On 9 June 2022, Duke-NUS’ former dean Professor Ranga Krishnan was conferred the Honorary Citizen Award by the President of the Republic of Singapore Madam Halimah Yacob at a ceremony at the Istana. Receiving the award alongside fellow Duke-NUS pioneer Emeritus Professor Duane Gubler, Krishnan was recognised for his contributions not just to Duke-NUS but the nation’s entire biomedical and innovation landscape in a range of roles, but most notably as the longest serving chairman of the National Medical Research Council (NMRC).

While in town, Krishnan stopped by the School for a fireside chat with current dean Professor Thomas Coffman. Together, they walked down memory lane, picking out some of the decisive moments that enabled the School to grow into the research powerhouse and leader in medical education that it is today.

Former Duke-NUS Dean Professor Ranga Krishnan talks about the journey to becoming an academic medical centre with SingHealth in this highlight from the fireside chat with current dean, Professor Thomas Coffman

Here is an abridged version of their exchange:

Thomas Coffman: It is really fantastic to have you here and we are really proud of your Honorary Citizen Award. You have had a significant impact on Singapore through your role at the NMRC and elsewhere. As a lot of people know you and your background, could you start by talking a little bit about how you first got engaged with Duke-NUS and maybe some of the interesting behind-the-scenes stories during that early phase.

Ranga Krishnan: The story behind my joining is that back in 2004, 2005, when Duke signed the agreement, the first volunteer who came on the ground was Pat Casey. And it was an ophthalmologist who was supposed to come in as Dean, but for whatever reason, he chose not to come. And the leadership at Duke asked if I would consider looking at the position to get the School off the ground.

My initial response was not really. Things were going pretty well, and I didn’t know what I would be getting into. I didn’t even tell my wife. About a month later, it sort of came up in conversation, and my wife said, why not. So on 4 July 2007, we left North Carolina to move here to the old campus.

For me it was a once-in-a-lifetime opportunity and turned out to be one of the best things I could have done.

And I am really pleased that out of the many ventures in Singapore, Duke-NUS has continued to succeed and is really embedded here. And Tom, you’ve taken it to the next level.

Coffman: One of the early things that the School really got a lot of attention for was TeamLEAD and incorporating new ways of teaching medical students. And you obviously were a key part of that. Can you talk a little about the thinking behind that and the difficulties in executing it.

Krishnan: So, if we had wanted to establish a traditional medical school with preclinical faculty—anatomy, physiology and biochemistry—imagine what we would have had to build and how many people we would have had to recruit from different places. It really was not going to be a pragmatic way of getting it off the ground, especially with the timeline we had. So, the intent was to leverage Duke. The content was taped and sent over on hard drives because the net was not that good at the time and the students got a hard drive.

The other thing that developed around the same time was that educators like Sandy Cook learned that students learn best by knowing things repeatedly, having to use that knowledge and connecting the knowledge to its use. And that’s how we designed TeamLEAD. And Janil [Puthucheary] was very involved in putting together the format of a guide on the side not a sage on a stage. And it really took off.

I still remember when the Provost from Harvard was here for a week. The Harvard curriculum has since been redesigned to look like the Duke-NUS curriculum. And you have variations of this around the globe and even here at the Lee Kong Chian School of Medicine.

And this could not have happened without tonnes and tonnes of people. I think when we started out, we were less than 15, 20 people and by the time I left, there were a thousand-odd clinical faculty, a huge number of engaged people. And that’s the key.

And as a result of that, we have come a long way and put the School on the map.

Coffman: We can add Duke to the list of institutions that adopted the TeamLEAD format, too. The other area where you have had a big impact was on the formation of the academic medical centre. Can you share a few stories about that?

Krishnan: There was a lot of scepticism. First, whether we really should do it. NUS was near, why did we need another one? SingHealth had always been focused on clinical care and was really great at it but academic medicine would be a different thing. It would need a mindset change.

SingHealth—under the leadership of Tan Ser Kiat and Ivy Ng—played a big role in saying we really wanted to do this. We could not have done it without them because when I gave my first presentation to them, showing them a triangle to demonstrate how this could work, the boards were not sure whether we could pull it off. Getting both boards to agree to go on this journey was really key.

