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VO L . 5 2 N O . 7 | J u ly 2 0 2 0 | M C I ( P ) 0 6 6 / 1 2 / 2 0 1 9
DOCTORS IN TRAINING
MEDICAL TRAINING IN
Ext r a o r d i n a r y T i m e s
Orthopaedic Training
amid COVID-19
COVID-19’s Impact on
Medical Education
news
CON T E N T S
Vol. 52 No. 7 2020
Editorial
EDITORIAL 04 The Editor's Musings
BOARD Dr Tina Tan
Editor
Dr Tina Tan
Deputy Editor Feature
Dr Chie Zhi Ying 05 Orthopaedic Training
Editorial Advisors amid COVID-19
A/Prof Daniel Fung
A/Prof Cuthbert Teo Dr Liang Zhen Chang
Dr Toh Han Chong
Members
Dr Ganesh Kudva President's Forum
Dr Lim Ing Haan 08 Training in the Past,
Dr Jipson Quah
Dr Tan Tze Lee
Present and Future
Dr Jimmy Teo Dr Tan Yia Swam Doctors in Training
Dr Alex Wong 24 The Chaotic Last Stretch of a UK
Medical Student
EX-OFFICIOS
Dr Tan Yia Swam
Council News Dr Denise Au Eong
Dr Ng Chew Lip 10 Highlights from the
Honorary Secretary
EDITORIAL
OFFICE Dr Ng Chew Lip Reflections
27 Caring for COVID-19 Heroes (Part 2)
Senior Manager
Sarah Lim
Opinion
Assistant Manager
Sylvia Thay 11 Different Struggles in Different AIC Says
Times: From SARS to COVID-19 30 Overcoming Challenges in Advance
Editorial Executive
Daryl Lai Dr Clement Sim and Dr Agnes Tay Care Planning for Patients
Agency for Integrated Care
ADVERTISING AND
PARTNERSHIP 14 (Healthcare) Avengers, Assemble!
Li Li Loy Dr Jipson Quah
Tel: (65) 6540 9174
Allan Kuek
Tel: (65) 6540 9175 16 First 100 Days of COVID-19 –
Email: adv@sma.org.sg
How It Impacted Medical Education
PUBLISHER A/Prof Nigel Tan
Singapore Medical Association
2985 Jalan Bukit Merah
#02-2C, SMF Building 18 There and Back again:
Singapore 159457 An Orthopod’s COVID-19 Journey
Tel: (65) 6223 1264
Fax: (65) 6252 9693 Dr Jonathan Tan
Email: news@sma.org.sg
URL: https://www.sma.org.sg
UEN No.: S61SS0168E
20 A Ray of Hope
Dr Alvin Tan and Dr Estelle Tan
DESIGN AGENCY Indulge
Oxygen Studio Designs Pte Ltd
32 The Chara-cteristics of Joy
PRINTER
Event Grace Tan
Sun Rise Printing & 22 Telemedicine: Continued Care in a
Supplies Pte Ltd COVID-19 World
Daryl Lai
Opinions expressed in SMA News reflect the
views of the individual authors, and do not
necessarily represent those of the editorial
board of SMA News or the Singapore Medical
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editorial
Not long ago, I had the privilege of
speaking to the Duke-NUS Medical
order to come up with safe and
sustainable solutions to the training Dr Tina Tan
School class of 2020 on behalf of the of doctors and education of medical
SMA before they graduated. With students. And all of this had to be Editor
me was fellow Council Member and done as quickly as possible. It has
former classmate, Dr Lim Kheng been no easy feat that the class of Dr Tan is a consultant at the Institute
Choon. We spoke to the class through 2020 from our medical schools has of Mental Health and has a special
Zoom, and the class graduated over graduated, and is now working in the interest in geriatic psychiatry. She is
that weekend, also through Zoom. wards as Post Graduate Year 1s. also an alumnus of Duke-NUS Medical
It really was a sign of the times to be School. Between work and family
This issue’s focus is on our doctors
graduating in the midst of the havoc life, she squeezes time out for her
of COVID-19. in training, and in more ways than one.
Dr Liang Zhen Chang, Dr Jipson Quah favourite pastimes – reading a good
In the past few months, as trainees and A/Prof Nigel Tan have written (fiction) book and writing.
found themselves abruptly deployed about changes that have been made
or unable to change postings due in training and medical education as
to cross-institution concerns, many a result of enhanced infection control
of our juniors were left asking measures. Our COVID-19 snippets
whether they could still take their published a continuation of the
continue with reflections from doctors, Singapore Psychiatric Association’s
examinations, how examinations who’ve experienced changes to their
would be conducted, and whether series of comics, as a reminder to look
professional lives, some more directly after ourselves and each other as we
traineeship would be delayed. than others.
Similarly, when medical student trudge on through this pandemic.
postings came to a sudden halt, We are very pleased to feature It goes without saying that
students were left pondering whether articles from Dr Denise Au Eong and COVID-19 has brought disruption,
they could progress through medical Dr Clement Sim as they graduate inconvenience and heartache for
school or even graduate properly and enter the wards during this time. all of us. And yet, the same can be
(although the answer to that last Dr Sim’s contribution is accompanied said of any new and unexpected
question has pretty much been a by a special response from Dr Agnes change. The remarkable thing that
resounding yes). Tay, as she reflects on her experience the pandemic has shown me is that
during SARS. humans are resilient, and we can
There is no doubt that educators
and residency programmes all around Closer to my heart, of course, is adapt – for better or worse. Let’s
the globe have had to scratch their the mental well-being of healthcare make it better, and turn this new
heads and think out of the box, in workers during this time. We have normal to our advantage.
