Dr Yeoh Poh Hong.
A M Ismail Oration 2014
Delivered at opening ceremony of College of Surgeons ASM in Kuching.
I want to thank the President and the Council of the College of Surgeons of Malaysia for giving me the honour to deliver this year’s A M Ismail Oration. It is especially significant for me because I have known the late A M Ismail in person over several decades, although we are from different generations.
He was the eldest of twelve children born to humble parents and spent an exciting childhood growing up attending school as well as having to earn income in various capacities, including as a golf caddy, trader, farmer and waiter. In the days before television and computers, he occupied himself going to the movies, fishing, and doing all the things a local kampong boy would delight himself in. Not withstanding his escapades, he still emerged as the top Malay student from the Victoria Institution and was sent to the King Edward VII school of Medicine in Singapore.
Abdul Majid Ismail graduated from the University of Malaya in Singapore in July 1950, after an undergraduate course interrupted by the Second World War. He was sent to do his FRCS as a Queen’s scholar and subsequently to obtain his Masters in Orthopaedic Surgery in Liverpool University. This led to all subsequent surgeons wishing to pursue a career in Orthopaedics to also follow in his footstep to Liverpool. This continued well into the 1980s until we started our own Masters Programme in Orthopaedics. Some of us in this hall came from that period of time.
He achieved distinction by becoming the Director General of Health during which time he put into place far reaching programmes in developing our health care services but more especially planning the manpower development for our future. There followed an explosive boom in the training programmes open to our doctors. I dare say the majority of surgeons in this room benefited from this farsightedness.
Abdul Majid, or Koko as he was fondly referred to, was the founder of this College of Surgeons and was for many years its President. He had envisaged that this country should evolve a system like that in the United Kingdom with specialty accreditation being in the hands of the Profession. He was not in favour of a University based programme as practiced now, believing that Universities which are under the Government cannot be independent in establishing and preserving the high standards he espoused.
Unusual as it were to have an eponymous lecture instituted to honour the memory of a living person, this eponymous oration was established to honour him soon after this College was established in November 1972. His co-founders
were of such a determined persuasion that they did not entertain his objections.
Koko is one of the most humble person I have known. Long after his retirement from all medical activities, the members of the Alumni Association realised that he had never been its President. I was tasked to persuade him. He informed me that it was not necessary for him to be the President to continue to support us and to enjoy our company at our frequent fellowships. He informed me that he has been over-rewarded in life and has no need for additional accolades and honours at that point in his life. Life had been good to him in all respects and that he was truly contented with his lot in life, in this the closing years of his life. That attainment of ‘contentment’ has always swirled in my mind, hence the topic of my presentation today.
I can now understand his state of mind. There comes a time in your life when titles and accolades no longer carry any significance when you are fortunate enough to have left the rat race to achieve high status in life or advancement in career.
As I look back now, I believe I have been blessed with not just survival, but with a wealth of experiences that have moulded me into a reasonably contented person, sharing with A M Ismail some of his attitudes to life. Being contented is a state of wellbeing and this will include a degree of satisfaction in all aspects of life as a person and a surgeon.
To be contented must necessarily mean that you are satisfied with your choice of a career in Surgery and that your daily life is not a drudgery. Financial sufficiency is a major factor. It is quite difficult to be contented if you are struggling to survive. Our needs and aspirations differ and therefore the amount of income we need will also differ. I am not trying to preach but it is important for us to remember that we chose to do medicine because deep down within each of us, we wanted to save humanity. We may have imagined as a student that we could make some fantastic medical discovery that will save mankind or cure some lifelong illnesses.
As we settle down into our established daily working lives, we begin to accept that depending on our individual niche, our work will only affect some individuals at a time and sometimes entire communities or even the nation. Most of us in our daily work help and touch the lives of the people we treat. At the individual level, there is a finite number that we can reach. The heart transplant surgeon will probably directly affect the lives of a few hundred people in his lifetime, and also not for indefinite periods. The Ophthalmologist that does 100 cataract operations per month can in his life time give new life back to about 36,000 persons. The Director General of Health, like Koko was, although not directly doing any procedures, may by his decisions in health delivery affect the wellbeing of millions of people.
