2015, 1–7, Early Online
AROUND THE WORLD
Medical education in Singapore DUJEEPA D. SAMARASEKERA, SHIRLEY OOI, SU PING YEO & SHING CHUAN HOOI National University of Singapore, Singapore
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Abstract Allopathic medical education in Singapore extends for more than a century from its simple beginnings. In recent times, changes have been rapid, both in undergraduate and postgraduate specialty medical training. Over the last decade, undergraduate medical education has increased from a single to three medical schools and the postgraduate training has expanded further by incorporating the Accreditation Council for Graduate Medical Education International framework. With these changes, the curricula, assessment systems, as well as teaching and learning approaches, with the use of technology-enhanced learning and program evaluation processes have expanded, largely based on best evidence medical education. To support these initiatives and the recent rapid expansion, most training institutions have incorporated faculty development programs, such as the Centre for Medical Education at the National University of Singapore.
Introduction Singapore, often dubbed the ‘‘little red dot’’ for its small size (716.1 km2), is a city-state located in Southeast Asia. Home to nearly 5.4 million people, it is a bustling and cosmopolitan global city, a reflection of the culturally diverse population, with a large expatriate community from different parts of the world. Ranked Asia’s best city in 2014 (Mercer 2014), it is often a popular choice among expatriates to work and live, particularly the Asians (ECA International 2012). With its strategic location and international appeal, it is hardly surprising that Singapore is a preferred location for global meetings (Fischer 2013), having hosted major events like the World Health Summit Regional Meeting in 2013. Singapore was founded in 1819 by a British statesman, Sir Stamford Raffles, and remained as a British colony till 1959 before it gained independence in 1965 (Lee 2000). The nation transformed from a developing to a developed nation status rapidly over the next three decades (Lee 2000). The system of healthcare delivery has also mirrored the changes to the economic development and it is one of the most cost-effective and efficient healthcare systems in the world. Singapore currently has a doctor to population ratio of 1:490 (Ministry of Health Singapore 2014) The strong historical British roots have played a pivotal role in the development of medical education in this city-state. For more than a century, Singapore had one undergraduate medical school. However, due to population expansion and healthcare needs, over the last decade, two other medical schools have been established. The recent developments include the merger of medical schools with the hospitals into Academic Medical Centres. The article outlines medical education developments in Singapore, both undergraduate and postgraduate over the last
Practice points
Allopathic medical education in Singapore celebrates its 110th year in 2015. There is rapid expansion of both undergraduate and postgraduate medical education in Singapore. Curricula have been developed based on best practices and leverage on the use of technology. The strong Government support and the establishment have contributed to the success of medical education in Singapore.
century, and will highlight some important challenges and ways forward.
Undergraduate medical education Brief history The roots of medical education in Singapore can be traced back to its humble beginnings in 1905, where the poor and deteriorating condition of healthcare drove a group of local community leaders, headed by a prominent businessman, Mr. Tan Jiak Kim, to ask the Governor to establish a medical school to produce the doctors required (Lim 2005; Tambyah 2005). With sheer determination, they managed to raise $87,000, which was way above the $71,000 target set by the Governor. This was an astonishing feat, considering that a bowl of noodles was priced at 2 cents then (Lim 2005). On 3 July 1905, the Straits and Federated Malay States Government Medical School was established and the initial intake of 23 students was taught via a combination of
Correspondence: Dujeepa D. Samarasekera, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 11, Dean’s Office, Singapore 119228, Singapore. Tel: 65 163760; Fax: 65 68721454; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/15/000001–7 ß 2015 Informa UK Ltd. DOI: 10.3109/0142159X.2015.1009026
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‘‘clinical apprenticeship’’ and bedside teaching by British clinicians (Cheah & Ng 2005; Lim 2005). The Licentiate in Medicine and Surgery (LMS) was conferred on the graduates. The LMS degree offered by the school to the subsequent batches of graduates was eventually recognised by the General Medical Council (UK), which was itself a testimony of the success of the school (Lim 2005). The school underwent several name changes, to King Edward VII Medical School in 1912 and King Edward VII College of Medicine in 1921 (Cheah & Ng 2005). In 1949, the school became the Faculty of Medicine when it was combined with the Raffles College (Arts and Science) to form the University of Malaya (Lim 2005), which was renamed as University of Singapore in 1962. With further expansion, in 1980, the university was renamed as National University of Singapore (NUS). To recognise a generous $100 million donation by the Yong Loo Lin Trust, the Faculty of Medicine was renamed the Yong Loo Lin School of Medicine (NUS Medicine) in 2005. With a matching Government grant, the school expanded its infrastructure (Lim 2005). With further changes to the healthcare delivery landscape and increasing focus on translational research, NUS Medicine, Faculty of Dentistry, Saw Swee Hock School of Public Health and the National University Hospital merged to form the National University Health System (NUHS) in 2008. The NUHS Academic Medical Centre has facilitated tripartite mission – service, education and research. Together with a strong leadership, committed staff and faculty plus outstanding students, NUS Medicine is currently a leading medical school in Asia and ranked 21st in the world [QS World Ranking by Subject (Medicine) 2014]. To bolster Singapore’s capability in translational medicine, the second medical school – Duke-NUS was established (GMS) (Soo 2005) as a partnership between NUS and Duke University in the United States. GMS is a graduate entry medical school which has offered a 4-year MD program since 2007. Recently, the third medical school, Lee Kong Chian School of Medicine (LKCSoM), a joint collaborative effort between Imperial Medical School (UK) and Singapore’s Nanyang Technological University, opened its door to its inaugural batch of 54 students in August 2013. It was established to address the surge in healthcare demands posed by the declining birth rate and aging population. All medical schools in Singapore are public and the government subsidises the students’ tuition fees (Wong 2005).