Coffman: The Ranga triangle of academic medicine has survived. It still comes up in every presentation.

Krishnan: So when we got the approval, the trust to proceed, we started with six ACPs, which was hard enough at the time.

I still remember that first year, Ivy and I had 300-odd lunches over an 18-month period. It was not good for my health. My cholesterol went up crazy. But I am really proud of how far it has come. It has become a true academic health system that is globally recognised. I hear about it even when I am travelling.

Credit goes to the many people who embraced it because again, the downside risks were very obvious. The upside was not as clear, but it was a clear commitment by the faculty on the ground.

Around the same time, we also brought in US-style residency training. That was a major change, moving from a British system to a US system, convincing the ACGME [American Council of Graduate Medical Education] to actually support it and convincing the Ministry. But the real plus we had on our side was that we had the commitment and willingness to change and to take the risk.

Coffman: In retrospect, introducing residency training was one of the best things that happened as a consequence of Duke-NUS. It really organised postgraduate training in a new way. So, the ripples continue to spread across the pond.

Krishnan: Right. And as part of this transformation, David Epstein came on board to build the Centre for Technology & Development. He played a big role in shaping the culture to be one where we take the opportunity of creating entities, et cetera. And now sitting on the other side, I can see how far it has come in a short period of time, both at SingHealth and here. And I think it has also helped NUS and everybody else to engage in the same way which led to the creation of the National Health Innovation Centre. And that has also taken off and done really well.

It’s been a very good journey. Personally, it was mostly because of the people, that’s what made the difference. All of them took a risk coming here and it has paid off. They made it work for the benefit of everyone in Singapore.

I am also so proud of the students. It is amazing how far they have come, establishing themselves in all aspects of healthcare. This is the best outcome anybody could have dreamt of and far better than any of us thought would happen.

Coffman: I also wanted to talk a bit about your transition to Rush. What were the things that you drew on from here and the things that maybe we could learn from based on your experience?

Krishnan: Rush has its own long history, but it was very traditional and when I moved there as dean, the purpose was to adapt and change the curriculum, which we did very quickly. I took the things we learnt here and asked the students to design what the curriculum should be and they designed a curriculum that looks like Duke-NUS’. And we implemented it in 18-months and got it off the ground. That helped us survive the pandemic because everything was in place before COVID hit. I am sure it helped you, too, to have that whole system in place during that period of time.

 The next part was to create an academic system like we had here. And then came the addition of the hospitals. And that journey started just before the pandemic. We brought in three hospitals and we’re opening a fourth hospital. But it was also a chance to see what’s happening in healthcare in the next five to 15 years.

The big changes are obvious. The first is the workforce shortage, which is global. The second, we’ve delivered healthcare in a hospital-centric manner for decades around the world. And the third thing was, it is delivered around increased sub-specialisation of providers. So, you treat the person as a disease, not the person as a whole. And all of these contribute to escalating costs.

The biggest opportunity is rehabilitation. Take cancer care as an example. Nobody built true aftercare and that was one of the first things we did at Rush. We opened a programme starting in one location, and then three months later we had 15 locations across the state of Illinois because that’s what patients need. It’s now patient-focused to help them recover from the treatment, surgery and radiation. We have 71 locations in less than a year for rehab. And then we opened the long-term acute care and rehab combined to care for people with long COVID.

Then the other part that connects to this is an entity we worked with called Dispatch to help cut unnecessary visits to the emergency room. We created a fleet of special vehicles each with a built-in lab and two staff. You book it through an app and the team comes to assess you. If you don’t need to be admitted, they can take care of you there and then. We introduced it in September and every month it's been growing 100 per cent a month. The reason is that is what people want. The way healthcare is going to be delivered will change.

And for the next part of my journey in the US is to strategically plan to meet the needs of people so that when we interact with them, we provide each person with what they need when they need it, where they need it.

Coffman: It’s a shame that we only have you for a short time or we could have gone on. Thank you for spending the time with us and congratulations on your award.