We soon realise that there are limitations and that we are unlikely to become multi-millionaires from our professional activities alone nor are we going to make any earth shaking contributions that will immortalise our names in the Annals of Medicine; almost all of us that is. But we should however try to reach out to as many people as we can with the expertise that we have acquired.
My presentation today is not a treatise on the advancement of treatment or the espousal of any fundamental philosophy of surgical practice. I am not here to lecture or to instruct or teach you. I have been preceded by 40 illustrious orators whose credentials and subject matter I cannot hope to equal. Besides I note from the programme that there are many scientific presentations which will be made this weekend which will be better suited for that.
I stand here at the closing years of my career to share with you some experience in my own life. It may not be of any great significance to those in the audience in my same vintage who will most likely have their own similar as well as unique experiences to share.
Instead I hope to be of some assistance and encouragement to the many colleagues who have decided to embark on a lifelong career in this our chosen vocation. The future is not going to be easy and I shall be making reference to the challenges ahead. I hope to share with you many things that can happen in the private surgical practice that you are unlikely to know. Those employed in the Government sector have never understood the issues prevalent in the private sector. Indeed the public sector has always, to some extent, held the impression that the private sector is comprised of nothing but avaricious doctors who earn astronomical income, while the poor doctors in the Government sector are the ones doing the majority of the work, including inheriting all the serious complications that the private sector doctors refer when they have squeezed the last dollar from their patients.
Choice of Surgery
We chose a career in Surgery for different reasons but with the acceptance that it will be a difficult and demanding life. We have all come to know the lives of surgeons, perhaps from the many television shows and films that we have seen as children. We may have been drawn by the glamour or the sacrifices of our individual heroes. The reality of life can be very different and just as our decisions can change the lives of our patients, our decisions can also change our careers and lives.
Keeping abreast with the rapid advances in surgery will be a major challenge. As rapidly as new advances are reported, new reviews and new knowledge have relegated many of the surgical procedures we used to do routinely into the trash bin. Many of our established beliefs and conventional wisdom have also been debunked. But we continue to see surgeons do procedures which have been proven to be ineffective. The same surgeons are probably also the ones who have not kept abreast and are under the impression that the knowledge they graduated will serve them for their entire life.
Looking back, the earliest surgeries in history were crude at best and likely to have been performed out of desperation or ignorance. Surgery as we know it did not truly begin until the late 1800s, and even then, infection was common and outcomes were poor. Surgical procedures that are commonplace today, such as appendectomies, were not common then. In fact, until 1885, a person with appendicitis was expected to die of the infection that occurred once the appendix ruptured. Early techniques were rudimentary, or even barbaric by today's standards, as anaesthesia was not commonly used until the mid- to late 1800s.
The inevitable advance in our research and understanding has also had a tendency to change our established practices. Take for example the discovery of Helicobacter pylori which made obsolete the various surgical assaults on the human stomach for ulcers as well as cancers. The advent of immunisation against HPV in young girls will probably reduce incidence of cervical cancer to such an extent that major procedures such as Wertheim’s procedure will no longer be practised. The advent of the MRI will has debunked our whole understanding of surgery for degenerative spinal disk disease.
Other advances in the past decade alone that will have a similar tendency to dictate our surgical practice will include Stem Cell research which has produced promising results. Application in a wide range of conditions are being studied. There is also a possibility to produce replacement body parts. This will certainly be good for Malaysia which I understand is second last in the countries surveyed for organ donors.
Many of our first line treatment will also be in the field of Stem Cell Research where we can replace tissues. In the area of osteoarthritis, I can envisage that joint replacement, which are after all not curative procedures, will become obsolete.
The success of the human genome project has brought about a number of discoveries, as well as revealed mistakes and produced medical advances. It has made changes in our deep seated beliefs in medicine. The future is likely to be in preventive medicine. When our successors in the next century look back to the surgeries we now do, they will no doubt consider the many procedures akin to barbarism and mutilations, as we do of the procedures done by our early brethren two centuries ago.
New anti-Cancer drugs as well as target specific drugs will improve survival rates and reduce need for massive surgical procedures. Surgeons will also need to keep abreast with advances with minimally invasive surgery. Robotic techniques will improve surgical precision and make it potentially possible for surgeons to operate on patients remotely. Imagine that we can have the most experienced surgeon perform surgery on our patients and for us to be able to learn techniques as the surgical assistant on the ground but assisting the remote surgeon who may be on the other side of the globe.