Admission to medical schools All three schools employ a holistic selection method to matriculate students who are academically inclined and equipped with the desired humanistic traits found in doctors. At NUS Medicine, a new selection format was introduced in 2013 to circumvent issues associated with interviews. Prior to that, applicants were selected based on their high school results (e.g. ‘‘A’’ Levels), personal portfolio, recommendation letters, performances in an essay test evaluating their language and critical thinking skills (Wong 2005), in addition to two semi-structured interviews. Currently, a Focused Skill Assessment which evaluates domains (e.g. empathy, 2
communication) and a MCQ-based Situational Judgment Test are used in place of the interviews. Not to deny candidates who are outstanding in non-academic fields, since 2005, up to 10% of the total places are set aside each year for applicants who for example, excel in sports and other extra-curricular activities with qualifying academic grades (Tambyah 2005). The GMS applicants are considered based on their undergraduate academic results, Medical College Admission Test (MCAT) scores and at least three letters of recommendation. They are also interviewed and the final selection is based on their performance in each of these components (Duke-NUS, n.d.a). Apart from high school results and portfolio submission, admission to LKCSoM is also based on the candidate’s Biomedical Admissions Test (BMAT) score and performance during the Multiple Mini-interviews (Nanyang Technological University 2014a).
Medical curricula Like many other countries, the medical curriculum in Singapore has undergone many changes, to consistently adopt the best practices and to meet the health needs of the nation and the public’s expectations (see Figure 1). Until 1997, NUS Medicine’s curriculum was largely a traditional subject-based model shaped by the British medical education of that period. With a global trend of re-orientating medical education, the NUS Medical curriculum underwent a few major reviews with the intent of meaningful integration of subjects for better student learning. Students learn the foundation of basic medical sciences in the first two years (normal and abnormal body structures and functions), followed by clinical clerkships from their third to fifth year of study. An interactive ‘‘hybrid’’ system incorporating problem-based learning and didactic teaching was used, with the latter predominantly used much earlier in the course (Hwang 2005; Ong 2005; Lam & Lam 2009). After 2006, there was a move towards an integrated systems-based structure with the focus on learning outcomes. The Entrustable Professional Activities (EPAs) were developed recently to define the graduates’ outcome capabilities, which also act as a blueprint. The EPAs will be used to standardise clinical teaching at all clinical teaching sites in Singapore. Additionally, EPAs are now being linked to the clinical problems and conditions identified by various specialties as core learning through a curricular rationalisation process. Clinical learning has evolved from the student being an observer to a member of the healthcare delivery team. This has been developed through students being embedded within the healthcare teams which allow them to work in the real clinical settings where they are also given access to relevant electronic health records. Valuable experience in caring for patients, communication and team working skills are gained through this gradual embedding experience (Jacobs & Samarasekera 2012). The school also leverages on simulation-based learning by integrating simulation components into student learning. Clinical relevance is highlighted during Basic Sciences, and simulation training is used to train the students in foundational clinical skills when they are in early clinical
Medical Education in Singapore
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Figure 1.
Overview of the medical curriculum in Singapore.
Figure 2. NUS medicine curriculum. years. For the final-year students, simulation is used to refine their clinical skills. With increased focus on developing a holistic physician, several curricular initiatives were launched from 2006 onwards. The Longitudinal Tracks running through the entire five year program – ‘‘Health Ethics, Law and Professionalism’’ (HELP) and ‘‘Medicine and Society’’ to train and provide learning opportunities to develop the ‘‘softer’’ side of doctoring (National University of Singapore 2012a). Additionally, programmes such as ‘‘Professional Development and Communication’’ were incorporated in the last decade, as well as Electives and Student Internship Programme (Ong 2005). Non-programme related initiatives include the voluntary signing of the ‘‘Statement of Commitment to Professionalism’’, where students are given the opportunity to reflect on the issue of professionalism, on top of the customary ‘‘White Coat Ceremony’’ on the first day of school. Students also participate in a reflective journey to respect the cadavers before they start working on them in a ‘‘Silent Mentor’’ ceremony during their anatomy classes. This helps to develop their sense of altruism and gratitude. Currently, NUS Medicine uses an assortment of interactive teaching–learning methods, not limited to only small groups (case-based learning, tutorials and simulation learning sessions), but also interactive large groups using technologybased modalities (Samarasekera 2014) (Figure 2). Similar to NUS Medicine, LKCSoM students’ learn basic sciences in the first two years, before beginning their clinical postings from Year 3 onwards at Tan Tock Seng hospital in a five-year programme. Team-based, simulation-based and
e-learning are key modes of teaching in the earlier years of study (Nanyang Technological University 2013a). LKCSoM students participate in a practical laboratory lesson weekly during Year 1 and Year 2, and attend an ‘‘innovations in medicine’’ course where they are reminded of the importance of non-doctors who often identify the solutions to medical issues (Nanyang Technological University 2014b). Duke-NUS Graduate Medical School offers a 4-year program, with the first year focusing on imparting basic sciences knowledge to the students using team-based learning as the main modality of instruction (Duke-NUS n.d.b; Samarasekera 2014). Thereafter, they will begin their clinical postings in the second year. Students spend a significant amount of their time in the laboratory as Duke-NUS emphasize on developing research skills during the third-year of study to produce graduates who are more likely to become physician–scientists. The final year relates to clinical clerkships.
State-of-the-art teaching facilities 2012 marked the official opening of the Centre for Translational Medicine (CeTM) at NUS Medicine, tasked with promoting high-level research on diseases prevalent in Singapore, and training highly competent medical and nursing graduates. This is supported by the Centre for Healthcare Simulation (CHS) located within CeTM. CHS is one of the region’s largest simulation centres and resembles a hospital setup with facilities such as operating theatre and wards (National University of Singapore 2012b), thereby providing undergraduates with the opportunities to hone their communication and clinical skills in this safe, interactive simulationbased learning environment.
TeamLEAD pedagogy As mentioned previously, Duke-NUS employs a flipped classroom teaching approach termed TeamLEAD (Learn, Engage, Apply and Develop). This innovative method has attracted vast interest from medical schools abroad; in fact, more than 170 delegations from 28 countries visited the institution to study the model (National University of Singapore n.d.). TeamLEAD aims to instil the importance of working and learning in collaborative teams among the students, and preliminary data so far has been promising (Krishnan 2011).
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Interprofessional education Interprofessional education (IPE) is a key feature in many medical schools’ curricula. In a similar vein, this has been an integral component of the NUS Medicine’s syllabus since 2011 when the Interprofessional Core Curricula and Interprofessional Enrichment Activities were incorporated into Medical, Nursing, Dentistry, Pharmacy and Medical Social Work undergraduate programmes at NUS (Jacobs et al. 2013a). The six indispensable domains including ethics, communication and reflection/learning are put into practice, when medical students interact and seek the opinions of pharmacy, nursing, Medical Social Work and dental students.
