Postgraduate Medical Education in Singapore

LOW Poh Sim, YAP Hui Kim & Stacey TAY Kiat Hong
Department of Paediatrics, National University of Singapore, Singapore.

 

Medical Education in Singapore

The history of medical education in Singapore dated back to 1905 when the King Edward VII College of Medicine was founded. Through the years, its name has undergone several changes - King Edward VII College of Medicine, Faculty of Medicine in the University of Malaya, Faculty of Medicine in the University of Singapore and finally in 1980, it took the current name of Faculty of Medicine in the National University of Singapore (NUS). The medical course is closely modeled after that British medical schools and the medical degree is accreditated with the British General Medical Council.

Postgraduate Medical Education in Paediatric Medicine

Before 1957, Singapore doctors pursue postgraduate medical training in the various specialties including paediatric medicine in overseas institutions. Postgraduate medical education became organized with the founding of the Academy of Medicine, Singapore in 1957 and the Committee of Postgraduate Medical Studies in 1961, the predecessor of the School of Postgraduate Medical Studies (PGMS). In 1962, there were only six trained paediatricians in Singapore. In 1962, the Department of Paediatrics of the University of Singapore trained postgraduates locally and these doctors sat for their higher qualifying examinations in the United Kingdom (MRCP) or Australia (MRACP). Between 1962 and 1970, five paediatricians were trained. With the establishment of the PGMS, the Department of Paediatrics organized training programmes and courses for local training of paediatricians. Candidates sat for examinations leading to the Master of Medicine in Paediatrics degree. In a span of ten years, 62 paediatricians were trained. This system laid the foundation stones for postgraduate training and certification of paediatricians and with this programme Singapore achieved a high standard of child health. The infant mortality and neonatal mortality rates fell from 31.2 and 19.1 per 1000 live births respectively in 1962 to 11.8 and 8.4 per 1000 live births respectively in 1976.

It was soon realized that the basic training of three years and the holding of the Master of Medicine in Paediatrics or its equivalent do not make the postgraduate a paediatric specialist. In 1991, a Joint Committee on Advanced Specialist Training (JCAST), a tripartite body comprising representatives from the Academy of Medicine Singapore, the Postgraduate School of Medical Studies, NUS (and subsequently the Graduate School of Medical Studies, NUS in 1998) and the Ministry of Health was formed to coordinate the training requirements and assessment of postgraduate training of doctors. This body was legislated to become the Specialist Accreditation Board in 1997.

In 1997, there was a change in the postgraduate examination system with the establishment with the Royal College of Physicians (UK) of the conjoint examination with MRCP (UK) and Master of Medicine in Paediatrics. Following changes in the Membership examination system in the United Kingdom this relationship was subsequently transferred to the Royal College of Paediatrics and Child Health for a conjoint examination in the MRCPCH diploma and the Master of Medicine in Paediatrics since the year 2000.

Training Requirements in Paediatric Medicine

Basic training in Paediatric medicine commences a year after full medical registration and lasts for three years during which the postgraduate doctor must acquire a recognized postgraduate degree of Master of Medicine or MRCP or MRCPCH. Conferment of the postgraduate qualification together with fulfillment of training requirements signifies the completion of basic training. The next phase of training (Advanced Specialty Training) comprises another three years and upon fulfillment of training requirements, the doctor is assessed in an exit evaluation for final accreditation as a Paediatric Specialist.

Summary of Training Programme and Examinations

  1. Basic Training in Paediatric Medicine

    Master of Medicine in Paediatrics (NUS, Singapore), conjoint with MRCP (UK) / MRCPCH (UK)

    Primary examination for MMed (Paediatrics) or MRCP (Part I) or MRCPCH (Part I)
    Final examination for MMed (Paediatrics) or MRCP (Part II written and clinical) or MRCPCH (Part II written and clinical)
  2. Advanced Training in Paediatric Medicine

    Training period: 3 years
    Entry requirements: Completion of 3 years Basic Training including passing MMed / MRCP/MRCPCH.

    Exit Assessment:

    The Board of Assessors will review the following:
    a. Quality and quantity of training
    b. Research and publications
    c. Teaching experience
    d. Structured oral assessment

The following is the structure of basic and advanced training programmes in Paediatric Medicine in Singapore.