In more than 40 years of intimate association with doctors from both sides of the public – private sector divide, with policy makers and politicians, as an outspoken advocate of doctors while serving in various positions in professional organisations, and having sat through countless disciplinary enquiries, I can be candid in my remarks without need to resort to rationalisation or to embellish my remarks to lessen the less palatable side of our profession.
Too Many Doctors
The President of the Malaysian Medical Association in a recent statement expressed concern that this country may soon have a glut of doctors. He may well be right.
For a country of 28 million people, we have 40 medical schools producing some 5000 new doctors every year. We also have overseas graduates returning from another 375 recognised overseas medical colleges. We now see a situation where we do not have sufficient housemanship training positions within the government hospitals and new graduates are idle for prolonged periods. The situation is not likely to change much because in the last 5 years, only 2 new public hospitals has been built.
There is a need for the Government to change its policy to accord similar status to Private hospitals with respect to the provision of not only housemanship training but also post-graduate training. Indeed, in the drafting of the Private Health Care and Services Act, in which I participated, changes and requirements were incorporated to compel our private hospitals to organise their operations to parallel that of teaching hospitals. Presently our Private Hospitals are only a market place for independent specialists practicing independently and in parallel with their colleagues. There is no unification of specialists into departments to provide shared responsibilities to ensure optimal care to patients. There is certainly no mechanism to enable the posting of trainees to work in private hospitals.
If there is concern with overproduction of doctors, we should also be concerned with the candidates being admitted into undergraduate and postgraduate training.
About 30 years ago, when we had five medical schools, the then Prime Minister in opening a medical conference declared that the way to stem the rising cost of medical care was to flood the market with doctors. This statement had been made following a period of continuous complaints in the media about exorbitant fees being charged by doctors. As always, a casual statement by the Prime Minister can soon became the national policy.
While it was eminently evident that the high cost of private health care was not caused by doctors, whose total fees tend to comprise only 20 to 30 percent of the total cost, the government and the private hospitals for their own convenience allowed and even diverted attention to doctors as the culprits of the high costs. The majority of the cost were actually the room charges and high mark-ups of services and medications provided by the private hospitals. What must have been disturbing to the public and the medical profession was the subsequent listing of private hospitals in the stock exchange. Health Care was now the Health Industry, to ensure dividends for investors and share-holders from the sufferings of patients.
The Malaysian Medical Council then drafted a memorandum to warn against such a simplistic approach to solve a single aspect of health care cost. Obviously, as is often the case, Governments in their Cabinet Meetings make decisions best suited to their own aspirations. It has been said that while Health Care Planners plan for the next generation, Governments plan for the next election.
As a result of the explosive growth in medical schools both in the public and more so in the private sectors, many expected problems has arisen. Having served more than 10 years in the accreditation of medical schools, the principal area of concern in every medical college has been the shortage of staff and failure to meet the original set standard of staff: student ratios. In addition, there is a shortage of teaching staff with more than 10 years post graduation and the continual pinching of staff among institutions has seen rapid promotions of inexperienced staff to professorial levels.
In last Sunday's papers, it was reported that staff shortage had become critical in one of the major medical school in the country, having lost 38 senior lecturers in 6 months, who claimed to have been overworked and underpaid. Obviously they were not at all contented.
There is an urgent need for Government institutions and even private medical colleges and institutions to restructure the remuneration of the doctors to reduce the wide disparity between the public and private sectors. I shall refer to this a little later.
There is also an urgent need for Medical Colleges to recruit private practice doctors to assist in their teaching programme. The large majority of senior and experienced doctors are in the private sector. Because by a natural progression, the doctor who is in Government service will ultimately leave for the private sector once he has acquired he necessary working experience or when he finds that his income is unable to support the needs of his family.
Because many of the Medical Colleges have affiliations with overseas colleges, the Medical Act was even amended to allow for foreign doctors with suitable teaching experience to be registered for the purpose of teaching. This is even if their basic qualification is not registrable. Disappointingly, Private Medical Colleges have not responded by recruiting from foreign universities of excellence to serve, even for short periods. This is because local specialists and specialist from neighbouring third world countries are a lot cheaper.
Because private colleges are commercial enterprises and to fill the vast number of places, there has been occasion when they have been pulled up for breaching their own entry qualifications. There were two occasions when the Accreditation Committee did not recognise the inaugural intakes from two separate medical colleges.