04 jul 2020 SMA News
FEATURE
Amid COVID-19
Text by Dr Liang Zhen Chang
This ongoing COVID-19 crisis has hit us and practical solutions that can be were stopped with immediate effect.
fast and hard. First reported in Wuhan, adopted as we adapt orthopaedic In a bid to protect vulnerable patient
China, in late December 2019 as a training to this crisis. populations and conserve hospital
cluster of pneumonia cases,1 it has now resources, non-urgent elective surgeries
spread to involve various countries Impact on orthopaedic training were cancelled. Outpatient clinic
across multiple continents. The World in Singapore numbers were reduced, and non-urgent
Health Organization has declared this reviews deferred for three to six months
Singapore has been dealt a particularly
COVID-19 outbreak a global pandemic, to minimise hospital overcrowding.
hard blow by this ongoing COVID-19
calling for an international effort to In a procedural specialty like
pandemic. We were among the first
stem its burgeoning spread. Health countries to report confirmed COVID- orthopaedics, which is heavily
services resources and manpower are 19 infections outside of China. With skewed towards elective work, this
focused on containing this outbreak. confirmation of early community has inevitably affected the surgical
Inevitably, medical training will have spread, the Ministry of Health, on 7 caseload significantly and hence
to take a backseat, as critical resources February 2020, raised the Disease residents’ operative experiences.
are being channelled towards front-line Outbreak Response System Condition The situation is compounded by the
efforts. Of these, procedural specialties, alert level to Orange.2 With this, a significant amount of uncertainty
like orthopaedics, are perhaps the number of disease control measures surrounding this viral crisis – in
hardest hit. Dwindling outpatient commenced, among which included particular, how long will it last? To
clinics and cancelled elective surgeries mandatory twice-daily temperature suspend training indefinitely is not a
have resulted in decreased educational screenings for all healthcare staff and pragmatic move. We must therefore
opportunities for orthopaedic surgeons two-week quarantines for staff with strive to ensure continuity of quality
in training. Creative solutions will need pertinent contact and travel histories training in these difficult logistical
to be sought to ensure the quality and to mainland China. Due to these times. We had to look beyond
continuity of orthopaedic training restrictions, inter-hospital residency traditional resources to maintain
even in these trying times. In this rotations, cross-hospital deployments training volume, progression, quality
commentary, I will share some insights and face-to-face teaching sessions and standards.
Jul 2020 SMA News 05
Using technology to demonstrate procedures, surgical To this end, we can work with external
our advantage techniques and even anatomical equipment vendors to organise these
dissections for surgical approaches. This implant demonstration sessions. With
This is thus an opportune time for
can be supplemented with instructional regard to trauma teaching, sawbone
orthopaedic educators to leverage
videos, webinars and online resources workshops can be organised to further
upon technology to fulfil their enhance our proficiency in fracture
such as those available on the AO
residents’ training needs. With the reduction and fixation.8 Arthroscopic
Trauma3 and VuMedi4 platforms. These
cancellation of physical meetings, can then be followed by faculty-led simulators can also be utilised to hone
technology can be harnessed to deliver discussions to further help residents our arthroscopy skills in a stress-free
teaching goals that could otherwise consolidate their learning. Innovative environment. In addition, given that a
only be achieved with didactic sessions. teaching modalities like these have significant proportion of orthopaedic
To this end, didactic teaching sessions been shown to be advantageous in injuries can be conservatively managed,
have been moved to online platforms facilitating learning5 and enhancing masterclasses in cast setting and
using video-conferencing software. interactions6 compared to conventional application have been organised for
Faculty and residents are now able to teaching methods. residents to further hone their skills in this
conduct teaching sessions remotely art that is often deemed “long-lost”. 9, 10
for their learning, with case-based Orthopaedic surgery is uniquely
discussions being facilitated real-time. implant- and equipment-centric, unlike
most other specialties. Our implant An all-rounded doctor
Early feedback has been extremely choices can determine our patients’ A highly skilled surgeon does not
encouraging. Residents have been clinical and surgical outcomes.7 This necessarily make a good doctor. In
observed to be more forthcoming with relative reduction in clinical load due to addition to domain-specific knowledge
their questions. Two-way interaction the pandemic can be taken advantage and skills, non-cognitive attributes like
between faculty and residents is of to better familiarise ourselves with teamwork are equally important as well.
simple and has been enhanced as the nuances of various implant designs This COVID-19 crisis presents a unique
a result. The video conferences can and orthopaedic equipment. This can opportunity for us to be taught rich
also be recorded and stored in our range from the simple compartment lessons in these non-cognitive attributes,
repository of educational materials pressure monitors to the more complex beyond what books and residency
for future teaching needs. Besides (eg, femoral nail/total knee replacement rotations can offer. Orthopaedic residents
didactic sessions, video-conferencing designs, external fixators and even have been rostered for shifts in the
technology can also be utilised to skeletal traction devices/pelvic clamps). emergency department (ED) seeing
non-orthopaedic patients. This fosters
camaraderie between the orthopaedic
residents and their ED colleagues and
alleviates ED manpower difficulties at
the same time. It also delivers powerful
lessons in courage, versatility and
leadership as we learn to adapt to fluid
situations at the forefront of this COVID-
19 battle, and it provides us with the
opportunity to revisit our general medical
skills, which can sometimes be lost after
years of specialised orthopaedic training.
This allows us to develop into more
holistic medical professionals, standing
us in good stead as the orthopaedic
surgeons of tomorrow.
Even with a reduced elective
caseload, this COVID-19 crisis presents
us with unique learning opportunities
that we can capitalise on, to develop
values and skill sets beyond what
textbooks and rotations can offer. Be
comfortable with utilising technology
and emphasise on improving the
“softer” skillsets. That should be the
way forward.
06 jul 2020 SMA News
References
AO Trauma 1. Zhu N, Zhang D, Wang W, Li X, Yang B, Song
Founded in Switzerland in 1958, Arbeitsgemeinschaft für Osteosynthesefragen J, et al. A novel coronavirus from patients
with pneumonia in China, 2019. New England
(AO; German for Association for the Study of Internal Fixation) runs training Journal of Medicine 2020; 382(8):727-33.
courses in surgery and medical care. AO is a not-for-profit organisation that
2. Ministry of Health. Risk assessment raised
focuses on education and research in orthopaedics. Their global community
to DORSCON Orange. Available at: https://bit.
has established five specialty areas, including AO Trauma, and they regularly ly/31EnZfD.
hold courses internationally for orthopaedic surgeons.
3. AO Trauma. Available at: https://bit.
Currently billed as the world’s largest global trauma and orthopaedic ly/3dPZoa8.
community, AO Trauma focuses on the surgical management of trauma 4. VuMedi. Available at: https://bit.ly/2BoLNJV.
and disorders of the musculoskeletal system. With the impact of COVID-19,
5. Lamba P. Teleconferencing in medical
AO Trauma has transformed their usually face-to-face events into online education: a useful tool. Australas Med J 2011;
webinars to complement their existing collection of webinars and webcasts. 4(8):442-7.