STRUCTURED TRAINING PROGRAMME FOR PAEDIATRICS

The goal of the Structured Training Programme for Paediatrics is to provide broad educational exposure to the paediatric trainee in order that he/she attains sufficient competency to practise general paediatrics in the community, as well as to participate as a team member with the various paediatric subspecialists in providing comprehensive care to children with chronic and complex illnesses.

A.

Programme targets

The targets for the basic paediatric trainee are to:

  • Be competent in the medical interview, physical examination and ordering of investigations and management of general pediatric conditions
  • Learn to diagnose and manage acute pediatric emergencies
  • Learn to diagnose and manage chronic problems that require tertiary care
  • Recognize normal and abnormal growth and development from infancy to adolescence
  • Recognize normal and abnormal child behaviour and development
  • Understand the influence of genetics on diseases
  • Be competent in handling social and ethical issues related to the patient and his/her family
  • Develop communication and interpersonal skills
  • Develop procedural skills
  • Be familiar with common paediatric surgical, orthopedic, otorhinolaryngeal and ophthalmological problems
  • Participate in research/paper writing
  • Inculcate a personal commitment to continuing medical education.

Paediatric trainees are expected to obtain eligibility for the conjoint MRCPCH(UK)/M.Med(S'pore) degree in Paediatrics after two years of training.

The targets for the advanced paediatric trainee are to:

  • Undergo training so as to attain competency in practising paediatrics as a consultant
  • Attain subspecialty training
  • Develop maturity and appreciation for the bioethical issues in patient care
  • Undergo training in clinical/laboratory research
  • Acquire and hone teaching skills

Upon satisfactorily completing advanced training as ascertained by the Specialist Training Committee (STC) for Paediatric medicine and accreditation by the Specialist Accreditation Board (SAB) of the Singapore Medical Council (SMC), he/she can be registered as a paediatric specialist and be appointed Senior Registrar /Associate Consultant.

 

B.

Duration and scope of programme

For basic paediatric trainees, the duration of basic training is at least 3 years, and must include a miniumum of 6 months of neonatology rotation and 1 year of general paediatrics rotation. The scope of training includes a broad exposure to the health care of children and experience in the management of diverse acute and chronic pathological conditions. During the paediatric rotations, the trainee is expected to receive exposure to the paediatric subspecialties such as paediatric emergency medicine, ambulatory paediatrics, allergy and immunology, cardiology, endocrinology, gastroenterology and hepatology, haematology and oncology, nephrology, neurology, pulmonology and critical care medicine in terms of outpatient clinics, multidisciplinary combined clinics and inpatient management.

Advanced paediatric trainees will receive 3 years of advanced training, during which a trainee must have at least 1 year's experience in general paediatrics, and may rotate through a maximum of 3 subspecialties, which may be any of the following: paediatric emergency medicine, allergy and immunology, cardiology, critical care, endocrinology, genetics, gastroenterology and hepatology, haematology and oncology, nephrology, neurology and developmental paediatrics, pulmonology and neonatology. Neonatology is a minimum 6-month compulsory rotation.

In addition, a minimum of 6 months of paediatric emergency rotation either in a paediatric emergency or combined adult/paediatric emergency facility, or 1200 hours of acute walk-in clinics rotation, must be completed within the 6 years of training.

 

C. Core content

Basic Trainees

1. Didactic teaching

This should be conducted on a regular basis and should include the following components:

  • Core lectures which emphasize on pathophysiologic correlates and principles of diagnosis and management of the various acute and chronic diseases, and basics of biomedical statistics and evidence-based medicine
  • Journal updates
  • Seminars
  • Interactive problem solving sessions, which comprise of data analysis, grey cases and slides of clinical material.
  • Clinical conferences
  • Weekly teaching rounds that focus on the educational objectives of recognition of multi-organ failure, integration of clinical and laboratory assessment, and management principles of acutely ill patients
  • Mortality rounds
  • Clinical teaching sessions which prepare trainees for the conjoint MRCPCH(UK)/M.Med.(Singapore) clinical examinations
  • Paediatric radiology sessions

The core lectures are conducted as a national programme for all basic trainees whereas the other components of clinical training are center-based.