It is probably a given fact that it will unlikely for our Universities to claw themselves out of their dismal international rankings.
Another area of concern is the fact that none of our private medical schools have their own teaching hospitals. They are all squatting and sharing facilities in Government Hospitals where the students and their teachers are mere observers in the management of patients. There is some participation of Government specialists in teaching in some general hospitals. This is to alleviate resentment that lecturers examining hospital patients in the wards are an interference and discussions by the bedside is a criticism of their patient management. I have always pressed for Teaching Hospitals to be made mandatory at the Accreditation level in order that Medical Colleges can develop Centres of Excellence in their various locations. No medical school has yet to do this and as a member of the Board of Governors of the IMU, I understand that there are, for reasons unknown, obstacles placed by the Health Ministry itself.
Consequences of a Crowded Market
The large number of new graduates pouring out of our medical schools which are beset by staffing problems will affect the quality of doctors taken in for surgical training. As a natural progression, there will be a concomitant increase in the number of surgeons and we will be facing a crowded marketplace. Those of you now actively involved in postgraduate training will have to brace yourselves to be dealing with less than ideal material.
When I started private practice, there were six Orthopaedic Surgeons in private practice in the Klang Valley and Seremban. There were only two major private hospitals in Kuala Lumpur. Today there are 17 orthopaedic Surgeons in my hospital alone with 20 private hospitals in the Klang Valley
In the private sector, the pool of patients is not increasing at the same rate as the personnel and facilities are. This has led to intense competition for scarce private patients amongst doctors. I have heard discussions among colleagues that every patient must now be seen as a commodity from which to extract maximal financial benefit. Herein lie, to me, the greatest disillusionment in the practice of surgery in particular and medicine in general. There is increasingly the practice of commercial rather than ethical medicine.
Patients are subjected to unnecessary investigations and procedures. In almost 30 years as a member of the Malaysian Medical Council, I have participated in hundreds of disciplinary inquiries against doctors; and studied literally more than a thousand complaints. The overwhelming majority of them have been against the unscrupulous conduct of our colleagues.
There has also been an increase in malpractice litigation and the premiums for our medical defence organisations have shot through the roof, prompting obstetricians to opt for office gynaecology, myself to give up spine surgeries, and many others to opt for early retirement when insurance premium can be a significant proportion of your total income.
In medical schools, we are taught to practice ethical medicine with the welfare of our patients as our only concern. Our decisions should be evidence based. Everything changes when we are in private practice.
Many of us will have high repayments to meet from over lavish investment in our new clinic and the staff under our employment. It is a constant battle to generate sufficient income each month to meet our occupational and family commitments.
In addition, the fees; that surgeons can charge is regulated by Law. The fees that you can charge is contained in Schedule 13 of the Regulations to the PHCFS Act. Failure to comply is an offence punishable by a Court of Law.
Under such a scenario, it will be difficult to achieve contentment. This has led some doctors to unbundle the fees or to falsely charge under a higher category, which is of course not morally acceptable and considered unethical.
Doctors should be able to have incomes commensurate with his years of training and very demanding nature of the work. Towards the end of the last millennium, there was a Committee formed by the Academy of Medicine to establish how doctors in the future should be remunerated.
The committee strongly advocated the integration of the Public and Private sectors under a single Commission and envisaged that doctors will be salaried and not become businessmen by going out into private practice. Their income should be sufficient to provide for a life-style commensurate with their status. They should be given time-off for self-improvement, do research, attend Conferences and time of for recreational activities.
Bonuses above their standard income will be based on output. They should be allowed to practice only ethical and evidence based medicine. They should not be managing small business as private practitioners. As an employee, you need not do unnecessary surgery, charge exorbitant fees, and at the same time having to manage your business enterprise.
Employment Against Self Employed
I a recent publication, a very large numbers of doctors in America were recently polled. Due to changes in the Health Care system, the majority of self employed doctors tend to be in the older age group. In doctors less than 40 years old, there were twice as many employed doctors.; Almost half of this group work in hospitals or are in groups now owned by hospitals. The rest work for large private groups, community health centres, corporate laboratory services, military bases and also correctional institutions.