They also have a library of online videos and learning tools including
6. Augestad KM, Lindsetmo RO. Overcoming
lectures, practical exercises and instructional videos. Most interestingly, AO distance: video-conferencing as a clinical and
Trauma has their Surgical Reference repository, an online tool containing educational tool among surgeons. World J
clinical reports and step-by-step surgical procedures based on up-to-date Surg 2009; 33(7):1356-65.
evidence that is constantly being updated. 7. Padgett DE, Kahlenberg CA, Joseph AD.
Impact of implant design on outcome of
primary total knee arthroplasty. Orthopaedic
Proceedings 2018; 100-B(SUPP_12):34.
VuMedi 8. Hetaimish BM. Sawbones laboratory in
orthopedic surgical training. Saudi Med J
A healthcare education platform for clinicians, VuMedi’s mission is to help 2016; 37(4):348-53.
doctors make optimal patient care decisions via comprehensive video 9. Bryson DJ, Shivji FS, Price KR, Lawniczak D,
education. VuMedi prides themselves as a “YouTube” platform for medical Chell J, Hunter JB. The lost art of conservative
practitioners, hosting one of the largest numbers of educational videos management of paediatric fractures. Bone
from a wide range of sources including hospitals, manufacturers and key and Joint 360 2016; 5(1):2-8.
opinion leaders. Up-to-date materials include webinars, surgical videos 10. Jones CB. Are cast application and
and case studies. maintenance of complications a lost art?
Commentary on an article by Christian
Founder Roman Giverts was inspired by his girlfriend’s father, an J. Zaino, MD, et al.: “The effectiveness of
orthopaedic surgeon, watching a DVD of a rarely performed surgical bivalving, cast spreading, and webril cutting
technique. After speaking with him, Giverts realised the potential a surgical to reduce cast pressure in a fiberglass
video-sharing website could bring to doctors the world over, and thus short arm cast”. J Bone Joint Surg Am 2015;
97(5):e29.
VuMedi was born.
As technology advances, doctors are finding new ways to gather the
information they need. VuMedi, a physician-only community, provides a
platform for surgeons to view and upload surgical videos. The community
allows for discussion on posted videos, fostering a healthy forum for sharing
of medical techniques. Dr Liang is an aspiring
clinician scientist and is
The COVID-19 landscape has seen VuMedi expanding into new specialties currently an orthopaedic
due to the urgent need for physicians to learn as much about COVID-19 as surgery resident with the
possible in a situation where physically seeking out information can be difficult. National University Health
System. When not tinkering
with metal and research,
he enjoys a good read and
hunting down good food.
Be comfortable with utilising
technology and emphasise on
improving the “softer” skillsets.
Jul 2020 SMA News 07
PRESIDENT'S FORUM
Doctors in training have always been
close to my heart. Although I recall my
own training days with fondness, I am
also very glad that they are over! It was
full of hardship along the way. Looking
back, I think the challenges faced back
then toughened us up and equipped us
to continue on to tackle other real-life
problems that crop up from time to time.
Training woes
Medicine has always been competitive.
Young doctors of all generations have
faced shortages of training positions,
or even difficulties trying to get into
desired postings. My cohort then had
to figure out how to get into the basic
specialist training (BST) and subsequent
advanced specialist training (AST), and
how to secure a training position –
which does not always happen together.
Also, how to pass examinations, actually
be good at clinical work, operate,
maintain a logbook, write papers,
and maintain relationships – with
colleagues, with seniors, and with
boyfriends/girlfriends! Even after the
exit examinations, we worry about
securing an associate consultant, and
Illustration: Dr Justinian Zai
then a consultant job.
Housemanship
Housemanship was a rite of passage.
There were many firsts – learning how to
write the case sheet entries during ward
rounds, how to do discharge summaries
while being paged by every ward to
settle more changes, and scarier tasks
like being called to see a patient with
i n t h e
chest pain, an abnormal ECG, or who
n i n g
had outright collapsed! Having to talk to
T r a i
an angry family (even worse when you
are on call and it’s not your patient!), or
n t
answering your first official complaint,
r e s e
or your first Singapore Medical Council
Past, P
“summon” letter.
With COVID-19, I can very well imagine
that aside from these challenges of work,
accumulating clinical experience and
t u r e
taking examinations have an additional
a F u
layer of difficulty.
n d r Tan Yia Swam
Education
I would like to applaud the educators for
Text by D protecting the students and maintaining
08 jul 2020 SMA News
their educational progress. I want to replaced the BST/AST system). Some tele-consults – we must not forget that
thank the junior doctors for working doctors complete a diploma, Masters or it is still the doctor-patient relationship
hard and rising to the COVID-19 chal even a PhD in their areas of interest. This that holds paramount meaning and
lenges. We are all so glad that you are ongoing lifelong learning is what makes significance in our noble profession. The
part of the workforce, joining us in medicine so enriching and fulfilling. duty of care for our patients is the same,
looking after patients. This is a situation even if the modes of delivery have
The SMA Centre for Medical Ethics
when we need all hands on deck, and changed with the times – parchment,
and Professionalism has developed
I am thankful for your youthful energy paper and now iPad.
further courses in medical ethics and
and enthusiasm. Tele-conference: We are all adapting
professionalism; it behoves each and
As a mother, it fascinates me how my every one of us to take part in these to online meetings and webinars for
kids have such different personalities medico-legal seminars and courses, CME points, peer review learning and
and learning styles. to better understand the different public talks. It requires a different skill
layers of complexity in the practice of set to meaningfully engage participants
Looking back at medical training, I
medicine. One can do the right thing, and to multitask: look at the gallery of
realised that I learn better on the job. I
the wrong way. One can do a wrong participants who have their videos on,
was a mediocre student. Book learning
thing, but not intentionally. One can do look at the list for raised hands, and keep
bored me – I would doodle or drift off
the correct thing, rightly, but still seen to an eye on the chat.
during lectures. But once I started work,
and met real patients with problems be at fault for a bad outcome. To better
– that’s when I got very interested to understand the nuances of each case, What can SMA do for you?
