the same. Because we maintain very high clinical standards, we would not do a Cesarean section unless there is a clinical requirement. So if the patient chose c-section because it's the right time of the month or it's the way she wants we would actually not recommend it because for us it is the clinical standard that is the most important. So you find that we wouldn't do a Cesarean section unless there is a clinical need.

David: And what is the percentage of birth that are c-sections?

Pik Wan: C-sections right now are about 25 percent in this hospital, which would be, I think, what you would have. Probably a little bit higher than the norm for KK Hospital, but that has to do with a fact because we do a number of complicated pregnancies and high risk pregnancies that these sometimes are inclined towards c-sections. If you have young women they are talking about normal pregnancies.

David: And what sort of programs do you have for patient safety, for training physicians and nurses. Are there any particular programs that you have related to obstetrics or just overall?

Pik Wan: We are a JCI accredited hospital. So we would have maintained, or exceeded even all the clinical requirements expected of a JCI accredited hospital. Because we are not only a hospital providing patients with services, but because we are also setting the standards of health care as the national hospital for obstetrics, you will find that we look very carefully to see whether our protocols are acceptable.

For example, if you look at our neonatal department, you will find that we are on the Vermont Oxford Network, which is a voluntary group, comprising hospitals who would submit their data to see, relative to the rest of the neonatal units in the world or those who want to participate in this voluntary network, what are their outcomes.

So we want to make sure that our results match the best in the world, and if they don't, well, what do we need to do about it?

Other things we do, we also do a fair amount of research. So, for example, our neonatal department would be doing a fair amount of longitudinal studies. We follow the children from the point they are neonates right to the point they are seven years old. Because of these longitudinal studies, it allows us to ensure that our practices provide for good outcomes that are proven by time, rather than they have been discharged and that's the end of the story.

In obstetrics, for example, I think we are probably the best in the world, in terms of the fact that we have one of the shortest turnaround times, from the point we realize that the child is not doing well, when mommy's having a normal delivery, to the point we can then bring the woman into the OT and deliver the baby. Our time is seven minutes.

Now, this ensures very good outcomes for the child, because once he's not doing well in mommy, then the quicker you bring him out, the better his survival and the outcome would be. And all this is possible because we are a very large hospital, and therefore we coordinate our systems such that we can deliver this.

For example, what we have--and you probably have not heard it this afternoon, because I haven't--is that we have a code green. So you've seen our delivery suites. Once they are in the delivery suite and we notice that she is not well, baby is not doing well, the nurses immediately call a code green. This announcement goes out throughout the entire hospital.

Now, once the announcement goes out, whilst the team in delivery suite is busy preparing the woman to be pushed into the operating theater, the surgeons in the OT are already scrubbing up. So the minute the patient arrives...

And you have seen our layout. It's just 10 meters away, between delivery suite and operating theater. Once the woman goes in, it's scalpel and baby is out in a matter of minutes. Neonatologists, because they have heard the code green cry, have already gone into operating theater, waiting to ensure that they can provide good outcomes.

So these are the kinds of things that I think are beyond safety. We are trying to go for good standards that then we can ensure that the rest of Singapore is also held to very high standards.

David: Now, what happens in the event that there is a bad outcome? For example, in the US, whenever there's a cerebral palsy baby, even if there's no particular reason to think that there was a problem with the obstetrical care, there's usually a lawsuit. What is the typical course of action in Singapore?

Pik Wan: In a typical course of action in Singapore, patients can still sue at the end of the day. I think we may have had perhaps one or two in the last two years. So it's not a very prevalent phenomenon yet, at this point in time.

But what would happen would be that, if they go to court, then they would be allowed to call their own expert witnesses in, to determine whether this was really something that they could have been told of, or whether it's really one of these things in life where you couldn't tell whether this child was going to be CP or otherwise. So there is still a recourse into the courts.

And in Singapore, at this point in time, we're probably seeing one or two cases in courts every year. We have about 39,000 births, so I'm not sure how that compares to the US.

David: It's not higher than the US, I'll say that.

Pik Wan: [laughs] OK.

David: I noticed as I was walking through the halls some posters talking about pricing and about--I think value pack was the term--and it seemed as though you were offering a fixed pricing. I think this was maybe for gynecological surgeries, I'm not sure, but that was based on a full package. Can you tell me a little bit about the thinking behind that?

Pik Wan: The value pack really is not something at this point in time that is available to foreign patients. If you understand the health care system in Singapore, we have deliberately gone on the model that hopefully takes the best of the US and UK models and tries to minimize what are the weaknesses of the models.

So I don't think that Adeline has shown you what we provide for our poorest patients, all right, but the philosophy of health care in Singapore is that people who can afford health care should try and pay for their own health care. Where people can not afford their own health care, the government will provide a safety net.