2. Rotations

Inpatient Rotations

The bulk of the rotations will be through general paediatrics but 1 to 2 monthly rotations should be made through the following subspecialties such as: paediatric intensive care, cardiology, endocrinology, gastroenterology and hepatology, haematology and oncology, neurology, nephrology, and pulmonology. A 6-month rotation in neonatology and at least one year in general paediatrics is compulsory during basic training. During the inpatient rotations, there must be sufficient exposure in emergency and acute illness management. The purposes of night call are to provide patient care, assume clinical responsibility, teach and supervise and accumulate clinical experience. Night and weekend duties must be sufficient for these purposes and should occur with a monthly average of 5 per month. Call-free rotations should not exceed 4 months during the 3 years of training. The 1-year training in general paediatrics must include at least 450 hours of intensive care calls.

The core content for inpatient experience should include diagnosis and management of acute episodic medical illness including meningitis, sepsis, dehydration, pneumonia, respiratory failure, diarrhoea and dehydration, cardiac failure, urinary tract infections, renal failure, seizure, shock, coma, hypotension, hypertension and respiratory illnesses. The trainee should also be provided training in the diagnosis and management of acute problems associated with chronic diseases including diabetic ketoacidosis, status asthmaticus, status epilepticus, oncologic therapy and complications, congenital heart disease, chronic renal disease, chronic lung disease, gastrointestinal disorders, hepatic failure, metabolic disorders and neurologic disorders. The trainee should also acquire knowledge and experience in the paediatric aspects of the management of surgical patients, both preoperatively and postoperatively, including interaction with the surgical team.

The comprehensive experience for all residents should also include but not be limited to the following disorders:

  1. Acute childhood infections, sudden infant death syndrome, skin infections and childhood exanthems.
  2. Acute major and minor surgical problems such as acute appendicitis, bowel obstruction, burns, foreign body inhalation/ingestion, abscess drainage and head trauma.
  3. Poisonings
  4. Non-accidental injury and sexual abuse
  5. Minor trauma including splinting, casting and suturing
  6. Major trauma, including active participation with the trauma team
  7. Acute psychiatric, behavioural and psychosocial problems
  8. Routine newborn care, developmental assessment, vaccinations schedules, safety issues and childhood nutrition

Outpatient Rotations

Monthly rotations will be made through the following subspecialties such as ambulatory paediatrics, cardiology, endocrinology, gastroenterology and hepatology, haematology and oncology, neurology, nephrology, pulmonology, allergy and immunology. All trainees must have a minimum of 400 hours outpatient clinic experience under supervision during the period of training, with a maximum of 600 hours per year.

3. Clinical supervision

Trainees must be supervised at the inpatient and the outpatient levels by registrars/senior registrars/consultants.

The procedural skills appropriate for the basic trainee are:

  1. Basic and advanced life support
  2. Endotracheal intubation (20)
  3. Venepuncture (100)
  4. Placement of intravenous (50), osseous (1) and arterial (10) lines
  5. Umbilical artery (5) and vein (5) cannulation
  6. Lumbar puncture (20)
  7. Urinary catheterisation (20)
  8. Thoracocentesis and chest tube placement (5)
  9. Subcutaneous, intradermal and intramuscular injections
  10. Conscious sedation
  11. Inhalation medications
  12. Suprapubic tap

( ) indicates the minimum number of procedures required for competence.

4. Medical Information Sciences

The trainee will be required to:

  • Acquire basic computer skills to be able to utilise hospital-specific patient management networks
  • Perform electronic retrieval of medical literature
  • Access electronic information networks

5. Academic Papers & Conferences

The trainee will be exposed to the many on-going clinical trials and research projects in the department. As such, they will assimilate the concepts, strategies and work of these researchers and may also choose to participate in research. Participation in research will provide the trainee with the opportunities to author a paper and attend conferences to present his/her work.

Advanced trainees

The advanced paediatric trainee is expected to be competent in the above core content for basic trainees. In addition, he/she is expected to participate in the following programmes listed below.

1. Didactic teaching

This should be conducted on a regular basis and should include the following components:

  • Departmental grand rounds and mortality rounds
  • Clinical conferences
  • Journal updates
  • Seminars
  • Subspecialty conferences
  • Paediatric radiology sessions

The advanced paediatric trainee should be actively involved in the preparation, presentation and critique in the above sessions.

