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
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.
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:
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.
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.
1. Didactic teaching
This should be conducted on a regular basis and should include the following components:
The core lectures are conducted as a national programme for all basic trainees whereas the other components of clinical training are center-based.
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:
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:
( ) indicates the minimum number of procedures required for competence.
4. Medical Information Sciences
The trainee will be required to:
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.
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:
The advanced paediatric trainee should be actively involved in the preparation, presentation and critique in the above sessions.
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:
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.
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.
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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