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Public service ethos: Service learning Unlike other parts of Asia, where service learning is relatively underutilised (Wee et al. 2011a), many community projects have been launched at NUS Medicine to foster team spirit, promote community bonding, in addition to moulding their humanistic traits such as empathy. For instance, programmes such as the Public Health Screening (PHS) and Neighbourhood Health Screening (NHS) allow students to reach out to the underprivileged and elderly populations (Wee et al. 2011a). These are student-led, faculty supported projects. Studies on their effectiveness highlighted the impact on developing wellrounded graduates, with increasing ability to recognise key social issues plus long-standing management of chronic illness (Wee et al. 2011a). The community has also benefitted tremendously from these programmes (Wee et al. 2011b). Recently, students are also given opportunities through the Longitudinal Patient Experience Programme to visit patients’ home and comprehend how they deal with their conditions.
Nurturing undergraduate scholars All three schools place an emphasis on developing clinicians who are innovative through involvement in research. At NUS Medicine, a special focus is being given to cultivate spirit of inquiry and innovation in students. Students with a special interest in research can opt to join the Wong Hock Boon Society where they engage mentors and research scientists to develop their area of research and interest. The Undergraduate Research Opportunities Programme provides an opportunity for students to engage in research during their undergraduate years, write it up as a mini-thesis and are given curriculum credit for it. All students are encouraged to share their scholarly work through yearly student-led and faculty supported projects such as Student Medical Education Conference (SMEC) where medical students from all three medical schools in Singapore actively participate in. It also provides them with the platform to exchange research-related ideas and projects. Students who wish to share their work at regional/international conferences (e.g. Asia Pacific Medical Education Conference (APMEC)) can also apply for funding support from the school. In a more formal setting the students are trained in research skills through programmes such as ‘‘Information Literacy and Critical Thinking’’ or during electives and the community health projects in the later years. The focus of these formal training courses is to provide training in the basics of research 4
and as well as the opportunities to engage thoroughly in research work.
Assessment Assessment in the first two years of study at NUS Medicine is centred on the students’ medical knowledge, communication skills as well as basic physical examination skills. Key focuses in the clinical phases of learning in years 3–5 are clinical reasoning, decision-making and management, respectively. This, together with the curriculum reforms, contributed to tackling the problems faced earlier, including a lack of focus on providing appropriate patient care, communication skills, ‘‘evidence based decisions on diagnostic and therapeutic interventions, develop and carry out management plans. . .. professionalism’’ (Wong 2005). A mixture of tools like skillsbased objective structured clinical examinations, knowledgebased short essay questions and workplace-based assessments such as the mini-clinical evaluation exercise are used to assess the students. In 2011, NUS Medicine reformed its system of grading from the usual ranking to that of a Distinction/Pass/Fail format for students in Phases I and II. In a related study, findings revealed that the conversion did not affect the students’ performance however significantly reduced their stress of school life and improved their curricular activities (Jacobs et al. 2013b).
Postgraduate medical education Development With a steady pool of high quality graduates from the Faculty of Medicine, there was an impetus to set up a postgraduate school to train specialists for Singapore. In 1957, the Academy of Medicine became the first formal postgraduate education body to oversee developments in this area (Nambiar & Chee 2007). The Academy of Medicine in collaboration with the Alumni Association, with support from specialty schools from Australia and UK, started the School of Postgraduate Medical Studies (Lim 2005). Since the 1970s, the school has been responsible for awarding the Master of Medicine for all the key specialities, and the accreditation of subspecialties (Lim 2005). Training events with the Royal Colleges were key features of graduate medical education in Singapore until 2008 (Huggan et al. 2012). The current Division of Graduate Medical Studies, responsible for postgraduate training and examination in Singapore, started as the Committee for Postgraduate Medical Studies in 1961 (Chew & Chee 2005). The Committee was established to manage postgraduate education and to formulate policies (Nambiar & Chee 2007). It later became the Graduate School of Medical Studies (Chew & Chee 2005).
Accreditation Council for Graduate Medical Education-International In 2009, Singapore engaged the Accreditation Council for Graduate Medical Education-International (ACGME-I) to manage the accreditation of its postgraduate training (Huggan et al. 2012), and to develop standards in domains
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Medical Education in Singapore
such as assessment and training. Major re-formulations took place, including the appointment of Designated Institutional Officers (DIOs) (Huggan et al. 2012), who oversee the administrative system that manages the residency programme. Singapore was the first country which successfully received the ACGME-I accreditation for its residency training in 2010. There are several DIOs, each overseeing a specific health cluster – National University Health System (NUHS), SingHealth and National Healthcare Group. Taking NUHS as an example, the DIO office was established under the Medical Affairs (Education) department to oversee the postgraduate training in the institution. The Graduate Medical Education Committee chaired by the DIO consisting of the programme directors (PDs) and subcommittee chairs was established to run the residency programmes in NUHS. The Ministry of Health (MOH) funds the Educational Full Term Employment (FTE). This allows for protected time for the DIOs at 0.5 FTE, Associate DIOs at 0.3 FTE, PDs at 0.5 FTE, Associate PDs and core faculty at 0.2 FTE to administer the residency programme. In addition, the MOH also provides funding for manpower development as well as other operating expenditures. To ensure that the funding is properly used, clear key performance indicators have been set up, where 50% is in manpower deliverables, i.e. hiring of additional doctors to backfill the educators. The other 50% is based on achievement of training deliverables, i.e. residents’ satisfaction with the programme and residents training performance. The MOH also provides funding for institutions to employ administrators to run the programmes at the institution and programme level. Furthermore, the MOH also funds 0.2 FTE of the residents’ time for training. As for the oversight, Resident Advisory as well as National Examination Committees have been set up.
Academic medical centres (AMCs) Medical schools and hospitals in Singapore have come together to form AMCs, to promote as well as integrate education, clinical care and translational medicine research all under one roof. NUHS is one of them, where entities like NUS Medicine, NUS Faculty of Dentistry, NUS Saw Swee Hock School of Public Health and National University Hospital came together. In 2012, SingHealth partnered with Duke-NUS to form the second AMC. The AMCs provide undergraduate and discipline specific postgraduate training (both ACGME-I and non-ACGME-I) to students and residents.