So the Singapore government's promise to every citizen is that regardless of whether you are rich or you are poor we will ensure the same outcome for your child, all right. Now if you go to our ICU, our delivery suite, I don't think you can tell which is a rich patient, which is a poor patient, right?

Because in these high equity areas things like air con, and whether you have a mini bar or so on, are not important. So how we differentiate is that on clinical outcomes--there is no difference for every patient, whether rich, whether foreign, whether local.

However, for the hospitality aspect for example, do you have air conditioning, do you have a private bath or do you share a room with six patients--now that is where the differentiation comes in. So what happens is we find sometimes with patients is that they are not poor...

Now I forgot to mention, that for our poorer patients, which we call subsidized patients because the government provides a much larger subsidy, the approach is a team care approach, which means that as you come to the hospital, you are taken care of by a team of doctors. You don't go and choose and say I want to see Professor X. Because you are a subsidized patient, it is a team care approach. However if your child comes in and he requires cardiothoracic surgery, then of course he has to see Professor X, because it can't be a team of doctors led up by Professor X.

So that's how we ensure the same clinical outcome for all patients. But if a patient has a little tummy ache and it's not established what that tummy ache is, then you don't see Professor X unless you have a stomach cancer, you know, so this is our philosophy in health care.

Now what we have found sometimes is that patients who perhaps can afford to choose their own doctor, all right, very often choose then to go in to subsidized wards when they need a surgery, all right? And that comes in very often and I've found that--is that I don't know how large the hospital bill will become, all right? So we try to address these needs of patients who would like to choose their own doctor, but are very worried and therefore end up choosing a subsidized class instead.

So value pack really was developed to address this group of patients who wanted to choose their own doctor, but they were very afraid of the bill and so it offered something that says OK, it's a package--this is what it's going to be. Then people feel a lot more comfortable and want to choose their own doctors and have the air conditioning.

David: I want to ask you a little bit about the fertility services that are offered here. Can you tell me about what are the main services that the hospital offers for fertility and in particular, which services might be relevant for patients who are coming from abroad?

Pik Wan: I think when it comes to fertility that there are essentially three parts you want to look at. There is the pre-IVF where perhaps some procedures need to be done because possibly the patient--assuming it is a female issue and not an issue with the husband--maybe that they have fibroids or similar things that need to be done before you actually go for IVF procedure.

So OK, then we have obviously the minimally invasive surgery and so on which would ensure that the condition that needs to be treated can be treated even before IVF is considered, and nowadays with minimally invasive surgery many times that is a good option for such patients.

Then of course we have IVF, and our rates are comparable to the kind of rates and outcomes that are provided in the rest of the world. The only difference though is that Singapore is very strict, and therefore if the couple is not married, we are not able to provide the IVF procedure. That may not be the same requirement in the US or UK at this point in time.

Then once conception has take place and there is a viable pregnancy, sometimes you tend to have multiple births rather than singletons. What we try and do is to really try to ensure singletons, because as you know twins and triplets are much higher risk, but you don't really know and you can't guarantee it all the time.

So when it comes to twins and they need more careful monitoring, then of course our team of doctors is here, because the fact that we have maternal-fetal medicine, we have the antenatal diagnosis and so on that would ensure that the support that the parent needs for this pregnancy, we can take care of.

David: Is it practical for patients to travel long distances for IVF or other fertility services, or is it really only relevant for people who are in Singapore or in the region?

Pik Wan: Our experience has been that patients will travel the distance to come to Singapore for the treatment, because what happens is that they would come here to Singapore and they would probably spend a week or two weeks here getting diagnosed and getting the whole workup for us to determine--is there something we can do for you, and what needs to be done.

Now after that two weeks and if the investigations and all that is done and we find that it is viable, then the patient and the husband can go home and be given a set of injections and so on that they need to do.

So they don't have to stay here for that entire pre-insemination workup, so they can actually go back and stay home and do the injections at home and so on, and get some lab tests done before they come to Singapore again for another week or ten days where we would then do the in vitro fertilization and then have the implantation back.

So we are seeing a demand coming from the region--I haven't seen them to be honest, coming from the US or UK yet except for expatriates around the region. But certainly around the region, from Bangladesh, from India, from Indonesia, they are actually coming.

David: And what's the cost for an IVF cycle?

Pik Wan: An IVF cycle would be about seven, eight thousand Singapore dollars.

David: And what is your approach to marketing to patients in the United States--it sounds as though that hasn't been a focus so far, is it something that you're thinking of doing?

Pik Wan: It is something that we are thinking of doing. We are getting a fair amount of interest, but as you have rightly observed we haven't done anything yet. Where we have gone, really, is that there has been a lot of interested parties who currently provide these services who are based in the US, saying to us we'd like to be part of the group of hospitals that they would inform patients about, and would arrange... so we have taken very baby steps at this point in time, in this particular area.

David: I thank you very much for speaking with me today.

Pik Wan: Thank you very much.