싱가폴의 의학교육 개괄 (Medical Teacher, 2015)

싱가폴의 의학교육 개괄 (Medical Teacher, 2015)

Medical education in Singapore

DUJEEPA D. SAMARASEKERA, SHIRLEY OOI, SU PING YEO & SHING CHUAN HOOI

National University of Singapore, Singapore

싱가폴에 대한 일반적 설명

Singapore, often dubbed the ‘‘little red dot’’ for its small size (716.1km2), 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).

싱가폴 역사, 의료

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)

영국의 영향

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

Undergraduate medical education

Brief history

의학교육의 역사

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 “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).

명칭 변경의 역사

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).

Yong Loo Lin 명칭의 역사

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].

두 번째 의과대학

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.

세 번째 의과대학

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.

모든 의과대학은 공립이며 등록금 면제

All medical schools in Singapore are public and the government subsidises the students’ tuition fees (Wong 2005).

Admission to medical schools

Holistic selection을 하고 있음

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.

2013년에 새로이 도입된 선발형태 설명, 10%는 학업외 활동 우수자 선발

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, 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).

1997년까지는 과목중심

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).

2006년 이후 통합교육

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.

임상교육

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 years. For the final-year students, simulation is used to refine their clinical skills.

Longitudinal tracks

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.

상호작용 강조

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 technology-based modalities (Samarasekera 2014) (Figure 2).

State-of-the-art teaching facilities

시설 추가

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 simulation-based learning environment.

TeamLEAD pedagogy

TeamLEAD

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).

Interprofessional education

IPE

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.

Public service ethos: Service learning

공공에 대한 봉사 (아시아 다른 지역에서는 service learning이 별로 활용되고 있지 않음)

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 well-rounded 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

학자로서 기르기

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 and as well as the opportunities to engage thoroughly in research work.

Assessment

평가

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 skills-based objective structured clinical examinations, knowledge-based 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

Continuous medical education (CME)/professional development (CPD)

Challenges

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.

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.

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.

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.

---

Med Teach. 2015 Feb 19:1-7. [Epub ahead of print]

Medical education in Singapore.

Samarasekera DD1, Ooi S, Yeo SP, Hooi SC.

Author information

• 1National University of Singapore , Singapore.

Abstract

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.

PMID:

 

25693792

 

[PubMed - as supplied by publisher]