SINGAPORE — For several years now, the medical fraternity has been engaged in much talk, occasionally cantankerously, on how graduate training for medical doctors can be improved and adapted to ensure that the profession meets the needs of the population.
Some practitioners and educators have aired misgivings about the faster-track residency system — a curriculum change implemented by the Ministry of Health (MOH) in 2010 to boost the pipeline of specialist doctors within a shorter time period — while others spoke up in favour of the new methodology.
So when Senior Minister of State for Health Chee Hong Tat waded into the fray last month, announcing a review of the American-style system after noting that its outcomes “had not been as positive” as envisioned, doctors perked up.
In his speech, at a ceremony where some 400 doctors took the Physician’s Pledge — in which they affirmed their responsibilities to patients and the medical profession — Mr Chee acknowledged the challenges of implementing different elements of the residency system to fit Singapore’s context, saying that “good intent alone does not necessarily lead to good outcomes”.
His announcement — coming weeks after the MOH called for more doctors with “broad and general professional capabilities” to serve an ageing Singapore — hit the nail on the head for many doctors, who chimed in via letters to the media and online forums.
In August, the ministry’s director of medical services, Associate Professor Benjamin Ong, cautioned that narrow-capability specialty practice will become “less relevant”, as “many more doctors will need broad and general professional capabilities”.
Emphasis will now shift towards developing the more “generalist” disciplines with greater roles in the community, such as internal medicine, geriatric medicine, and rehabilitation medicine, he said.
In response to queries from TODAY, MOH said this includes a push for more general practitioners (GPs) and family physicians, who play key roles in bringing patient-centred care close to home and are well-placed to form “longstanding relationships” with patients and their families.
Some doctors interviewed by TODAY said the proposed review had been a long-time coming. They expressed concern that the earlier push for specialists has contributed to junior doctors not favouring “generalist” tracks. Others questioned if the authorities could have better foreseen the needs of an ageing population when introducing the residency programme seven years ago.
Residents-in-training, on the other hand, said the fraternity would gradually see a “glut” of trained specialists who are unable to find jobs in their fields if the system continues on its current path.
REASONS BEHIND THE REVAMP
Prior to May 2010, graduates of medical schools had to complete a year of housemanship and rotate through various postings at three- or six-monthly intervals before deciding on what route – specialist or generalist – to take.
Under this system, about half of local graduates opted for specialist training or to become family physicians. The rest became GPs after fulfilling their five-year bond in the hospitals.
Dr Lau Tzun Hon making a house-call at one of his patient’s home. Photo: Nuria Ling/TODAY
These numbers, combined with low first-time passing rates among aspiring specialists, did not help Singapore’s push to develop the Republic into a regional hub for medical tourism. Health economist Dr Phua Kai Hong noted that at the time, “there were calls for the medical profession to further specialise and pursue excellence with greater value-added approaches towards the growing regional market, and especially in medical tourism”.
Following a study of various training systems around the world, including in Australia and Europe, the MOH decided to adopt the American model, which is the current practice.
Under this system, aspiring doctors can apply to a residency programme for their preferred specialties either in their final year of medical studies or after completing a year of housemanship, depending on the specialty.
Senior specialists were appointed to oversee the trainees, and were required to allocate time for teaching. This broke with the past, when supervisors had to oversee their charges on a voluntary basis while devoting their time to patient care.
It now takes about four to six years for medical school graduates to be trained as specialist consultants, shaving one to two years off the time needed under the previous system.
The change was aimed at providing a more structured framework to helped trainees improve their competencies progressively, said Mr Chee in his speech on Sept 30.
HITS AND MISSES
They are currently 35 specialties recognised by the Specialists Accreditation Board.
These include anaesthesiology, cardiology, infectious diseases, internal medicine, plastic surgery, psychiatry and rheumatology, among others. Family medicine is not among them.
According to the Singapore Medical Council’s annual reports, the number of specialist doctors here has been rising steadily over the last decade.
Last year, the figure stood at 5,047 out of 13,478 medical practitioners, with niche specialities like renal medicine, hand surgery and internal medicine among the most popular.
In 2009, there were 3,180 specialists out of 8,323 medical practitioners.
The current residency system “churns out specialists like clockwork”, and these individuals are competent only in their respective fields, said a family medicine resident who declined to be named.