solve their problems and from there, and be more effective in self-gover Nothing? Everything? The SMA is only as
read around it. More importantly, the nance to administer justice in cases of strong as its membership. The President
hands-on part of surgery was what medical malpractice, we must undergo and Council are volunteers who put
captivated me. Staying back post call appropriate training, as rigorous as any in the extra time to do what we feel is
or standing for long hours was fun specialty training programme. right, to represent doctors in matters
as part of the surgical team. Clearly, In the recent few years, several of professional interests. For those who
not everyone learns the same way. high-profile cases were reported in know me, and have taken the time to
Some are excellent at academia – newspapers and caused uproar in understand my work with SMA, thank you.
reading and writing quality articles the medical community. The good For those who have stepped forth and
which help others, and some are things that came out of these are: given your time to further develop the
introspective thinkers who can make (1) a Ministry of Health-appointed various committees in the SMA, thank you.
creative breakthroughs. Some are of workgroup that has looked into, and During my term as President, I will
an administrative bent, and others are proposed reforms in consent-taking continue my engagement with all
essential public health leaders – those and disciplinary processes; (2) robust doctors and show that the SMA is here
who can see the big picture. In our discussions and active engagement by for all of us. I hope to win over the
complex healthcare system, there is a doctors; and (3) closer collaboration non-members. Your added strength in
role for everyone. between the professional bodies. membership numbers will increase the
I envision SMA to be the umbrella power of SMA representation.
Continuing education organisation for such complex
The MBBS/MD may be viewed as conversations.
Dr Tan is a mother to three
just the basic degree and entry into kids, wife to a surgeon; a
medicinal practice. Someone I know Tele-everything daughter and a daughter-in-
once said the MBBS is like the PSLE Telemedicine: The SMA held a joint law. She trained as a general
qualifications only. Further education webinar on 13 June as an introduction
surgeon, and entered private
and continued medical education are practice a year ago, focusing
to telemedicine for those of us who on breast surgery. She treasures
necessary for us, as medical advances have not used it before. This current her friends and wishes to have
develop rapidly. And, as patients have pandemic has brought together all more time for her diverse
more access to healthcare information, stakeholders, to make good use of interests: cooking, eating,
we need to stay ahead of them and technology to try and deliver the same
music, drawing, writing,
provide the best possible medical care photography and comedy.
quality of care to our patients. Our
and advice. panels discussed physical hardware,
There is compulsory continuing software, regulations, ethics, indemnity,
medical education (CME) to maintain business and logistics considerations.
clinical proficiency. Some doctors Even with all the advances in
specialise and enter the various technology – electronic medical
residency programmes (which have systems, telemetry of vital signs and
Jul 2020 SMA News 09
council news
From the Honorary Secretary
Report by Dr Ng Chew Lip
Dr Ng is an ENT consultant in public
service. After a day of doctoring
and cajoling his two princesses at
home to finish their food, his idea of
relaxation is watching a Netflix serial
with his lovely wife and occasionally Clarifications on subscription relief payment
throwing some paint on a canvas. for MPS Members
The Medical Protection Society (MPS), in recognition
of the impact COVID-19 is having on healthcare and
Clarifications on informal survey on TPAs the significant drop in income that members in private
practice have experienced, has announced in April 2020
that they will offer eligible members the equivalent of
It has been brought to SMA’s attention that a survey on
third-party administrators (TPAs) has been circulating via two months’ free membership.
informal channels among doctors as of 17 June 2020. The On 4 June 2020, some MPS members received:
survey, titled “Survey on TPAs Part 1” is not conducted or 1. An email from MPS with the subject “COVID-19:
sanctioned by SMA. Official communication from SMA will Access your subscription relief payment” with a
be accompanied by our SMA logo and marked clearly as
personal registration code and instructions on the
originating from SMA.
subscription relief payment; and
SMA’s position on managed care companies and TPAs 2. A second email from the Hong Kong and Shanghai
Bank (HSBC) with the subject “Your agreed
Many SMA Members would be aware that SMA has
payment from The Medical Protection Society
been calling for managed care companies or TPAs to be
Limited is waiting to be processed” inviting them
regulated by the Government, to ensure better standards
to submit their bank account details to receive the
and improve transparency.
subscription relief payment.
Between 2016 and 2017, SMA wrote to the Singapore
If you have received the above two emails, please be
Medical Council (SMC) to highlight the issue of percentage
assured that they are legitimate and not phishing emails.
fees being charged. S ubsequently, the joint efforts of the
Kindly follow the instructions detailed in the emails to
SMA, Academy of Medicine, Singapore and College of
Family Physicians Singapore culminated in the inclusion enable HSBC to process your subscription relief payment.
of guidelines on service fees paid to managed care If you have received the HSBC email, but NOT the MPS
companies, TPAs, insurance entities and patient referral email containing your personal registration code and
services in the SMC Ethical Code and Ethical Guidelines instructions, please check your email inbox and spam/
(2016 edition, guideline H3(7)). The three professional junk folders.
bodies also jointly issued two advisories.
It has come to our attention that some members had
Our correspondences with SMC and relevant advisories difficulty accessing their subscription relief payment
can be found at http://bit.ly/SMAstatements under through the HSBC portal using the registration code MPS
“Managed Care - admin fees”. provided. We would like to reassure you that the code is
SMA will continue to monitor the situation and push for correct but some of the characters may not be clear and
managed care companies to be regulated by the Government. distinct due to the font used. MPS has resent the same code
using a different font, which should make the registration
Nonetheless, we encourage doctors who are interested
code easier to read.
to engage us through proper channels by emailing to
sma@sma.org.sg. If you are not already an SMA Member, If you have any questions about the above or require
we encourage you to sign up so that SMA can better assistance, please write to singaporesubscriptionrelief@
represent the medical profession. medicalprotection.org.
10 jul 2020 SMA NewsOPINION
DIFFERENT STRUGGLES IN DIFFERENT TIMES
FROM SARS
TO
COVID-19
Anxiety and apprehension have been prevailing themes
in the upheavals brought about by this pandemic.