Continuous medical education (CME)/professional development (CPD) CME for doctors and specialists was launched in 1989 as a pilot program. The system was formalized in 1993 and it is under the purview of the Singapore Medical Council (CME Coordinating Committee). The process was made compulsory for all doctors registered and conditionally registered from January 2003 (Lee 2008). This has further expanded from 1st January 2005 to all medical categories in Singapore
when they are required to renew their professional practicing certificates. Singapore is one of the two countries in Asia where CME is compulsory. The CME/CPD points are awarded by professional bodies such as the Academy of Medicine, academic training institutions such as the three medical schools, postgraduate medical institutes, Academic Medical Centres as well as restructured hospitals.
Challenges Despite the relative success of medical education in Singapore over a short span of over 100 years, many challenges exist. The opening of LKCSoM has allayed concerns over the supply of doctors, albeit for the time being. However, this does not mask the fact that the demand will continue to surge as Singapore’s population ages.
Training facilities Learning spaces for students are probably a necessity if Singapore were to expand the pre-clinical teaching sites, although space constraints within the three medical schools’ campuses means that this issue will cause a bottleneck. The contemporary concept of building ‘‘up’’ (i.e. ‘‘vertically’’) in Singapore seems to be a viable option. For clinical training, the schools could use several upcoming hospitals, on top of the seven existing sites.
Staff Of particular concern will be the student–faculty ratios. In clinical settings, a huge challenge exists where tutors had to find time in their busy schedules to mentor students. This is especially so since patients will always be the doctors’ priority, often followed by research, since research output is frequently a key parameter in promotion and tenure appraisals. Several approaches have been taken to ensure Singapore has a sufficient number of excellent educators to maintain quality education and drive innovation. The University has recently introduced a new Educator track for pre-clinical teachers that rewards staff who wishes to focus on teaching and scholarly activity in education. The medical school has differentiated tracks including a track for Clinician Educators to recognise excellence and contributions in education. In addition, the Ministry of Health has recently infused a substantial increase in funding for clinical training. This has resulted in the appointment of more clinical teachers and development of infrastructure that supports education at clinical training sites all over Singapore. Another task at hand is to equip the faculty with appropriate training in teaching. Presently, professional faculty development courses in Singapore are mainly organised by the Centre for Medical Education (CenMED) at NUS Medicine. CenMED also organises the Asia Pacific Medical Education Conference (APMEC), an international meeting which attracted more than 800 participants from different parts of the world in 2012 and 2013. With the growth of the healthcare sector, there is a need to augment the systematic process of developing faculty, support staff and students. NUS Medicine established
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the Medical Education Unit (MEU) in 2001 which has developed now to be CenMED to help facilitate faculty development and to provide leadership for education innovation in the faculty. Over the years, CenMED has expanded into providing structured programmes and courses leading to certification level and also conducting courses for the local and overseas health professional training institutions. Recently, the Academy of Medicine, Singapore, through their Chapter for Clinician Educators, has developed plans to collaborate with the University of Maastricht to conduct the Masters Programme in health professions education.
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Clinical learning and institutional support The Ministry of Health Singapore as part of its efforts to improve undergraduate training of all health professionals has provided funding to set up an education office in each of the major clinical training sites. Under the pre-employment clinical training fund, the education office will oversee medical, nursing and allied health pre-employment training programmes. The education office will coordinate through a designated Clinical Educator Lead (CEL), the teaching and learning activities of the three medical schools’ clinical training with the relevant hospital departments. The training institutions have supported this initiative by appointing clinician– educators, administrators as well as providing space for education facilities. The hospitals have also been actively providing full as well as partial full-term employment for the clinician educator track.
Medicine and Family Medicine have graduated from it. MOH has recently appointed a Committee to look into the mid-term review of Residency training in Singapore. Depending on the findings and recommendations of this committee, further refinement of the residency system will be implemented.
Conclusions From a humble beginning 110 years ago, medical education in Singapore has developed and gained international recognition through its quest for excellence. In this context medical education in Singapore is confident that it can achieve greater breakthroughs, not just to meet our own healthcare demands, but also to benefit the greater global community.
Notes on contributors Dr. DUJEEPA D. SAMARASEKERA, MBBS, MHPE, FAMS, FAcadMEd, is the Director of Centre for Medical Education (CenMED), National University of Singapore and also the Vice-President of the Association for Medical Education in the Western Pacific Region (AMEWPR). Associate Professor SHIRLEY OOI, MBBS, FRCSEd(A&E), FAMS(Emerg Med), is the Designated Institutional Officer for Residency Program at National University Health System and a Senior Consultant in Emergency Medicine at the National University Hospital of Singapore. Mr. YEO SU PING, BSc (Hons), is a Senior Executive at the Centre for Medical Education at the National University of Singapore. Professor HOOI SHING CHUAN, MBBS, PhD, is the Vice Dean (Education), Yong Loo Lin School of Medicine, National University of Singapore.
Syllabus Singapore’s healthcare demography is evolving rapidly as the population of elderly and life expectancies increase. With that in mind, the medical curriculum will need to be tailored to meet future needs in these areas. Plans to setup teaching clinics and renovation of clinic spaces are underway to expand ambulatory teaching in community-based polyclinics as well as in hospital-centred clinics. Progressively, faculty and students are encouraged to engage in research projects, not just clinical studies but also in medical education, so as to hone their research skills for instance. This is evident by the increase in abstracts submitted to APMEC over the years from the three medical schools fraternity. In fact, free registration is available for NUS Medicine students attending APMEC as an incentive to cultivate a spirit of inquiry.
Advances and future directions The medical schools are now actively moving towards the use of small groups and technology to enhance student learning. At NUS Medicine, there is an active move to have more than 60% of their teaching learning activities in pre-clinical years of learning changed to interactive case-based using technology platforms to facilitate learning by 2020. While the ACGME-I residency system has put in place a more structured training program in Singapore, the system is still new and only a handful of residents in shorter programs like Emergency 6
Acknowledgment Authors thank Professor Matthew Gwee for providing useful insights and his assistance in improving the manuscript. Declaration of interest: The authors report no conflict of interest.
