Getting the formula for training specialists rightShared by:
Minister of State for Health Chee Hong Tat recently announced that the Ministry of Health (MOH) will review the residency programme to train graduate doctors to become specialists. MOH had introduced the American-style system in 2010 to boost the pipeline of specialists and to make their training more structured, but as Mr Chee acknowledged, its outcomes had not been as positive as hoped for. Training of medical specialists is important not just to doctors. Stakeholders include the government, which funds the programme, and, more importantly, Singaporeans, who utilise their services. Having been trained under the previous British-based system 20 years ago, I think it is useful to look at how we can draw on the two systems to come up with one that best serves Singapore. During my time, graduates from the Faculty of Medicine at the National University of Singapore (NUS) had to first serve a year of housemanship. This comprised three four-month postings in general medicine or general paediatrics, general surgery or orthopaedic surgery, and obstetrics/gynaecology. After housemanship, the young doctors spent one year as a Medical Officer in two six-month postings, such as in general surgery, ear-nose-throat, or orthopaedics. After that, they would be eligible to apply for Basic Specialist Traineeship (BST), which could be in general medicine, general surgery etc. BST took three years, during which the trainees spent three to six months in each of the sub-specialties within the specialty. BST trainees had to pass a basic specialist examination before they could proceed to Advanced Specialist Traineeship (AST). This would have typically taken another three years. By the time I became a junior specialist in 2002, I had spent eight years in post-graduate training: One year of housemanship, one year as a Medical Officer, three years in BST and another three in AST. The old BST and AST were more like mentorship/apprenticeship programmes, rather than well-planned and structured ones. I followed my two mentors, Professor SG Lim and Assoc Professor KG Yeoh, closely in their daily work. I learned from them how to manage patients and to perform procedures like endoscopies under close supervision. A key weakness of this system was its loose structure. Training depended mostly on the mentors. Trainees could only learn what they were exposed to, and what their mentors were willing to teach them. Some trainers were not good at teaching, and some did not have the time. Other trainees did not get wide exposure at their training institutions. WHAT NEXT? The new residency programme was introduced to formalise training, enabling each resident (or trainee) to learn through a structured programme. Trainers, typically senior specialists, are given proper training on teaching. Lectures are structured, and there is protected time for study and research. Residents’ working hours are limited to ensure they have time to learn and reflect on their cases. The programme also shortens the duration of training: Residents begin training right after graduation, and in some specialties, such as general surgery and orthopedics, training has been shortened to five years. In other words, medical graduates can become qualified specialists five to six years after graduation, or two to three years earlier than under the traditional British system. But the residency programme’s strengths have also become its weaknesses. First, since it starts immediately after graduation, young doctors have to decide their specialty of choice while they are still in medical school. By all accounts, this may be too early for them to choose what they would be doing for the rest of their lives. I chose internal medicine two years after graduation, and gastroenterology three years later. Second, specialists who undergo the current residency programme may not have wide exposure to other disciplines, as they start their training immediately after graduation. There is concern that their experience may be too narrow. In my case, though I specialise in internal medicine and gastroenterology, I had training in other disciplines like obstetrics, urology, general surgery, and orthopaedics during my earlier years. General knowledge in these areas is important as many patients could have medical problems that cross several specialties. For instance, up to half of pregnant women could have gastroesophageal reflux disease. Having experience in managing obstetric cases has helped me in my job as a gastroenterologist. Third, the shortened duration of training may not provide enough clinical exposure to the residents, even within the specialty. Residents’ training duration was further discounted from protected time for research and study. To be exposed to a wide variety of cases is a prerequisite for specialist training. The longer a doctor spends in training, the more likely he or she will learn to treat patients with different diagnosis and complexities. Lastly, in the old days, each hospital chose its number of AST trainees according to its projected manpower needs. So when I was hired as an advanced trainee, I knew a specialist job would be there for me after I finished the AST programme. Hospitals generally did not train excessively more AST trainees than they needed. But under the current residency programme, training is centralised. The number of residents permitted by MOH may not reflect the manpower needs at the respective hospitals. Singapore is a small country. A few years of over-training of specialists can easily tip the situation from shortage to over-supply. There will come a time when the number of qualified specialists under the residency programme exceeds the number of jobs available. This may be good for hospitals, and even patients, as they can now choose the better ones among a large pool of newly-qualified specialists. But to the young doctors who fail to get a specialist job, this means they will have to continue to work as junior doctors till more specialist posts become available. The review of the residency programme by MOH is therefore timely. So what tweaks should be made? For a start, the specialist training programme should not start immediately after medical school. Instead, young doctors should be given a year or two after graduation to decide what they want to do for the rest of their careers. Short training stints in areas like infectious diseases, geriatrics, general medicine, general surgery and family medicine can also be made compulsory before young doctors are accepted into a training programme. The duration of the residency progamme could also be lengthened to ensure each resident has gained sufficient experience in different types of cases in his respective specialty. And the number of training positions should be coordinated among all hospitals and MOH to ensure that most, if not all, qualified specialists are gainfully and meaningfully employed in their specialties. Singapore has had the unique experience of having experience in both the British and American training systems. It is high time we derived our own training system, one that takes the best practices from both sides of the Atlantic. ABOUT THE AUTHOR: Dr Desmond Wai is a gastroenterologist and hepatologist in private practice.
27 Oct 2017 - General