Indeed, how do our juniors feel as they graduate in
this very unique academic year and enter the wards as
newly minted house officers? To find out, we invited
three Duke-NUS Medical School graduates to share their
concerns. And to address those concerns, we felt there
would be no better group of doctors than our seniors
– those who battled with SARS 17 years ago. We were
interested to hear what the seniors, with the wisdom of
experience and hindsight, would have to say to this new
cohort. Thus, we have paired one senior with each junior
for this special series, and will be featuring their insights
in the coming months.
Jul 2020 SMA News 11AN UNPRECEDENTED EDUCATION Text by Dr Clement Sim
In Singapore, the activation of the safe distancing measures are essential, such times will allow us to appreciate
Disease Outbreak Response System it has definitely made my final few the various measures taken within the
Condition (DORSCON) level to Orange months in medical school difficult. hospital, as well as inculcate safe practices
meant the universal ban of all medical Once our final examinations were which are cornerstone to the profession.
students from any clinical posting. This done, the only thing left was our While I am grateful to be back in the
was a sensible decision with the intention Student-In-Practice (SIP) postings which clinical setting, I am worried about the
to protect medical students from the were also required for our timely curriculum of my juniors. I have heard
high-risk situation and to minimise the graduation. Fortunately, the faculty at their concerns about being out-of-touch
possibility of transmission from the Duke-NUS Medical School was quick to with their clinical skills as well as the
hospital to the community. However, as come up with an alternative to our usual delays in their curriculum in general.
a medical student, it was initially difficult curriculum while waiting for clearance To this end, I continued to encourage
to appreciate these intentions; to us, from the Ministry of Health to allow them to make the most of their time to
our education was more important. Our us back into the clinical setting. They revise on their clinical knowledge, spend
graduation was more important. designed four weeks of content that time with their families and look after
With the announcement of involved both online Zoom lectures as themselves, both physically and mentally.
DORSCON Orange on 7 February 2020, well as appropriate face-to-face sessions. These uncertain times have required
my family medicine posting at Bright These online lectures focused on various the implementation of unprecedented
Vision Community Hospital was halved. skills needed during our time as a house measures. It has definitely taken a toll
I was upset at the loss of a valuable officer and important lessons by allied on everyone, not just the medical profes
opportunity to finally learn about the healthcare professionals. In addition, sionals. Fortunately, it is encouraging to
importance of community hospitals in simulation exercises were organised for see the various initiatives to help the
the transition of our patients’ care back small groups for sessions such as critical community as well as those who volunteer
into the community. In addition, I was conditions and airway management. to help within the hospitals. This is not a
starting to become concerned about Overall, these four weeks proved to be fight we can win as individuals but one we
the prospects of my final examinations both beneficial and productive amid can win together. While some may worry
as well as student internship, both of these uncertain times. about graduating as a doctor to enter
which were required for the completion When we were informed that we were the workforce during such times, I am
of my medical degree. It was a period of going to begin our SIP postings on 4 May genuinely excited about finally being able
uncertainty I had to live with. 2020, I finally felt relieved. Relieved that to contribute and doing what I can to help.
With the implementation of safe I was done with the numerous online
distancing measures, many aspects of lectures, relieved that I could finally head
the final examination were affected. back to do clinical work, and relieved Dr Sim is a House Officer from Duke-NUS
Medical School currently posted to the
Firstly, group study sessions had to that I could graduate on time. Due to Department of Orthopaedics Surgery in
be done online, making physical safe distancing measures, students were Singapore General Hospital.
examination and procedural practices posted to hospitals nearest to them; even
difficult. Next, the actual examination within the various institutions, SIPs were
itself saw the unprecedented need to divided into smaller groups to prevent
segregate not just the students, but cross-contact. At the point of this writing,
the patients and the faculty as well. I have successfully completed my SIP in
Finally, once we were done with our surgery and one week of my medical SIP.
examinations, we were not able to From my point of view, getting students
congregate as a class to celebrate. While back into the clinical setting during
12 jul 2020 SMA NewsTHE EVOLUTION OF PREPAREDNESS
Text by Dr Agnes Tay
February 2020: “Paediatric clinics lives, all fear is gone, because I know He the many battles faced by GP colleagues,
count as specialist clinics, so we’re not holds the future…” to whom I take my hat off!
allowed to order Ministry of Health A few years after SARS, there was the In most medical practices outside
(MOH) personal protective equipment H1N1 pandemic. That time, MOH was a of dormitories and hospitals, patient
(PPE) from Zuellig. “Tried calling lot better organised and my solo practice attendance during the circuit breaker
Zuellig, can never get through!” “Zuellig received a generous stream of free PPE! has plummeted drastically. While
will supply two boxes of N95 masks It turned out to be a bit of a false alarm, personally thankful that I am now a
but they only have the 8210, no stock which lulled me into a sense of salaried employee in a small group
of the smaller 8110 that we use…” complacency – I thought I would never practice, I am well aware of mounting
The flurry of texts and conversations have to struggle with N95 masks again. financial pressures in these practices,
brought a sense of deja vu, giving me including ours. Yet, though the economic
flashbacks to a similar hunt for N95 Yet, here we are, in May 2020, three
months after moving into Disease lookout is grim, the sight of our closet
masks during SARS… filled with PPE gives me courage for the
Outbreak Response System Condition
March 2003: Alone in a solo practice Orange, and still in the throes of circuit long road ahead to recovery.
that wasn’t even two years old, I breaker. In many ways, COVID-19 is a Pandemic or not, internship through
struggled to hunt for information tougher battle than SARS, much longer the ages has traditionally been a year of
ranging from PPE vendors willing to drawn out and with many puzzling sleep deprivation and missed meals, a
supply PPE in small volumes, to medical facets. Still, there is much to be thankful roller coaster of highs and lows, but most
updates. Even worse, I recall vividly for. After some initial hiccups, we are of all, it is a time of learning. As the battle
the crushing sense of isolation and now blessed with a steady supply of against COVID-19 continues, internship
helplessness that engulfed me when I PPE – items made more precious when will surely be a year of precious lessons
saw on the news that a dear friend M, we read about the shortages faced by in the science and art of medicine. I
a solo GP, had seen a SARS patient who healthcare workers elsewhere... urge our young graduating doctors
was then linked to a cluster. Although we to embrace fearlessly the challenge of
Today, thanks to much improved
had been good friends in junior college caring for patients, colleagues and self.
electronic communication, healthcare
and medical school, SARS happened in This is the challenge our profession
workers in Singapore no longer face
the era before WhatsApp and Facebook, has faced through the ages, and one in
a pandemic in isolation. Indeed, we
so it was a scramble just to find a current which we stand in greater solidarity than
sometimes contend with information
contact for her. It was a relief to find her ever before, as we seek to serve together
overload instead. I am very thankful for
well after her self-quarantine, but sadly with sincerity and humility.
my MBBS 1984 class WhatsApp group,
SARS went on to claim the lives of several
with its amazing mix of journal updates,
healthcare workers in Singapore.