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AROUND THE WORLD
Medical education in Singapore DUJEEPA D. SAMARASEKERA, SHIRLEY OOI, SU PING YEO & SHING CHUAN HOOI National University of Singapore, Singapore
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Abstract Allopathic medical education in Singapore extends for more than a century from its simple beginnings. In recent times, changes have been rapid, both in undergraduate and postgraduate specialty medical training. Over the last decade, undergraduate medical education has increased from a single to three medical schools and the postgraduate training has expanded further by incorporating the Accreditation Council for Graduate Medical Education International framework. With these changes, the curricula, assessment systems, as well as teaching and learning approaches, with the use of technology-enhanced learning and program evaluation processes have expanded, largely based on best evidence medical education. To support these initiatives and the recent rapid expansion, most training institutions have incorporated faculty development programs, such as the Centre for Medical Education at the National University of Singapore.
Introduction Singapore, often dubbed the ‘‘little red dot’’ for its small size (716.1 km2), is a city-state located in Southeast Asia. Home to nearly 5.4 million people, it is a bustling and cosmopolitan global city, a reflection of the culturally diverse population, with a large expatriate community from different parts of the world. Ranked Asia’s best city in 2014 (Mercer 2014), it is often a popular choice among expatriates to work and live, particularly the Asians (ECA International 2012). With its strategic location and international appeal, it is hardly surprising that Singapore is a preferred location for global meetings (Fischer 2013), having hosted major events like the World Health Summit Regional Meeting in 2013. Singapore was founded in 1819 by a British statesman, Sir Stamford Raffles, and remained as a British colony till 1959 before it gained independence in 1965 (Lee 2000). The nation transformed from a developing to a developed nation status rapidly over the next three decades (Lee 2000). The system of healthcare delivery has also mirrored the changes to the economic development and it is one of the most cost-effective and efficient healthcare systems in the world. Singapore currently has a doctor to population ratio of 1:490 (Ministry of Health Singapore 2014) The strong historical British roots have played a pivotal role in the development of medical education in this city-state. For more than a century, Singapore had one undergraduate medical school. However, due to population expansion and healthcare needs, over the last decade, two other medical schools have been established. The recent developments include the merger of medical schools with the hospitals into Academic Medical Centres. The article outlines medical education developments in Singapore, both undergraduate and postgraduate over the last
Practice points
Allopathic medical education in Singapore celebrates its 110th year in 2015. There is rapid expansion of both undergraduate and postgraduate medical education in Singapore. Curricula have been developed based on best practices and leverage on the use of technology. The strong Government support and the establishment have contributed to the success of medical education in Singapore.
century, and will highlight some important challenges and ways forward.
Undergraduate medical education Brief history The roots of medical education in Singapore can be traced back to its humble beginnings in 1905, where the poor and deteriorating condition of healthcare drove a group of local community leaders, headed by a prominent businessman, Mr. Tan Jiak Kim, to ask the Governor to establish a medical school to produce the doctors required (Lim 2005; Tambyah 2005). With sheer determination, they managed to raise $87,000, which was way above the $71,000 target set by the Governor. This was an astonishing feat, considering that a bowl of noodles was priced at 2 cents then (Lim 2005). On 3 July 1905, the Straits and Federated Malay States Government Medical School was established and the initial intake of 23 students was taught via a combination of
Correspondence: Dujeepa D. Samarasekera, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 11, Dean’s Office, Singapore 119228, Singapore. Tel: 65 163760; Fax: 65 68721454; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/15/000001–7 ß 2015 Informa UK Ltd. DOI: 10.3109/0142159X.2015.1009026
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‘‘clinical apprenticeship’’ and bedside teaching by British clinicians (Cheah & Ng 2005; Lim 2005). The Licentiate in Medicine and Surgery (LMS) was conferred on the graduates. The LMS degree offered by the school to the subsequent batches of graduates was eventually recognised by the General Medical Council (UK), which was itself a testimony of the success of the school (Lim 2005). The school underwent several name changes, to King Edward VII Medical School in 1912 and King Edward VII College of Medicine in 1921 (Cheah & Ng 2005). In 1949, the school became the Faculty of Medicine when it was combined with the Raffles College (Arts and Science) to form the University of Malaya (Lim 2005), which was renamed as University of Singapore in 1962. With further expansion, in 1980, the university was renamed as National University of Singapore (NUS). To recognise a generous $100 million donation by the Yong Loo Lin Trust, the Faculty of Medicine was renamed the Yong Loo Lin School of Medicine (NUS Medicine) in 2005. With a matching Government grant, the school expanded its infrastructure (Lim 2005). With further changes to the healthcare delivery landscape and increasing focus on translational research, NUS Medicine, Faculty of Dentistry, Saw Swee Hock School of Public Health and the National University Hospital merged to form the National University Health System (NUHS) in 2008. The NUHS Academic Medical Centre has facilitated tripartite mission – service, education and research. Together with a strong leadership, committed staff and faculty plus outstanding students, NUS Medicine is currently a leading medical school in Asia and ranked 21st in the world [QS World Ranking by Subject (Medicine) 2014]. To bolster Singapore’s capability in translational medicine, the second medical school – Duke-NUS was established (GMS) (Soo 2005) as a partnership between NUS and Duke University in the United States. GMS is a graduate entry medical school which has offered a 4-year MD program since 2007. Recently, the third medical school, Lee Kong Chian School of Medicine (LKCSoM), a joint collaborative effort between Imperial Medical School (UK) and Singapore’s Nanyang Technological University, opened its door to its inaugural batch of 54 students in August 2013. It was established to address the surge in healthcare demands posed by the declining birth rate and aging population. All medical schools in Singapore are public and the government subsidises the students’ tuition fees (Wong 2005).