2. Rotations

During the three years of training, a trainee must have training in general paediatrics and may rotate through a maximum of three subspecialties, which may be any of the following: allergy and immunology, cardiology, endocrinology, genetics, haematology, hepatology and gastroenterology, intensive care, neurology and developmental paediatrics, nephrology, oncology, pulmonology, and neonatology. A 6-month rotation through neonatology and a 1-year rotation through general paediatrics are compulsory for all advanced trainees. The 1-year rotation through general paediatrics must include at least 3 months experience in the intensive care setting, or 600 hours of intensive care calls.

3. Clinical exposure and supervision

Clinical duties will include supervision of a ward, inpatient consults, outpatient general and subspecialty clinics, and special procedures provided in a subspecialty. Responsibility for supervision is accorded by the consultant heading that particular subspecialty, and includes clinical work, research focus and 6-monthly assessments. Subspecialty trainees in the following divisions are expected to achieve competence in the following:

  1. Allergy and Immunology - to be familiar with interpretation of skin prick tests, allergen challenge tests and desensitization protocols. To have a good working knowledge of the management of atopy, acquired allergic disorders, immunodeficiency disorders, and current consensus about immunization and vaccines.

  2. Cardiology - to be able to manage and coordinate care for patients with simple and complex cardiovascular lesions, particularly congenital and acquired heart disease in the acute and chronic settings. To be able to participate in the care of pre- and post-operative patients having open and closed heart surgery. To have special emphasis on X-ray interpretation, electrocardiography, echocardiography, exercise testing and ambulatory electrocardiography. To have experience in diagnostic cardiac catheterisation, electrophysiologic testing and pacemaker implantation.

  3. Critical Care - to be able to manage patients with acute life-threatening conditions in the context of the intensive care unit, and to develop special competence in areas such as cardiopulmonary resuscitation, stabilization for transport, trauma, triage, ventilatory, circulatory and neurological support, continuous monitoring and nutritional support. The trainee should gain procedural experience in long line and central line insertion, endotracheal intubation, thoracostomy tube placement, sedation, and be familiar with the use of pulmonary artery catheters and intracranial monitoring.

  4. Developmental Paediatrics - to understand child development from infancy through young adulthood and to be able to diagnose and manage developmental disorders, learning disabilities and behavioural disorders.

  5. Emergency Paediatrics - to be able to manage and evaluate paediatric emergencies, and to develop a special competence in areas such as cardiopulmonary resuscitation, trauma, transport, triage, sedation, and to develop skills in prioritising and managing the emergency care of multiple patients.

  6. Endocrinology - to be able to diagnose and manage a spectrum of endocrine disorders such as diabetes mellitus, short stature, and endocrine disorders of the pituitary gland, hypothalamus, thyroid and adrenal gland physiology and problems of reproductive endocrinology, calcium metabolism and endocrine neoplasia. To be able to perform and interpret the appropriate hormone stimulation and suppression tests.

  7. Genetics - to be able to identify congenital anomalies, birth defects and syndromes, and to be able to provide genetic counselling for the parents. To be able to interpret genetic tests such as karyotyping, linkage analysis and to be familiar with the appropriate laboratory techniques used in diagnosis of genetic diseases.

  8. Haematology and Oncology - to develop an understanding of the pathophysiology of paediatric haematologic and oncologic disorders and competence in the clinical diagnosis and management of these disorders. The trainee must be familiar with all aspects of chemotherapy, surgical therapy, radiotherapy and bone marrow transplantation in managing patients with malignant diseases. They must also be able to manage complications and treat infections in the immunocompromised host. They should be able to stage and classify tumours, to understand the application of multimodal therapy and also to have experience in supporting the patient, family and staff in dealing with a terminal illness.

  9. Hepatology and Gastroenterology - The trainee is expected to have experience in diagnosis and management of acute and chronic gastroenterological and hepatological disorders. Practical skills and technical knowledge in GI endoscopy, abdominal paracentesis, percutaneous liver biopsy, rectal biopsy, small bowel biopsy, anorectal manometry, breath hydrogen analysis and oesophageal pH monitoring is expected.

  10. Infectious Diseases - to be able to provide optimal care and consultation to paediatric patients with infectious diseases, and to be familiar with concepts in immunology, epidemiology and infection control in the context of prevention of infectious diseases.