MOH chats, jokes, brain teasers and Dr Tay enjoys her work in a small paediatric
Fear of infection aside, one of my debates. (Thanks, CK, for feeding us the group practice in the heartlands. Outside
growing fears during SARS was that latest journal articles complete with of work and church, she busies herself with
of insolvency. Not only was there little explanations and commentaries; and reading, writing and revising her bucket list
revenue because patients were scarce, post-COVID-19.
George, for faithfully relaying MOH
but there were loans to be serviced and chats and circulars!) Similarly, our
bills for bulk purchase of PPE to be paid. private paediatrician chat group serves
On the long drive to work each morning, up a blend of journal articles, webinar
I tried to encourage myself with these reminders and humour. Thanks to
lines from my favourite hymn, “Because COVID-19, I learnt to use Telegram and
He lives, I can face tomorrow. Because He now have a much better appreciation of
Jul 2020 SMA News 13OPINION
Text by Dr Jipson Quah
The COVID-19 pandemic has utterly
changed the way we live in the last
six months. In my last editorial for the
June issue, I suggested that COVID-19
is akin to Thanos, the scourge of
mankind in Marvel’s Avengers. As
doctors from different disciplines and
specialties, we are like an assembled
team of superheroes (nothing like the
Virus Vanguard please!).
The GPs and family physicians are
represented by the Guardians of the
Galaxy – well, because they continue
to work tirelessly in long clinics despite
heightened risks and decreased
revenue. They also “guard” the
community by conducting Swab And
Send Home (SASH) clinics and running
the Public Health Preparedness Clinic
programmes, serving as the primary
institutions of care.
Our polyclinic colleagues have
been overwhelmed with a horde
of acute respiratory infection cases,
SASH requests and isolation facility
deployments, on top of the already
exploding polyclinic caseload. A bit
like Groot and Drax the Destroyer,
strong and stoic.
As part of the “Doctors in
Training” issue, I would like to
reflect on how Thanos has forever
changed the way we, as doctors,
learn and interact. Many of us
have suffered as a result of Thanos’
desire to decimate the population.
Countless local and overseas
postgraduate examinations,
including the Graduate Diploma
in Family Medicine (GDFM), have
been cancelled or postponed. This
inevitably delays specialist exits
and promotions. Our public sector
heroes, represented by Captain
America and Captain Marvel, cannot
be promoted to Major just yet.
Worse still, there are some among
us who have been called back from
Health Manpower Development
Programmes (HMDP), with no
make-up plans in sight as yet. As the
14 jul 2020 SMA Newspandemic situation progresses, it may tutorials have been very well Necessary sacrifices
still be a while before HMDP training instructed. Tutors and tutees alike
With digital learning, we lose out
institutions, especially those in the US, have coped well with the change in
on the ability to conduct hands-
UK and Europe, welcome back HMDP the method of instruction, despite
on sessions, which is absolutely
fellows from Singapore. Just like Thor the lack of face-to-face interaction;
imperative as we hone our skills
without his mythical hammer Mjolnir, online tutorials have also reduced
as medical practitioners. Objective
our surgical colleagues are grounded, the problem of having to book an
structured clinical examinations
unable to fly or operate. Perhaps like appropriate meeting place for the
are a big part of our training. By
in Marvel’s Avengers: Endgame, they session each time.
now, there are many tutors who
risk turning to booze and getting fat As one of the largest postgraduate reminisce fondly about grilling their
due to severe inactivity. programmes, the GDFM has quite tutees and examination candidates,
a sizeable attendance. During the spurring them to greater heights of
Taking the battle online circuit breaker period, we have been medical knowledge.
On the bright side, Zoom/Webex/ able to each save about one to two
hours of travelling time to and from Lastly, I am sure many of us also
Google Meet tutorials are probably miss seeing our friends and teachers
here to stay. In my GDFM course, the tutorial or workshop locations. For
a class of 500, that equates to about in person, and sharing a catered
we used to have problems with tea-break with them (and sometimes
attendance-taking at the module 700 man-hours. Assuming that the
Guardians of the Galaxy are able to multiple ones). Hey, Avengers need
workshops, forming long snaking to eat too right? It would be really
lines when the lecture was just convert these hours into time worked
at the community isolation facilities nice for the Avengers to assemble
about to start. Additionally, the over food and education too, once
presentations and speakers are (paying at a rate of $140/hr), that is
about $98,000 per week! we have settled Thanos.
invariably delayed during physical
sessions, causing further disruption With the proliferation of online
to our learning. With online tutorials, webinars, it has also been much
at least ten to twenty minutes can easier to accumulate continuing Dr Quah is a GP and
be saved, though it is usually spent medical education points. In the pathology clinical officer in
waiting for everyone to settle down. past months, in addition to GDFM private practice. He enjoys
music-making, fitness
lectures and tutorials, we have been
Online GDFM workshops also tend activities and editorial
treated to a buffet of webinars. Not
to move along faster, as participants work in his spare time.
only do we have superb updates
are able to ask questions in an
on COVID-19 management, we can
open chat room, which encourages
choose to attend webinars from all
speaker-audience interaction,
different disciplines. SMA recently
minimises awkward silences and
conducted a hugely successful
allows the presenters to focus on
three-hour webinar on telemedicine,
key questions. In a chat room, many
in conjunction with the Ministry
colleagues are much more keen in
of Health, Academy of Medicine,
asking difficult questions and the
Singapore, College of Family
chat room format also allows for
Physicians Singapore and Enterprise
top questions to be sifted out for
Standards Singapore, and we had
discussion. It has also probably been
close to 1,800 participants, mainly
easier to “arrow” participants from
comprising doctors. You will be
the audience, with everyone’s name hard-pressed to find a location that
and MCR number proudly displayed can hold that many participants, not
in the participants’ list. to mention parking lot availability.