Admission to medical schools All three schools employ a holistic selection method to matriculate students who are academically inclined and equipped with the desired humanistic traits found in doctors. At NUS Medicine, a new selection format was introduced in 2013 to circumvent issues associated with interviews. Prior to that, applicants were selected based on their high school results (e.g. ‘‘A’’ Levels), personal portfolio, recommendation letters, performances in an essay test evaluating their language and critical thinking skills (Wong 2005), in addition to two semi-structured interviews. Currently, a Focused Skill Assessment which evaluates domains (e.g. empathy, 2
communication) and a MCQ-based Situational Judgment Test are used in place of the interviews. Not to deny candidates who are outstanding in non-academic fields, since 2005, up to 10% of the total places are set aside each year for applicants who for example, excel in sports and other extra-curricular activities with qualifying academic grades (Tambyah 2005). The GMS applicants are considered based on their undergraduate academic results, Medical College Admission Test (MCAT) scores and at least three letters of recommendation. They are also interviewed and the final selection is based on their performance in each of these components (Duke-NUS, n.d.a). Apart from high school results and portfolio submission, admission to LKCSoM is also based on the candidate’s Biomedical Admissions Test (BMAT) score and performance during the Multiple Mini-interviews (Nanyang Technological University 2014a).
Medical curricula Like many other countries, the medical curriculum in Singapore has undergone many changes, to consistently adopt the best practices and to meet the health needs of the nation and the public’s expectations (see Figure 1). Until 1997, NUS Medicine’s curriculum was largely a traditional subject-based model shaped by the British medical education of that period. With a global trend of re-orientating medical education, the NUS Medical curriculum underwent a few major reviews with the intent of meaningful integration of subjects for better student learning. Students learn the foundation of basic medical sciences in the first two years (normal and abnormal body structures and functions), followed by clinical clerkships from their third to fifth year of study. An interactive ‘‘hybrid’’ system incorporating problem-based learning and didactic teaching was used, with the latter predominantly used much earlier in the course (Hwang 2005; Ong 2005; Lam & Lam 2009). After 2006, there was a move towards an integrated systems-based structure with the focus on learning outcomes. The Entrustable Professional Activities (EPAs) were developed recently to define the graduates’ outcome capabilities, which also act as a blueprint. The EPAs will be used to standardise clinical teaching at all clinical teaching sites in Singapore. Additionally, EPAs are now being linked to the clinical problems and conditions identified by various specialties as core learning through a curricular rationalisation process. Clinical learning has evolved from the student being an observer to a member of the healthcare delivery team. This has been developed through students being embedded within the healthcare teams which allow them to work in the real clinical settings where they are also given access to relevant electronic health records. Valuable experience in caring for patients, communication and team working skills are gained through this gradual embedding experience (Jacobs & Samarasekera 2012). The school also leverages on simulation-based learning by integrating simulation components into student learning. Clinical relevance is highlighted during Basic Sciences, and simulation training is used to train the students in foundational clinical skills when they are in early clinical
Medical Education in Singapore
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Figure 1.
Overview of the medical curriculum in Singapore.
Figure 2. NUS medicine curriculum. years. For the final-year students, simulation is used to refine their clinical skills. With increased focus on developing a holistic physician, several curricular initiatives were launched from 2006 onwards. The Longitudinal Tracks running through the entire five year program – ‘‘Health Ethics, Law and Professionalism’’ (HELP) and ‘‘Medicine and Society’’ to train and provide learning opportunities to develop the ‘‘softer’’ side of doctoring (National University of Singapore 2012a). Additionally, programmes such as ‘‘Professional Development and Communication’’ were incorporated in the last decade, as well as Electives and Student Internship Programme (Ong 2005). Non-programme related initiatives include the voluntary signing of the ‘‘Statement of Commitment to Professionalism’’, where students are given the opportunity to reflect on the issue of professionalism, on top of the customary ‘‘White Coat Ceremony’’ on the first day of school. Students also participate in a reflective journey to respect the cadavers before they start working on them in a ‘‘Silent Mentor’’ ceremony during their anatomy classes. This helps to develop their sense of altruism and gratitude. Currently, NUS Medicine uses an assortment of interactive teaching–learning methods, not limited to only small groups (case-based learning, tutorials and simulation learning sessions), but also interactive large groups using technologybased modalities (Samarasekera 2014) (Figure 2). Similar to NUS Medicine, LKCSoM students’ learn basic sciences in the first two years, before beginning their clinical postings from Year 3 onwards at Tan Tock Seng hospital in a five-year programme. Team-based, simulation-based and
e-learning are key modes of teaching in the earlier years of study (Nanyang Technological University 2013a). LKCSoM students participate in a practical laboratory lesson weekly during Year 1 and Year 2, and attend an ‘‘innovations in medicine’’ course where they are reminded of the importance of non-doctors who often identify the solutions to medical issues (Nanyang Technological University 2014b). Duke-NUS Graduate Medical School offers a 4-year program, with the first year focusing on imparting basic sciences knowledge to the students using team-based learning as the main modality of instruction (Duke-NUS n.d.b; Samarasekera 2014). Thereafter, they will begin their clinical postings in the second year. Students spend a significant amount of their time in the laboratory as Duke-NUS emphasize on developing research skills during the third-year of study to produce graduates who are more likely to become physician–scientists. The final year relates to clinical clerkships.
State-of-the-art teaching facilities 2012 marked the official opening of the Centre for Translational Medicine (CeTM) at NUS Medicine, tasked with promoting high-level research on diseases prevalent in Singapore, and training highly competent medical and nursing graduates. This is supported by the Centre for Healthcare Simulation (CHS) located within CeTM. CHS is one of the region’s largest simulation centres and resembles a hospital setup with facilities such as operating theatre and wards (National University of Singapore 2012b), thereby providing undergraduates with the opportunities to hone their communication and clinical skills in this safe, interactive simulationbased learning environment.
TeamLEAD pedagogy As mentioned previously, Duke-NUS employs a flipped classroom teaching approach termed TeamLEAD (Learn, Engage, Apply and Develop). This innovative method has attracted vast interest from medical schools abroad; in fact, more than 170 delegations from 28 countries visited the institution to study the model (National University of Singapore n.d.). TeamLEAD aims to instil the importance of working and learning in collaborative teams among the students, and preliminary data so far has been promising (Krishnan 2011).
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Interprofessional education Interprofessional education (IPE) is a key feature in many medical schools’ curricula. In a similar vein, this has been an integral component of the NUS Medicine’s syllabus since 2011 when the Interprofessional Core Curricula and Interprofessional Enrichment Activities were incorporated into Medical, Nursing, Dentistry, Pharmacy and Medical Social Work undergraduate programmes at NUS (Jacobs et al. 2013a). The six indispensable domains including ethics, communication and reflection/learning are put into practice, when medical students interact and seek the opinions of pharmacy, nursing, Medical Social Work and dental students.