One result of this is that some find themselves without a job in their preferred specialty, he added.
“You end up with people who have five years of surgical training, but because there’s no space for full surgeon consultants, some end up quitting their residency and becoming GPs. This reduces the quality of GPs as these are surgeons at heart who have no broad-based training at all,” he said.
The residency programme has “worked too well”, said another family medicine trainee, who also asked to remain anonymous.
“What we are seeing now is that we have a lot of specialists, but our need has shifted. We need more generalists because the tertiary hospitals are overcrowded and the current model of care is unsustainable,” he said.
Healthcare delivery in Singapore has traditionally focused on episodic, acute care in hospitals. While acute care remains important, the growing demands of an ageing population have made the hospital-centric model unsustainable.
A medical doctor examines a patient with a stethoscope. Photo: Bloomberg
Recognising this change, the medical sector has been shifting its focus towards preventive and community care. The shift began in 2000, when the MOH launched programmes such as the Primary Care Partnership Scheme to encourage collaboration between the hospitals and other healthcare providers.
Some doctors who are critical of the current training programme said they believe that this shift in focus did not extend to the training of doctors, because other priorities were deemed more important.
“(The authorities) more or less could have forecasted the changing demographics,” said Dr Desmond Wai, who specialises in liver and gastrointestinal diseases at Mount Elizabeth Novena Hospital. The prioritisation of other needs, however, led to “the (current shortage of generalists), which is the price we have to pay,” he said.
A doctor who was part of the team tasked to see the programme through its infancy felt it was introduced “rather hastily”.
“It was too fast and drastic a change. The intent was good, but the transition could have been paced out, and the authorities should have sought more feedback from the ground,” said the internal medicine specialist, who declined to be named.
Nevertheless, the new programme has its advantages, as it provides a more direct route to specialist training, he said.
Veteran GP Dr Leong Choon Kit said the residency programme helped make the way family medicine is taught more systematic. For instance, it includes administration- and business-related modules into its curriculum, which most clinicians were not trained in previously.
In an interview on the residency programme published in the Singapore Medical Association’s (SMA) newsletter in July 2015, several doctors lauded the clear goals and uniform training of the revised residency programme.
However, others noted that it also introduced a “certain rigidity” into training, and this predisposes junior doctors into committing very early to a defined, multi-year programme.
For instance, Dr Tan Wu Meng, who is also Member of Parliament for Jurong GRC, said some doctors may have wished to have take a “meandering path”, exploring different options before deciding on what they were passionate about.
The oncologist cited an article published in the July 2013 edition of the SMA’s newsletter, where an anonymous writer recounted how taking her time to decide what she wanted to do resulted in a “demotion” when she eventually applied for a residency.
“Though the through-track residency programme provides a more direct path to specialisation, it also means the journey for self-discovery is shortened, and along with it, opportunities for a more diverse medical experience,” Dr Tan told TODAY.
THE REVIEW: WHAT DOCTORS HOPE TO SEE
The upcoming review, then, has been welcomed by many in medical circles. Mr Chee’s announcement, however, was scant on details.
He noted only that the time is now right for a review, adding: “We have to be honest and acknowledge that while the residency programme has its advantages and good points, some of the outcomes have not been as positive in practice as what we had originally hoped for.”
The Republic needs a “right mix of specialists”, he said, including larger numbers with expertise in areas like internal medicine, geriatric and palliative care.
MOH, in response to queries from TODAY, said it could not share details on which aspects of the programme it is looking at and when it expects the review to be completed.
Nevertheless, doctors interviewed had no shortage of suggestions. Beyond looking at the numbers of specialists vis-a-vis that of generalists, the review also provides an opportunity to localise the training curriculum to include Singapore-centered topics in the relevant specialties, such as managing dengue fever and atopy, some said.
Dr Tan suggested that a SkillsFuture framework be set up for graduate medical training, allowing junior doctors to accumulate credit by taking up training in diverse disciplines so they do not have to “start from scratch” when they enrol into a residency.
“This also helps accommodate those who may want to shift between family practice to specialist practice, and vice-versa… We should do our best to ensure that there is no ‘wasted’ experience,” he said.