There are many reasons for choosing employment and they are also applicable to our country. They include:
- Financial security, with guaranteed income with good benefit packages,
- Fewer administrative responsibilities, not having to be concerned with staff recruitment and equipment upkeep, and
- Better hours, work-life balance, with malpractice coverage combined with limited or no night calls.
In this country, private practice, in most cases, will reduce you to be an isolated practitioner enclosed in your own cocoon of decision making and execution of the management plans.
I make reference to this issue to suggest that all you surgeons try to stay as long as possible in the Public sector, even if your only intention in doing medicine was to go into private practice. Stay back and fight for changes. It was reported that the Ministry of Education has set up a joint Committee with the Malaysian Medical Association to find solutions to check the exodus of doctors from the Public sector. Do not believe that you will make millions by doing private practice. In the long term, you will get much more satisfaction in being able to practice good medicine and not have the spectre of the minimum amount you must to raise each month to service your loans, pay your rentals, your staff and not least, to provide for your own family.
You can then practice in a departmental environment where you will enjoy congeniality and have the benefit of your own colleagues’ opinions to help you. You need not be continuously anxious about the progress of your patients because they are all patients of the Department who are assigned to you. You can go on vacations and attend conferences without anxiety.
In private practise we will need to request a colleague to manage your patients for you. I know of many cases where you not only lose the patient, but the impression that you have not provided the correct treatment may be communicated to your patient. Making adverse comments against a colleague is unethical but I have been informed that your colleague can convey this by body language alone.
Due to the presence of so many specialists in the private sector, and the numbers can only grow, the pressure is so great we have seen cases of abducting patients from each other. There have been occasion where doctors provide hospitality and other forms of inducements to staff in the emergency department to divert cases to them. This deprives not only to the doctor on call but also doctors to whom the patient has been referred. I am not sure how prevalent this is today, but I am convinced it goes on from talk in the coffee room. I suppose this must be the origin of the phrase that in private practice it is a "doc eat doc" environment.
If you are in solo private practice, always have a few colleagues in another hospital to whom you can turn to for advice.; Keep yourself connected to the Internet to acquire ‘just in time’ information. Also keep in your smart phones various annals and textbooks and keep referring to them as and when you are uncertain of anything. I have no hesitation in whipping out my smart phone or do a quick search on the computer. Far from patients thinking I am completely ignorant, they have always become more confident in our joint management of their problems. Besides, many have already googled their conditions.
To keep yourself updated, do attend as many relevant Conferences, such as this one, where you will learn about the advances in your own specialty. Studies have shown that presentations that are applicable to your own patients are best imprinted in your memories. Otherwise, ninety percent of the information given will have been forgotten within one month. Be that as it may, perhaps remembering 10 percent of something is better than remembering 100 percent of nothing. At Conferences, it is always more useful to participate in hands-on workshops.
When recommending surgical intervention over conservative management, it would be wise to consider surgical intervention as a last resort. The patient or his family must be briefed fully. It has been noted that many surgeons do not themselves take informed consent for surgery. They leave this to the nurses. There are also occasion when the surgeon offer surgery as the first line of treatment and fail to alert patient of possible adverse outcomes. Importantly, you should only embark on procedures for which you have been trained to do.
Many of the medico legal action as well as complaints to the Medical Council relates to the failure to take informed consent and also due to the overzealous performance of unnecessary procedures. If you have done enough surgical procedures, you will have experienced complications. This can happen even when you have exercised extreme care, or are doing a procedure you do regularly.;
When there is an adverse outcome, my advice is to be completely open with the patient or relative. In my own experience, patients and their families are reasonable people and if you take them into your confidence, this will go a long to prevent litigation against you. This is not an admission of guilt on your part, even if you were to say you are sorry that the adverse reaction had occurred.
Refusing to discuss with the patient or family will always be taken to mean that you have something to hide. This invariably will lead to action for malpractice. Concomitantly, a complaint is also made to the Medical Council. The lawyers for your Defence Organisation will, however,; always tell you not to communicate with patients or their relatives. Their intention is to protect the Defence Organisations that employed them.
Being sued for malpractice and to be called up by the Medical Council with be the most stressful experience of your career. It will send you into deep depression and disrupt your surgical practice. The medico legal and disciplinary procedures can take several years and drain you physically as well as mentally. Your loss of income can also be catastrophic.