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Public service ethos: Service learning Unlike other parts of Asia, where service learning is relatively underutilised (Wee et al. 2011a), many community projects have been launched at NUS Medicine to foster team spirit, promote community bonding, in addition to moulding their humanistic traits such as empathy. For instance, programmes such as the Public Health Screening (PHS) and Neighbourhood Health Screening (NHS) allow students to reach out to the underprivileged and elderly populations (Wee et al. 2011a). These are student-led, faculty supported projects. Studies on their effectiveness highlighted the impact on developing wellrounded graduates, with increasing ability to recognise key social issues plus long-standing management of chronic illness (Wee et al. 2011a). The community has also benefitted tremendously from these programmes (Wee et al. 2011b). Recently, students are also given opportunities through the Longitudinal Patient Experience Programme to visit patients’ home and comprehend how they deal with their conditions.
Nurturing undergraduate scholars All three schools place an emphasis on developing clinicians who are innovative through involvement in research. At NUS Medicine, a special focus is being given to cultivate spirit of inquiry and innovation in students. Students with a special interest in research can opt to join the Wong Hock Boon Society where they engage mentors and research scientists to develop their area of research and interest. The Undergraduate Research Opportunities Programme provides an opportunity for students to engage in research during their undergraduate years, write it up as a mini-thesis and are given curriculum credit for it. All students are encouraged to share their scholarly work through yearly student-led and faculty supported projects such as Student Medical Education Conference (SMEC) where medical students from all three medical schools in Singapore actively participate in. It also provides them with the platform to exchange research-related ideas and projects. Students who wish to share their work at regional/international conferences (e.g. Asia Pacific Medical Education Conference (APMEC)) can also apply for funding support from the school. In a more formal setting the students are trained in research skills through programmes such as ‘‘Information Literacy and Critical Thinking’’ or during electives and the community health projects in the later years. The focus of these formal training courses is to provide training in the basics of research 4
and as well as the opportunities to engage thoroughly in research work.
Assessment Assessment in the first two years of study at NUS Medicine is centred on the students’ medical knowledge, communication skills as well as basic physical examination skills. Key focuses in the clinical phases of learning in years 3–5 are clinical reasoning, decision-making and management, respectively. This, together with the curriculum reforms, contributed to tackling the problems faced earlier, including a lack of focus on providing appropriate patient care, communication skills, ‘‘evidence based decisions on diagnostic and therapeutic interventions, develop and carry out management plans. . .. professionalism’’ (Wong 2005). A mixture of tools like skillsbased objective structured clinical examinations, knowledgebased short essay questions and workplace-based assessments such as the mini-clinical evaluation exercise are used to assess the students. In 2011, NUS Medicine reformed its system of grading from the usual ranking to that of a Distinction/Pass/Fail format for students in Phases I and II. In a related study, findings revealed that the conversion did not affect the students’ performance however significantly reduced their stress of school life and improved their curricular activities (Jacobs et al. 2013b).
Postgraduate medical education Development With a steady pool of high quality graduates from the Faculty of Medicine, there was an impetus to set up a postgraduate school to train specialists for Singapore. In 1957, the Academy of Medicine became the first formal postgraduate education body to oversee developments in this area (Nambiar & Chee 2007). The Academy of Medicine in collaboration with the Alumni Association, with support from specialty schools from Australia and UK, started the School of Postgraduate Medical Studies (Lim 2005). Since the 1970s, the school has been responsible for awarding the Master of Medicine for all the key specialities, and the accreditation of subspecialties (Lim 2005). Training events with the Royal Colleges were key features of graduate medical education in Singapore until 2008 (Huggan et al. 2012). The current Division of Graduate Medical Studies, responsible for postgraduate training and examination in Singapore, started as the Committee for Postgraduate Medical Studies in 1961 (Chew & Chee 2005). The Committee was established to manage postgraduate education and to formulate policies (Nambiar & Chee 2007). It later became the Graduate School of Medical Studies (Chew & Chee 2005).
Accreditation Council for Graduate Medical Education-International In 2009, Singapore engaged the Accreditation Council for Graduate Medical Education-International (ACGME-I) to manage the accreditation of its postgraduate training (Huggan et al. 2012), and to develop standards in domains
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such as assessment and training. Major re-formulations took place, including the appointment of Designated Institutional Officers (DIOs) (Huggan et al. 2012), who oversee the administrative system that manages the residency programme. Singapore was the first country which successfully received the ACGME-I accreditation for its residency training in 2010. There are several DIOs, each overseeing a specific health cluster – National University Health System (NUHS), SingHealth and National Healthcare Group. Taking NUHS as an example, the DIO office was established under the Medical Affairs (Education) department to oversee the postgraduate training in the institution. The Graduate Medical Education Committee chaired by the DIO consisting of the programme directors (PDs) and subcommittee chairs was established to run the residency programmes in NUHS. The Ministry of Health (MOH) funds the Educational Full Term Employment (FTE). This allows for protected time for the DIOs at 0.5 FTE, Associate DIOs at 0.3 FTE, PDs at 0.5 FTE, Associate PDs and core faculty at 0.2 FTE to administer the residency programme. In addition, the MOH also provides funding for manpower development as well as other operating expenditures. To ensure that the funding is properly used, clear key performance indicators have been set up, where 50% is in manpower deliverables, i.e. hiring of additional doctors to backfill the educators. The other 50% is based on achievement of training deliverables, i.e. residents’ satisfaction with the programme and residents training performance. The MOH also provides funding for institutions to employ administrators to run the programmes at the institution and programme level. Furthermore, the MOH also funds 0.2 FTE of the residents’ time for training. As for the oversight, Resident Advisory as well as National Examination Committees have been set up.
Academic medical centres (AMCs) Medical schools and hospitals in Singapore have come together to form AMCs, to promote as well as integrate education, clinical care and translational medicine research all under one roof. NUHS is one of them, where entities like NUS Medicine, NUS Faculty of Dentistry, NUS Saw Swee Hock School of Public Health and National University Hospital came together. In 2012, SingHealth partnered with Duke-NUS to form the second AMC. The AMCs provide undergraduate and discipline specific postgraduate training (both ACGME-I and non-ACGME-I) to students and residents.