Greater recognition for family medicine — such as by accrediting it as a specialty — is also welcome, to help shed the impression that GPs and family physicians are but “cough and cold doctors”, suggested MP for Tanjong Pagar GRC Dr Chia Shi-Lu.
This will also help support the authorities’ push towards “One Singaporean, One Family Doctor”, a vision laid out in its Healthcare 2020 Master Plan last year which envisions each Singaporean in a long-term partnership with a regular family doctor who is familiar with his or her needs.
BEYOND TRAINING, LONG-TERM REFORMS NEEDED TO CARE FOR AGING SINGAPORE
The doctors interviewed also pointed out that changing the medical training curriculum is but one part of the drive to gird Singapore’s healthcare system for the demands of tomorrow. With a growing number of elderly patients, a majority of whom suffer from multiple chronic conditions, a system centred on acute care will cause a tremendous strain on hospitals and specialist centres.
“The future needs of Singapore’s healthcare system are therefore better served by doctors who have a broad base of knowledge to provide comprehensive care, instead of being focused on one particular specialty,” said Singapore Medical Association president Wong Tien Hua.
Longer-term reforms will be needed to achieve this.
For instance, Dr Chia, who chairs the Government Parliamentary Committee (GPC) for health, suggested equipping nurses and allied health professionals with more skills to care for patients with chronic illnesses. “Beyond tweaking training programmes, the Government should continue to focus on primary care, especially in enhancing the training of professionals in the sector,” he said.
Dr Tan, the oncologist, said better general healthcare coordination will also be necessary.
Dr Lau Tzun Hon making a house-call at one of his patient’s home. Photo: Nuria Ling/TODAY
Family physicians or geriatricians can take on such a coordinating role in caring for each elderly patient, said Dr Tan, who is also a member of the Health GPC.
“If well-controlled, some conditions, like diabetes, may not require an endocrine specialist. Or they may only need to see a specialist from time to time, not regularly…so it is very important that we have more physicians who are able to provide holistic care and look at the big picture of a patient’s health journey,” he said.
This also helps reduce the number of medical appointments, which can take a toll on patients and their caregivers, he noted.
Going forward, some doctors think that the line between specialists and generalist doctors in caring for a greying population will become blurred.
GPs should be trained to handle various elements of rehabilitative and palliative care, geriatric medicine, internal medicine and psychiatry, said Dr Leong, while specialists must be comfortable with managing general ailments too.
Dr Wai added: “We must change the way we practise. We can no longer be so narrow-minded and must learn how to take care of broad problems too.”
To encourage more to be trained as generalists or family physicians, they should be better paid appropriately, said Dr Jeremy Lim, who leads the health and life sciences and public sector practices in the Asia-Pacific for consulting firm Oliver Wyman.
“Specialists are in general better paid compared to generalists, and can have shorter hours…GPs and doctors with more general specialties (such as geriatric medicine and rehabilitative care), in contrast, often have to work long hours, including weekends, because of the lower consultation fees,” he added.
But even when the playing fields are levelled in terms of remuneration and accreditation, the healthcare transformation will not be complete until patients and their caregivers truly appreciate and seek the support that generalist doctors can offer.
“Many patients still think that ‘expensive doctors’ are always better, and go to a specialist even for minor ailments that can be handled by a family physician,” said Dr Lau Tzun Hon, a family doctor who focuses on house-calls.
Calling for the community, including medical students, not to “belittle or under-estimate” the rigour involved in training generalist doctors, Dr Lim said: “Family medicine (and other generalist disciplines) should not become a ‘default’ for doctors who, for whatever reason, cannot practice in the specialty they were trained in. To accept this casually is, to me, an insult to the good work family physicians have been doing all these years.”
All this, the doctors admit, is some way down the line.
The review of the training programme that has been announced is as good a place as any to start the transformation, they said.
“We are now seeing the first batches of doctors who were trained completely within the ‘new’ residency system, and can learn from their experiences, as well as that of their trainers. It is not too soon to review,” said Dr Tan, stressing that the changes must square with Singapore’s future healthcare demands.
For the doctor who was involved in implement the programme, but did not want to be named, there is another lesson for those who will conduct the planned review: “We certainly hope that for this revamp, the authorities could keep their ears to the ground and consider the medical community’s feedback.”
