Winds of change in medical education in Singapore: what does the future hold?

摘要

The global landscape of medical education has evolved significantly over the past decade. While in the past, doctors largely learned by apprenticeship and medical education seemed to be governed by the ‘see one, do one, teach one’ principle, this is no longer considered acceptable in the modern technological era. Medical education in Singapore has developed in a different dimension in relation to the rest of the world.(1,2)In the past decade, most undergraduate medical schools placed more emphasis on integrating basic sciences into clinical medicine, and vice versa.(1) Simulation and case-based learning are now well established in the preclinical years. Other important facets of professional development such as medical ethics, cultivating ‘soft’ skills such as communications, and understanding healthcare policies and finances have also been introduced in the undergraduate curriculum(1) in Singapore and globally. In the last decade, Yong Loo Lin School of Medicine, National University of Singapore (NUS Medicine) was joined by two other medical schools, Duke-NUS Medical School and Lee Kong Chian School of Medicine, creating an element of friendly competition in Singapore medical education. NUS Medicine has implemented entrustable professional activities, or EPAs, that detail the knowledge, skills and attributes of its desired graduate.(3) The final MBBS (Bachelor of Medicine, Bachelor of Surgery) assessment has also taken a more comprehensive approach, introducing scenario-based modified essay questions on top of the traditional clinical short and long cases, and written examinations. The student internship programme, which prepares students for housemanship, is now a well-established part of the medical curriculum at the school. At the same time, the two newer medical schools have advanced even more innovative educational approaches, including team-based learning and mandatory interprofessional education in clinical rotations.(4,5)While these changes are in line with global trends and best practices, a monumental change in postgraduate medical education in Singapore also took place in the last decade. In the quest for better-quality specialty training as well as to meet the rising need for specialists in the late 2000s, Singapore shifted from the basic and advanced specialty training system to the United States (US) residency system under the purview of the Accreditation Council for Graduate Medical Education-International.(1,2,6) Most Singaporean specialists had been trained in a looser competency-based system where trainees rotated through different departments until they were able to demonstrate their clinical competency in rigorous clinical examinations. This gave way to an American system that had a more structured programme with clearly defined core competencies, greater documentation of supervision from the designated faculty, more rigorous formative assessments and feedback sessions, stipulated protected time for learning, and fixed time periods for basic and advanced training. Overall, this demanded greater accountability as well as documentation from both trainees and educators, while producing significant numbers of trainees who had completed the programme requirements.As we attempt to understand the impact of the new training system, we realise that a ‘utopia’ in medical education is very difficult to achieve. The adoption of the US residency system has had an impact that extends into the medical school years. Until recently, the majority of the graduating medical students would have decided on their choice of postgraduate residency programme during their final year of medical school, which has been described as being almost akin to a blind date, given the nature of medical school education in Singapore. In this issue of the Singapore Medical Journal, Ng et al(7) and Fong et al(8) explore the various reasons that students give for choosing their postgraduate training programme. These include their limited undergraduate experience with the institution and their financial background. While these may be significant factors influencing the choice of residency and institution in any setting, enrolment into a residency should be primarily based on a candidate’s aptitude and interests. The best fit can probably only be confirmed after a period of time and through exposure to different subspecialties including generalist rotations and family practice. This has been recognised, and applications for residency can now only be initiated after a year of rotating housemanship postings. The role of mentors and seniors as career counsellors, which many of us recall from our past, is another area that may need to be developed.Beyond the choice of postgraduate training programme, there is growing recognition that it is vital to strike a balance between clinical services and protected learning time. While work hours are restricted in the current US and US-style residency system, ‘hands-on’ time (particularly in th