  11. Neonatology - to develop competence in the management of critically ill neonates, including techniques of neonatal resuscitation, venous and arterial access, endotracheal intubation, ventilatory support, continuous monitoring, temperature control and nutritional support. To be able to institute the appropriate intervention for high-risk infants, to identify birth defects and counsel parents and to be able to perform routine newborn screening and the appropriate follow-up of infants with abnormal test results.

  12. Nephrology - to be able to diagnose, evaluate and manage acute and chronic renal conditions, fluid and electrolyte and acid base disorders, and to have experience in management of renal transplantation and dialysis therapy. To develop technical expertise in renal biopsies, renal ultrasound, acute and chronic peritoneal dialysis, acute and chronic haemodialysis and continuous arteriovenous/venovenous hemofiltration/dialysis.

  13. Neurology - to be able to perform and interpret evoked potential studies, nerve conduction studies, electromyography, electroencephalography and cranial ultrasonography. To have the critical knowledge required in the management of epilepsy, paediatric neurological disorders and neuromuscular disorders. To be able to manage the spectrum of neurological disorders requiring critical care.

  14. Pulmonology - to be able to diagnose and manage patients with acute and chronic respiratory disorders, and to be able to handle ventilators, and acute pulmonary emergencies. To be able to perform paediatric bronchoscopy under supervision and to interpret paediatric sleep polysomnography.

4. Research, Academic Papers & Conferences

The trainee should demonstrate a commitment to their own continuing medical education and participate in scholarly activities. Every advanced specialist trainee is encouraged to conduct one research project annually, and to present the results at a local/regional/international conference. The trainee must publish at least one first-authored journal paper during the period of advanced training. The trainees are encouraged to participate in clinical trials and also to undertake laboratory research.

5. Teaching responsibilities

Advanced specialist trainees are expected take an active interest in the education of medical students, interns and residents. The advanced specialist trainee should demonstrate a commitment to education and sound clinical teaching abilities.

 

D. Training documentation and assessment

Documentation of work experience and training received will be monitored for both basic and advanced trainees with the logbooks provided by the Graduate School of Medical Studies. Six-monthly assessments by the training supervisor and interview of the trainee will be performed. Six-monthly reports by the training supervisor will be submitted to the Graduate School of Medical Studies.

 

E. Programme organization

1. Eligibility

Application for paediatric traineeship is allowed if the individual has completed 1 year of housemanship and 6 months of residency upon graduation with a recognised basic medical degree with the Singapore Medical Council. Successful completion of basic training and the acquisition of the MRCPCH or Master of Medicine in Paediatrics from NUS will make the trainee eligible to go on to advanced training. Overseas-trained doctors who have obtained their postgraduate qualifications in paediatrics, such as the MRCPCH (UK) or Master of Medicine in Paediatrics (NUS), may apply to the Graduate School of Medical Studies for admission into the advanced specialty training programme, according to the guidelines and manpower needs set out by the Ministry of Health.

2. Minimum and preferred teaching faculty: trainee ratio

All the members of the teaching staff should have received accreditation by the Specialist Accreditation Board. The teaching faculty should represent all the full range of paediatric subspecialties and other related disciplines such as paediatric surgery, radiology and child psychiatry. The minimum teaching faculty to trainee ratio is 1: 2 and the preferred teaching faculty to trainee ratio is 1: 1.

3. Requirements for facilities for study and training

Adequate inpatient and outpatient facilities must be available to meet the needs of the general and subspecialty programmes. There must be a full intensive care facility, as well as a facility for dealing with paediatric emergency patients. Patients should range in age from newborn through to adolescence, and adequate numbers of inpatients and outpatients, as well as new and follow-up patients must be available. Support services should include clinical laboratories, intensive care facilities, occupational and physiotherapy, speech pathology, diagnostic imaging, respiratory therapy, pathology, pharmacology and social services.

Trainees must have access to on-site library or collection of appropriate texts and journals, as well as computer access to electronic databases and on-line search engines for medical literature.

4. Feedback

Six-monthly interviews with the trainees should be conducted to ensure that the training objectives for each rotation have been adequately met as well as to monitor for any difficulties workload and training activities. Feedback forms should also be provided at the end of each 6-month posting, and the programme supervisor should be responsible for collating the results and instituting the appropriate changes to improve the quality of the training programmes.

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