In a similar vein, our GDFM (No need to pay $12 parking fees
tutorials have also been conducted and queue at the exit gantry for
smoothly in an online setting. half an hour, where you can’t honk
Although connectivity and/or the horn or cut queue impatiently
sound issues may arise at times, I because every car has an SMA decal
personally find that these online and every driver is also a doctor.)
Jul 2020 SMA News 15OPINION
Text by A/Prof Nigel Tan
By now, we’re all familiar with the medical students could no longer and examinations soon after the
COVID-19 pandemic and its effects on learn and see patients in healthcare Disease Outbreak Response System
the world, society and our healthcare institutions. Faculty swiftly moved Condition level was raised to Orange. By
system. The disruption it has wreaked towards e-learning, online quizzes, video doing this collaboratively with medical
has been unprecedented in this century. conference tutorials via Zoom and using schools and the clusters, it provided
As doctors, our whole way of life, both simulation for procedural skills training. much needed clarity for the effective
personally and professionally, has been Final MBBS examinations had to be implementation of these adaptive
upended in a short space of time, ever adapted at short notice, using simulated changes. I was heartened by the
since Singapore’s first imported case of patients and reorganising the objective consultative approach MOH took with
COVID-19 infection in late January 2020. structured clinical examinations for the schools and the residencies. Tough
As a clinician-educator, I’ve seen student, faculty, staff and patient safety. decisions had to be made, and there
the same disruption happen to our Technology proved to be a major boon, was sometimes robust debate, but once
medical education systems – from and “technology-enhanced/enabled the decision was made, everyone pulled
medical schools to residencies – learning” became a new buzzword that in the same direction.
affecting thousands of students and the faculty quickly learned. For example, the final year students
residents. It has been a hectic and For residents, some previously had to start work slightly earlier after
trying time for students, schools, planned rotations were paused to passing their examinations to ensure
residents, programmes and faculty in avoid cross-institution movements, they were prepared for the new
the first 100 days of the pandemic as leading to much reorganisation demands and clinical environment
we struggled to adapt. Yet in many of rosters and rotations. Some of the COVID-19 pandemic. This
ways, this struggle has helped many of examinations were even cancelled – generated some unease among the
us clarify and reaffirm our professional for example, the Membership of the students – while some took to social
identities as doctors and educators. Royal College of Physicians Practical media to bemoan their shortened
So many things have happened Assessment of Clinical Examination holidays, others were concerned
that it would be impossible to Skills examination – leading to worried about infection risks. The schools and
describe them all, but I will try and residents wondering if they could MOH, recognising these sentiments,
describe some of what happened progress in their training without proactively communicated with the
and frame it using three themes – these examinations. Residents were students via dedicated Zoom sessions
adaptability, learning and solidarity. also posted out to community care to allay their concerns and explain
facilities. Residents and programmes, the rationale behind this policy. The
Adaptability however, adapted quickly to make students’ concerns were assuaged, and
contingency plans for rotations at this time of writing, they appear to be
This was what got us through the first
and examinations, communicating coping well as new house officers.
100 days. There were rapid and far-
frequently and proactively to residents
reaching changes in so many areas
as our understanding of the disease to allay concerns. Learning
changed and as Government and On a system level, the medical While on the surface our students
international policies shifted as we schools and the Ministry of Health and residents seem to “lose out” in
learnt more about the virus. The need (MOH) adapted swiftly as well. MOH learning opportunities, in truth the
for safe distancing measures meant crafted policies on conduct of training pandemic offers rich learning in other
16 jul 2020 SMA NewsSo many of my colleagues I’ve
spoken to have expressed how they’ve
rediscovered their values and identity
as a doctor amid this crisis. In the
dormitories, junior doctors find new
purpose in caring for our migrant
workers, inspired by senior doctors
working alongside them. In hospitals
and clinics, senior doctors now have a
little more time to reflect and refocus
on their clinical duties and the “core
business” of being a doctor. Whether
senior or junior, several colleagues
have told me how this reflection and
rediscovery of purpose has reminded
them of why they wanted to do
medicine in the first place, and that the
reforging of their professional identity
through the fires of the COVID-19 crisis
has made them even more determined
less-visible aspects of the medical example of professionalism despite to remain true to their mission of
curriculum. While the obvious new adversity, and I hope our junior doctors helping others.
learning opportunity is the skill of can learn from these exemplars.
donning/doffing of personal protective Conclusions
equipment, our students and residents Solidarity
It has been in many ways a tumultuous
are also learning about infectious
This brings me to the final theme of first 100 days of the COVID-19 pandemic,
diseases, epidemiology and public
solidarity. The hashtag #SGUnited has as seen through the lens of a clinician-
health in real time as the pandemic
been trending on social media, and educator. We’ve had to adjust and adapt
unspools around them.
has been a rallying point for many rapidly to help our students and resi
Importantly, as our medical Singaporeans. This pandemic has dents, with a tremendous amount of
officers and residents go out to also brought doctors in Singapore groundwork done by multiple parties,
the community care facilities to together in the realisation that we have but in return we have been rewarded
manage the populations there, or common goals, and that while we do with extraordinary opportunities to learn
when they take on new roles doing sometimes disagree, it is time to put new skills.
triage and screening of potential aside differences and fight a common I’m proud to say that as a profession
COVID-19 patients, they have an enemy. In the realm of education, it is we have been equal to the task, with the
invaluable opportunity to acquire new immensely satisfying to see schools, medical education system displaying
knowledge and skills. These include residencies, healthcare institutions and adaptability and resilience despite
resource management and logistics, MOH coming together to get things being buffeted by forces both local
decision-making in uncertainty, done (often with tight timelines and and global. These struggles have not
systems thinking, understanding over weekends) to ensure adequacy daunted us but instead given us
social determinants of health, the of training while not compromising invaluable opportunities to reflect on our
importance of communications, student or patient safety. professional identity, reaffirm our unity
and the role of culture in medicine. As educators, we talk about and rediscover our sense of purpose.
