“I remember my former boss Mr Lim Siong Guan used to remind us that “implementation is policy”. The effectiveness of a policy is not measured by how elegant it looks on paper, but how it is translated into reality during implementation. On this yardstick, we have to be honest and acknowledge that while the residency programme has its advantages and good points, some of the outcomes have not been as positive in practice as what we had originally hoped for. As with all major changes, what could have been better was a more gradual, step-wise implementation, with appropriate channels to acknowledge concerns of the medical fraternity, and to consider the impact of the changes from a holistic systems perspective.
After having some years of experience with the residency programme, the time is right for MOH to now review the programme. We want to retain the positive elements of the residency programme while taking concrete steps to address the problems we have encountered and improving the outcomes for our doctors. For this effort to succeed, we need to work closely with our professional bodies and doctors to listen to your feedback and see what we can do together to enhance the system. We need your help to work with us to achieve better training outcomes for our doctors and deliver quality care to our patients. I hope we can count on your support to embark on this review together”.
Senior Minister of State for Health, Mr Chee Hong Tat
Speech at SMC Physician’s Pledge Ceremony, 30 Sep 2017*
There you have it. Someone very senior has finally come out to declare that the Residency under the ACGME-I framework was and is a bad idea. Or at the very least, the implementation of the American system almost wholesale really sucked. This took honesty, courage and clarity of thought. Well, it was not for want of trying by many senior doctors and this hobbit as well to try to get the message across, but of course no one senior in MOH was really listening then.
Many fellow doctors have opined that the decision to introduce the American-based ACGME-I residency system was the brilliant work of some scholar or admin officer. This cannot be further from the truth. This was the idea of doctors, implemented by doctors, for doctors. Completely self-afflicted.
In my humble opinion, the urge to build personal legacies has a power to blind and deafen even brilliant and confident people, let alone insecure and lesser mortals. Many innocent and sincere people who tried to give real and useful feedback around 2008 to 2010 were steamrolled over like mush on the road after heavy monsoon rains. Some of them have left for the private sector as a result. They are now vindicated. May their professional souls rest in peace. Many of the others that remain continue to struggle daily to do their best to keep this residency system going, some against their best instincts. Hats off to them as well.
As for the residents themselves, they are also struggling. Junior MOs struggle to get a residency place now, since the number of places on offer are now greatly diminished. Those that are already residents know they need to see more patients and work harder to be properly trained, yet are curbed by work limits imposed on them by the ACGME-I system and they struggle to pass the British exams which are still part of their lives. And many of those that have exited as registered specialists with SMC and SAB now find themselves without jobs as Associate Consultants and have to settle for jobs with lower status and salaries in restructured hospitals. It is a lose-lose-lose situation that could have been entirely avoidable.
Anyway, just for old times’ sake, this hobbit reproduces two old articles about residency. The first is something he wrote which was published in the Nov 2009 issue of the SMA News (When he was still a regular contributor to the publication), “The Hobbit Residency Rap”. The second was a posting on this blog in Nov 2011, about a year after it had been rejected by the SMA News Editorial Board: “Residency Turkey”.
Dammit, I was funnier then.
“The Hobbit Residency Rap” (2009)
We should and must support residency
Just like we support urgency, hesitancy and intermittency
Yo! Doctor, please don’t criticise
Trust me, your words may get you ostracised
Don’t question and don’t be negative
Some folks take things personally and are very sensitive
If some things don’t make sense to you now
Please tell yourself, “That is because I am just dull”
Hey, we need many more specialists fast!
So too bad, apprenticeship is a thing of the past.
Trust the Americans to get healthcare right!
The traineeship system can go into the night.
Let the residents see fewer patients
While the rest see more with pure zest and elation
Hey baby, I know it sounds paradoxical
And some may even whisper, “It ain’t practical…”
But remember brother, you must not oppose this change
Lest they call you inappropriate or strange
You can decide which facets of truth you want to see
Unlike with BPH, then surely you cannot pee
Residency Thanksgiving Turkey (written in 2010)
As you read this, it’s near the end of the year and the holiday season is again upon us. Time flies. As with all things healthcare in Singapore recently (like Duke, JCI, Residency and Board Exams, the Hobbit goes American and celebrates Thanksgiving. For a start, here’s a recipe for a good Residency Thanksgiving Turkey:
One 7kg turkey, preferably caught from around College Road and slain by brute force with the bare hands of a simple-minded orthopaedic surgeon. If not, then get a frozen one imported from America that is suitably defrosted with naivety and bewilderment. Whatever the case, remember – remove the brain, heart and guts COMPLETELY! If not, this recipe will NOT work.
Juice of 2 BIG Singapore lemons
5 tablespoons of stupidity
5 tablespoons of single-mindedness and myopia
One cup of deafness
One cup of blindness
Mix the following:
One cup of hubris
One cup of white flour (Made from pure American Wheat)
Common Sense, boiled for 2 hrs, cooled, peeled and then finely chopped
National Pride – pounded violently and minced to paste
A finger of Local Tradition, grated to a fine dust
A sprig of parsley
One carrot finely chopped
One onion diced
Salt and Pepper to taste
A sprig of acceptance
A stem of blissful ignorance
3 tablespoons of cornstarch
2 cups of water
Salt and Pepper to Taste
Clean turkey. Remember to remove guts completely. Squeeze juice of two big Singapore lemons into cavity. Season skin and cavity with stupidity, single-mindedness and myopia. Stand for 30 minutes to soften muscle. Rub deafness and blindness onto skin and cavity liberally. Stand in roasting dish for 3 hours in the DARK. This is to ensure that when the bird is cooked, it is soft, compliant, tasty and quite divorced from reality.
Stuff Turkey with Stuffing. Close neck cavity and tail openings with string (not Prolene sutures, you idiot!).
Line roasting pan with lots of grease, preferably from Chicago or North Carolina. Roast Turkey in pan (breast-side down, to restrain/contain national pride).
For a 7kg turkey, 200C (or 400F, for the residents who are familiar with the American way of measuring things) for the first 30 minutes, then reduce to 175C (or 350F) for 2 hours, then reduce to 110C (225F) for next hour to hour and a half. Then raise temperature to 260C (500F) for 5 minutes to brown skin.
Remove bird to cool. Collect Oil and drippings into saucepan, add cornstarch and other gravy ingredients, flavor (Not “flavour”) with ignorance and acceptance. Bring to a boil and over low heat, reduce to a suitable opaque consistency.
Note – Residency Turkey usually tastes better when carved by senior medical administrators on footstools (never both feet on the ground). So do invite them for your next Thanksgiving Dinner!
Things to give thanks for over the Residency Turkey Dinner
We give thanks for
The fact that, like their American counterparts, our house officers (or R1) can only work continuously for 16 hours (i.e. no more over-night calls) and other residents will be entitled to 5 hours of uninterrupted sleep. They can only clerk several cases a day on call. In other words, they will probably stop work at 3pm when their quota is filled up.
And for all this, they will not get a pay-cut
We also give thanks that somehow with the residency programme, productivity and efficiency will seemingly be unaffected and healthcare costs will not go up, even though USA spends 16% of their GDP on healthcare and we spend 4%. Presumably, consultants can pick up the slack for free.
Finally, we also give thanks to the British training system that had more or less served us well but can now rest in peace.