The courts many decide against you and you will have to pay large sums of money as compensation; while the Medical Council may take away your license to practice.
My advice is to consciously do everything possible to shield yourself against such situations. Always practice surgery according to our own skills, for indications that are in our academic annals, and never offer surgery as a financial reward for ourself.; A disturbing trend I have noticed is the avaricious conduct of surgeons who not only perform unnecessary procedures, promise unrealistic outcomes, but also charging exorbitant fees.; Remember that it is easier to defend errors of omission rather than errors of commission.
Our Medical Defence Societies have always advised the keeping of proper records. Any claim on your part that the management of the patient was thorough will not hold water unless you have the records to prove them. Beginning today,; take time to enter everything you do into the patient's records. Also do write legibly because illegible records are taken as no records.
Always practice evidenced; based surgery and take care not to violate Schedule 13 of the Private Health Care Services Act or our Professional Code of Practice.
In the present evolution of health care into a multi-billion dollar industry, you as the pivotal arm in the entire care delivery system will see swirling around you multi-million dollar promotion of drugs, equipment and services. You are not party to the millions that the health entrepreneur is making and you may well feel deprived. You may of course join in the bandwagon of the entrepreneurs if that is your calling, but for those of us practicing surgeons, we must guard against a corruption of our moral and professional virtues by not being enticed into deeds contrary to our obligations.
As a registered medical practitioner, we are conferred privileges and powers by law and our written certifications are accorded due recognition by the Law and the public. Common violations are false certifications such as selling of sick certificates and falsifying of reports or exaggeration of medical opinions in
specialist reports. A case high-lighted in the news a few days ago serves to warn us of the consequences of such career ending activity.
As a specialist, and especially if you are in a position to influence purchase of equipment , drugs or services, you will be the darling of the industry. You will be plied with trips for overseas conferences and given extravagant hospitality. I know that it has become almost impossible for the ethical profession to combat this problem in all countries. All sorts of compromises have been produced as guidelines for acceptable bribery.
Even in the field of research, almost all funding now comes from the Industry which also decide whether your findings can be published or not. You now see in all journals a declaration of conflicts of interest by authors. If you are a famous authority, you may also be paid to have your name included as an author in research papers in which you have not participated.
I see no solution to this although when I was the President of the Malaysian Medical Association in 1987, I did convene a meeting of the heads of Industry to organise a system where recipients of travel awards from the Industry should be merit based on a mutually acceptable selection system open to the entire target population. At that time we also saw the beginning of lavish hospitality and entertainent at major hotels for drug company sponsored events.
My comments that this unhealthy practice was akin to the corruption of the profession by pharmaceutical companies attracted support from consumer advocate bodies as well as drew the attention of the media.
All pharmaceutical companies present were in complete agreement with me, provided everyone played by the same rules. I was flattered to be invited for dinner by the International Vice President of; Johnson and Johnson, who happened to be passing through. He commended me for my sentiments and informed me that no CEO in the Industry would disagree with me. He informed me that if there could be instituted such a system, they could cut billions from their sales promotion budget and reduce the price of their products significantly.
He also told me that in in younger days, he was also naïve like me to believe that such altruism can be fostered. He confided that when he was younger and in charge of operations in Italy, there was an agreement to stop lavish hospitality for doctors; only to discover on a flight to the very next overseas conference that the entire business class section was occupied by doctors sponsored by his rival company. Needless to say his sales suffered as a result.
I can only say that we must all act in accordance with our own conscience. The money spent on us is actually borne by our patients who have to pay for higher prices for their medications and services.
In choosing the term contentment, I envisage that we are all altruistic and conscientious doctors with the sole purpose of putting our skills towards the service of our patients without being hampered by external interference of a non-medical nature. Life and circumstance are however not so accommodating. I believe that if we are aware of what is to come and what can happen, then we can prepare to meet those eventualities without too much detriment to ourselves.
Contentment is a state of wellbeing where we feel satisfied that we are able to practice our calling in the manner that our predecessors have evolved through the centuries and to be able to enjoy the high regard we have come to be accorded within society.
We hope that when the time comes for us to put down our scalpel and turn our interest to other pursuits, we will feel satisfied that we have given our best and that we can hold our heads high in the knowledge that we have not done anything to mar the high reputation of our noble vocation.
I Thank you all for your Kind Attention and Indulgence.