Bureaucracy is not the enemy of progress; it is the friction that ensures progress is durable.
In Singapore's public hospitals, a cardiologist in his mid-thirties has quietly redrawn the boundaries of how heart disease is understood and prevented. Dr Nicholas Chew, working at the National University Heart Centre, discovered that one in ten heart attack patients carry none of the conventional risk markers — a finding that sent him looking beyond the heart itself, toward what the liver and kidneys had long been signaling without anyone listening. His work is less a technological breakthrough than a disciplined act of attention: connecting what different specialties already knew but had never thought to examine together. In choosing to stay within the public system that trained him, and in asking what kind of institution is worth staying for, he has placed a quiet but consequential question before Singapore's healthcare leadership.
- A significant share of heart attack patients in Singapore fit no known risk profile, exposing a blind spot that conventional screening has never been designed to find.
- Early dysfunction in the liver and kidneys often precedes cardiac events, yet these signals go unread because medical specialties rarely speak across their own borders.
- Chew's team is now working to catch these warning signs before a first heart attack occurs — shifting the system's posture from crisis response toward genuine prevention.
- The deeper disruption is institutional: promising clinician-scientists are leaving public medicine not from lack of purpose, but because the system offers survival conditions rather than conditions for flourishing.
- Chew argues that protected time, mentorship, and humane career pathways are not luxuries but the infrastructure on which durable healthcare transformation depends.
- His own measure of success has narrowed to something the system rarely tracks: finishing with integrity, treating colleagues well, and not losing what matters most along the way.
Dr Nicholas Chew spends his days moving between catheterization labs, hospital wards, lecture halls, and research data — a cardiologist in his mid-thirties who has chosen to remain inside the public system that trained him. That choice is not incidental. It is the ground from which everything else in his work grows.
What first unsettled his assumptions was a pattern in the patients arriving with heart attacks: roughly one in ten had none of the usual warning signs. Normal blood pressure, normal cholesterol, no smoking history, no diabetes. By every conventional measure, they should not have been there. The discovery revealed a population that existing screening pathways were missing entirely, and it pushed Chew to look elsewhere for answers.
He found them in the liver and kidneys. Many of his cardiac patients carried early signs of dysfunction in those organs — signals that had gone unread because no one considered them the cardiologist's concern. The insight was not a technological leap but a structural one: connecting what different specialties already knew but had never examined together in routine practice. His team is now working to identify these early markers before a first cardiac event occurs, building a case for integrated cardiovascular, kidney, liver, and metabolic care.
When asked what single investment would most accelerate change in Singapore's public healthcare system, Chew's answer is people. Technology can be acquired. Regulations can be rewritten. But clinician-scientists with the temperament to ask hard questions and push change through complex institutions are rare — and the system is quietly losing them. Not because they lack commitment, but because institutions too often measure success through publications and key performance indicators rather than through the development of the people generating that output. The result is a culture of survival, and in such environments, the most promising talent leaves without announcement.
Chew is candid about what sustains him: mentoring younger colleagues, the moment a patient walks out healthier, and a faith that reframes bureaucratic friction not as obstruction but as the discipline of serving faithfully where one has been planted. He pushes back gently against the narrative that younger clinicians are fragile. The generation he works alongside navigates more demanding training, heavier documentation burdens, and an intensified publish-or-perish culture — while being more honest about the emotional cost. That honesty, he says, is not weakness. A doctor who takes leave is more likely to serve with clarity and compassion for decades.
His ambitions have narrowed in a way that suggests maturity rather than retreat. He wants the evidence his team has built to become routine clinical practice. He wants to nurture the next generation of clinician-scientists. And beneath all of it, something simpler: to finish well, with integrity intact, having treated the people around him with care. In a letter to his future self at forty-five, his closing instruction is to take more leave.
Dr Nicholas Chew arrives at the National University Heart Centre most mornings knowing he might spend his day in any number of places: threading a catheter through a blocked artery, reviewing lab results on the ward, teaching medical students, or hunched over research data trying to understand why heart attacks are striking younger Singaporeans. He is a cardiologist in his mid-thirties working inside a public healthcare system that trained him, and he has chosen to stay.
That choice matters because of what he has noticed. About one in ten patients who come to the hospital with a heart attack carry none of the usual warning signs. They do not have high blood pressure. Their cholesterol is normal. They do not smoke. They have no diabetes. They are, by every conventional measure, healthy people who should not be having heart attacks at all. This finding upended what Chew and his colleagues thought they knew about cardiovascular risk in Singapore, and it revealed a population that existing screening programs were missing entirely.