Continuous medical education (CME)/professional development (CPD) CME for doctors and specialists was launched in 1989 as a pilot program. The system was formalized in 1993 and it is under the purview of the Singapore Medical Council (CME Coordinating Committee). The process was made compulsory for all doctors registered and conditionally registered from January 2003 (Lee 2008). This has further expanded from 1st January 2005 to all medical categories in Singapore
when they are required to renew their professional practicing certificates. Singapore is one of the two countries in Asia where CME is compulsory. The CME/CPD points are awarded by professional bodies such as the Academy of Medicine, academic training institutions such as the three medical schools, postgraduate medical institutes, Academic Medical Centres as well as restructured hospitals.
Challenges Despite the relative success of medical education in Singapore over a short span of over 100 years, many challenges exist. The opening of LKCSoM has allayed concerns over the supply of doctors, albeit for the time being. However, this does not mask the fact that the demand will continue to surge as Singapore’s population ages.
Training facilities Learning spaces for students are probably a necessity if Singapore were to expand the pre-clinical teaching sites, although space constraints within the three medical schools’ campuses means that this issue will cause a bottleneck. The contemporary concept of building ‘‘up’’ (i.e. ‘‘vertically’’) in Singapore seems to be a viable option. For clinical training, the schools could use several upcoming hospitals, on top of the seven existing sites.
Staff Of particular concern will be the student–faculty ratios. In clinical settings, a huge challenge exists where tutors had to find time in their busy schedules to mentor students. This is especially so since patients will always be the doctors’ priority, often followed by research, since research output is frequently a key parameter in promotion and tenure appraisals. Several approaches have been taken to ensure Singapore has a sufficient number of excellent educators to maintain quality education and drive innovation. The University has recently introduced a new Educator track for pre-clinical teachers that rewards staff who wishes to focus on teaching and scholarly activity in education. The medical school has differentiated tracks including a track for Clinician Educators to recognise excellence and contributions in education. In addition, the Ministry of Health has recently infused a substantial increase in funding for clinical training. This has resulted in the appointment of more clinical teachers and development of infrastructure that supports education at clinical training sites all over Singapore. Another task at hand is to equip the faculty with appropriate training in teaching. Presently, professional faculty development courses in Singapore are mainly organised by the Centre for Medical Education (CenMED) at NUS Medicine. CenMED also organises the Asia Pacific Medical Education Conference (APMEC), an international meeting which attracted more than 800 participants from different parts of the world in 2012 and 2013. With the growth of the healthcare sector, there is a need to augment the systematic process of developing faculty, support staff and students. NUS Medicine established
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the Medical Education Unit (MEU) in 2001 which has developed now to be CenMED to help facilitate faculty development and to provide leadership for education innovation in the faculty. Over the years, CenMED has expanded into providing structured programmes and courses leading to certification level and also conducting courses for the local and overseas health professional training institutions. Recently, the Academy of Medicine, Singapore, through their Chapter for Clinician Educators, has developed plans to collaborate with the University of Maastricht to conduct the Masters Programme in health professions education.
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Clinical learning and institutional support The Ministry of Health Singapore as part of its efforts to improve undergraduate training of all health professionals has provided funding to set up an education office in each of the major clinical training sites. Under the pre-employment clinical training fund, the education office will oversee medical, nursing and allied health pre-employment training programmes. The education office will coordinate through a designated Clinical Educator Lead (CEL), the teaching and learning activities of the three medical schools’ clinical training with the relevant hospital departments. The training institutions have supported this initiative by appointing clinician– educators, administrators as well as providing space for education facilities. The hospitals have also been actively providing full as well as partial full-term employment for the clinician educator track.
Medicine and Family Medicine have graduated from it. MOH has recently appointed a Committee to look into the mid-term review of Residency training in Singapore. Depending on the findings and recommendations of this committee, further refinement of the residency system will be implemented.
Conclusions From a humble beginning 110 years ago, medical education in Singapore has developed and gained international recognition through its quest for excellence. In this context medical education in Singapore is confident that it can achieve greater breakthroughs, not just to meet our own healthcare demands, but also to benefit the greater global community.
Notes on contributors Dr. DUJEEPA D. SAMARASEKERA, MBBS, MHPE, FAMS, FAcadMEd, is the Director of Centre for Medical Education (CenMED), National University of Singapore and also the Vice-President of the Association for Medical Education in the Western Pacific Region (AMEWPR). Associate Professor SHIRLEY OOI, MBBS, FRCSEd(A&E), FAMS(Emerg Med), is the Designated Institutional Officer for Residency Program at National University Health System and a Senior Consultant in Emergency Medicine at the National University Hospital of Singapore. Mr. YEO SU PING, BSc (Hons), is a Senior Executive at the Centre for Medical Education at the National University of Singapore. Professor HOOI SHING CHUAN, MBBS, PhD, is the Vice Dean (Education), Yong Loo Lin School of Medicine, National University of Singapore.
Syllabus Singapore’s healthcare demography is evolving rapidly as the population of elderly and life expectancies increase. With that in mind, the medical curriculum will need to be tailored to meet future needs in these areas. Plans to setup teaching clinics and renovation of clinic spaces are underway to expand ambulatory teaching in community-based polyclinics as well as in hospital-centred clinics. Progressively, faculty and students are encouraged to engage in research projects, not just clinical studies but also in medical education, so as to hone their research skills for instance. This is evident by the increase in abstracts submitted to APMEC over the years from the three medical schools fraternity. In fact, free registration is available for NUS Medicine students attending APMEC as an incentive to cultivate a spirit of inquiry.
Advances and future directions The medical schools are now actively moving towards the use of small groups and technology to enhance student learning. At NUS Medicine, there is an active move to have more than 60% of their teaching learning activities in pre-clinical years of learning changed to interactive case-based using technology platforms to facilitate learning by 2020. While the ACGME-I residency system has put in place a more structured training program in Singapore, the system is still new and only a handful of residents in shorter programs like Emergency 6
Acknowledgment Authors thank Professor Matthew Gwee for providing useful insights and his assistance in improving the manuscript. Declaration of interest: The authors report no conflict of interest.
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