Importantly, this helps to train professional identity formation,
adaptability, innovativeness and where a doctor (or medical student)
resilience, as our young doctors grows in “stages over time, during
wrestle with and solve emergent A/Prof Tan is a senior
which the characteristics, values and consultant neurologist at
problems on the ground in real time. norms of the medical profession are the National Neuroscience
I’m also gratified that many senior internalised, resulting in an individual Institute and Deputy
thinking, acting, and feeling like a Group Director Education
doctors – both from the private and
(Undergraduate) at SingHealth.
public sector – have volunteered their physician”, to quote from Richard and
help in these areas. I feel this provides Sylvia Cruess. This is an important
wonderful role-modelling for all to concept, where being a doctor is not
learn from. The way our senior doctors merely about acquiring knowledge
have quietly sacrificed their time (some and skills, but about internalising the
in private practice have even closed values of the profession and behaving
their practices) to steadfastly provide professionally at all times.
care in these facilities is a shining
Jul 2020 SMA News 17OPINION
THE
BAC RE A
rtho K A ND
s CO GA
An O
-19 J IN
po d’
VID
our ney
Text by Dr Jonathan Tan
The COVID-19 pandemic has caused the local community and another in migrant workers could not understand
upheaval and change all around the the migrant worker dormitories that why they had to be isolated. Some
world. For me, it has led me on a almost spiralled out of control. There had not even been told that they were
journey from being a spine surgeon are many people who have served COVID-19 positive. Those who knew
to an orthopaedic surgeon, then longer and contributed more over were worried as they had been reading
a doctor and finally to a potential the past few months then I have in for months about the mounting rate of
patient under quarantine. I suppose the short weeks that I was serving. COVID-19 deaths worldwide. They did
it was inevitable that I ended up on However for me, it was one of the not know how long they were to be
home quarantine. My siblings and I most chastening and humbling confined and when they would be able
are either doctors or have married experiences in my medical career. to return to work. I couldn’t tell them
doctors and most of us, in some I had treated many foreign workers when they would be out of isolation;
way or form, had been exposed to as an orthopaedic surgeon. I liked I didn’t know when things would
COVID-19 patients. My sister-in-law to think that I had been a caring be normal again. I could only hope
had worked in a medical ward the doctor and that I had done my best and assure them that things would
past month and she developed a to ensure their welfare. Working in improve, and they did. A steady stream
sore throat one Sunday morning. the dormitories, however, made me of supplies from both governmental
Before the day was over she had reconsider my opinion of myself. Did and non-governmental organisations
been swabbed and an ambulance I truly understand them as patients? began to arrive and seeing the workers’
had been dispatched to convey her Had I truly treated them as individuals morale and our rapport improve was
to the hospital. or as fractures to be fixed and patients an extremely fulfilling experience. I
to be sent home as soon as possible? hoped that I would be able to serve till
A tale of two cities Speaking to them, I learnt something the end of the circuit breaker but alas,
about what they liked to eat and a little this was not to be.
Prior to this, I had been serving as
part of the medical team in a migrant about what they believed – perhaps it
was time for me to learn more about In the same storm but not in
worker dormitory. I suspect that when
these men who built my country. the same boat
the history of the COVID-19 pandemic
in Singapore is written, it will be one As doctors we like to have answers When my sister-in-law got diagnosed
that tells of two different pandemics and solutions for our patient’s problems. I could not help but wonder – was I
in the same country. We all know the It was extremely humbling to realise the one who had brought the virus
story of a well-controlled outbreak in that I had none. Many of the infected home with me? Had I accidently
18 jul 2020 SMA NewsDr Tan is currently an associate
consultant at the Division
of Spine Surgery, National
University Health System. He
is grateful for the opportunity
to pursue his dreams, and
is thankful for the love and
support of his parents and
wife, without which none of
this would be possible.
touched my face or rearranged my I could not help but compare my that opportunity is taken away. I still
mask while seeing the patients? life under quarantine to those of my kept in contact with the rest of the
Had I breached the safety protocol patients. I did not have to worry about medical team and I got first-hand
in my haste to get out of the stifling my job and I knew exactly when it accounts of how many patients they
heat and personal protective would end. I did not have to deal with were treating and the issues they
equipment? It was okay if I was the uncertainties that my patients faced every day. It is very hard to be
infected; statistically I had a pretty dealt with. I could work to some part of a team and not contribute,
good chance of recovering, but degree and most importantly I was but I knew it was better to stick to the
what about my pregnant wife, my together with my loved ones. I could rules and complete my quarantine
young children and my parents? The take this opportunity to spend time rather than be the potential cause of
next few days were quite stressful with my family while I knew some of another cluster.
as both my kids had to be swabbed my patients had not seen their family This quarantine experience has
to make sure that they were not in years. Simple things like having the in some ways been a blessing in
asymptomatic carriers. Restraining a space to exercise or a choice in what
three- and two-year-old while they disguise; it allowed me to spend
to eat were luxuries my patients did time with my children and helped
are being swabbed is not a pleasant not have. It would have been churlish
experience for the child or the me prepare them for the arrival
of me not to count my blessings and of my third child. My sister-in-law
parent. I couldn’t help but wonder be thankful that all I had to deal with
what the neighbours thought about recovered without complications
was the stress of trying to sing my and no one else in my family was
the stream of ambulances appearing
daughter to sleep or re-enact the infected. At the same time, it made
at our house. Then a mobile team
story of David and Goliath for the me realise how fortunate and
was dispatched to my home and I
tenth time with my son. privileged I was to be a doctor, to
got to experience first-hand what
my patients experienced. Getting In many ways, the hardest part of be able to live in my country with
swabbed myself was an unpleasant being on quarantine was the feeling my family. I hope that when this
experience, and I realised that I had that I was no longer useful. I think that pandemic ends, we do not forget
not been entirely truthful when I one of the defining characteristics what we have learnt and make a
told my patients that it would only of all of us who practise medicine concerted effort to improve the
be mildly unpleasant. Thankfully we is a desire to be of service, to do living and working conditions of
all tested negative and it was time to our duty and help others. It can be these men who have helped build
settle in to life under quarantine. a disconcerting experience when our nation.
Jul 2020 SMA News 19You can also read