Building on that discovery, Chew began looking sideways—not just at the heart itself, but at what the liver and kidneys might be telling him. He noticed something hiding in plain sight: many of his cardiac patients carried early signs of liver or kidney dysfunction that no one had bothered to assess because those organs were not considered the cardiologist's business. The solution was not revolutionary. It was simply connecting what different specialties already knew but had never thought to examine together in routine practice. Now his team is working to identify these early warning signs before a first heart attack occurs, equipping clinicians to intervene with prevention rather than waiting for crisis.
When asked what single investment would most accelerate transformation in Singapore's public healthcare system, Chew does not choose technology or regulatory reform. He chooses people. Technology can be purchased. Rules can be changed. But clinician-scientists with the right temperament—people who ask difficult questions, find solutions in impossible situations, and have the stamina to push change through complex systems—are rare and difficult to replace. Yet the system is losing them. Young doctors and researchers leave not because they lack commitment to public service, but because institutions fail to give them protected time, meaningful mentorship, and career pathways that allow them to grow. Academic medicine often measures success narrowly: publications, grants, key performance indicators. It optimizes for output rather than for the development of the people generating that output. The result is a culture of survival rather than flourishing, and in such environments, the most promising talent slips away quietly.
Chew speaks from experience about what sustains a person in this work. Bureaucracy, he says, is not the enemy of progress—it is the friction that makes progress durable. But friction is exhausting. He finds renewal in time away from the hospital, in mentoring younger colleagues whose questions have not yet been dulled by institutional fatigue, and in the moment when a patient walks out the door in better health. His faith provides a frame for all of it: bureaucracy becomes not an obstacle to endure but part of the discipline of serving faithfully in the place where he has been planted.
There is a particular clarity in how he thinks about the next generation of public servants. They are not, as some suggest, a fragile generation that quits when things get hard. The young clinician-scientists he works with are differently resilient. They navigate training that is more demanding and more scrutinized than ever, manage clinical documentation that has become legalistic and burdensome, and contend with a publish-or-perish research culture that has only intensified. They do this while being more honest about the mental and emotional cost—and that honesty is not weakness. It is courage. The shift toward protecting time for family and rest is not a retreat from commitment. It is a more sustainable expression of it. A doctor who takes leave is more likely to serve patients with clarity and compassion for decades to come.
As Chew looks ahead, his ambitions have narrowed in a way that suggests maturity. He wants to help build a healthcare system where cardiovascular, kidney, liver, and metabolic care are integrated rather than siloed. He wants to see the evidence his team has assembled translated into routine clinical practice across Singapore. He wants to nurture younger clinician-scientists who will carry the work further and do it better. But beneath all of that is something simpler: he wants to finish well. To look back one day and know the work was done with integrity, that the people he worked alongside were treated well, and that he did not sacrifice what matters most in pursuit of fleeting gains. In a letter to himself at forty-five, he reminds his future self to take more leave.
Citações Notáveis
Public service is the quiet privilege of being entrusted with someone's health at their most vulnerable, and the wider responsibility of ensuring health systems we build today serve patients we may never meet.— Dr Nicholas Chew
The young clinician-scientists I work alongside are not less resilient—they are differently resilient. Their openness about mental and emotional cost is not fragility; it is honesty.— Dr Nicholas Chew
A Conversa do Hearth Outra perspectiva sobre a história
You identified that one in ten heart attack patients have no traditional risk factors. How did that discovery change what you do?
It forced us to stop assuming we knew who was at risk. We were screening the wrong people, or rather, we were not screening people we thought were safe. Once you see that, you cannot unsee it.
And then you looked at the liver and kidneys. That seems like a leap from cardiology.
It was not a leap so much as a connection. I noticed our cardiac patients had early liver and kidney dysfunction no one had assessed. The cardiologist does not usually look there. But the evidence was already there—we just had not thought to look together.
You say institutions are losing their best young talent. What would it take to keep them?
Time and trust. Give a young doctor the space to pursue a research question without anxiety about whether it lands in a top journal. Give them mentorship that is genuine, not performative. Let them grow at their own pace. The return might look modest in year one, but a well-supported clinician-scientist could reshape national guidelines in a decade.
You push back against the idea that your generation is fragile. What do you see instead?
I see people navigating more scrutiny, more documentation, more pressure to publish than my teachers ever did. And they are more honest about what it costs. That openness looks like weakness to some, but it is actually a different kind of strength—the strength to build something that lasts without losing yourself.
What keeps you in public service when you could earn more elsewhere?
The privilege of being trusted with someone's health at their most vulnerable. And the understanding that every guideline we refine, every student we inspire, ripples outward far beyond the hospital walls. That is not something money can replace.