Residency Revisited (2)

Now that MOH has announced that it will review the Residency Training System and also in the process seek feedback from stakeholders, here is some completely unreliable but nonetheless solicited feedback (This hobbit is a stakeholder – he’s going to need medical care later in life when he is an elderly hobbit. Remember, the Ring got thrown into the fire on Mount Doom and now this hobbit ages as rapidly as anyone else) to the relevant authorities when they seek to review the ACGME-I residency system and come up with a new and better system.

The new system could hopefully incorporate some of these feedback:

Feedback #1

A small country could be aligned to a foreign power or authority, but only if that alignment gives you benefits of recognition

Singapore needs to produce specialists of first-world standard. But the world may not believe us just because we say it’s first world standard. So, it probably needs some benchmarking to other larger, Anglophone first-world country: USA, UK, Australia etc.

We already had that in place when we took the UK exams. They recognised the MRCPs and FRCSes as equivalent to our M.Med exams and we had conjoint exams.

The problem with residency is that although the ACGME-I system is 80 to 90% similar to the ACGME system (no “I”), our ACGME-I products are not recognised to be good enough to practise in USA without further exams. ACGME-I is not even recognised in JB and Batam.

But what is the purpose of being under the American yoke when the Americans are not going to recognise us as being good enough to plough their fields? A yoked cow with no fields to plough makes no sense.

Feedback #2

Disappoint people earlier rather than later.

It is better to disappoint a house or medical officer early in his career. When he is young and unspecialised, he is like a “stem cell” – he has more options to differentiate. So, it is better to tell him, “Sorry, you cannot have the specialty (Say, ENT) you want”. He has options as a young doctor: he can apply for a family medicine or internal medicine training post or even leave for the private sector, work as a locum or join the ILTC sector or pharmaceutical industry etc.

When he is a licensed specialist, his options are limited. Sure, theoretically, you can tell the ENT specialist to join the ILTC sector, but is that realistic?

Feedback #3

Privileges come with responsibility. Specialty training is still an apprenticeship. Apprentices have to suffer more versus non-apprentices.

One of the most controversial aspects of the old residency system is that residents are mollycoddled with protected time and workload caps. In the past, trainees have to be better, faster and work harder than non-trainees for the same pay. This is entirely understandable because the rewards are there at the end of the road when the trainee becomes a specialist and a trainee is after all, an apprentice. An apprentice is a core part of the ‘family’ (specialty) while a medical officer on 6-monthly rotations is more like ‘hired help’. Apprentices have to work harder than hired help, because apprentices eventually inherit the mantle of the master. Hired help never takes over the master’s mantle.

The decision to let the resident work less than non-resident just flies in the face of fairness, especially in our Asian context.

Feedback #4

Rotation is good. Don’t stick to one institution

The ACGME-I system essentially ties you to one institution with very limited rotation opportunities. This may be necessary in large countries like USA and Australia. But in a small country like us, more rotation is better.

It allows a trainee to learn from different people and hospitals. Some hospitals and supervisors do things differently from others.

Also, rotation allows a better appraisal of the trainee from different vantage points. A trainee may not be bad, he may be, just for some reason, not well liked by his supervisor (i.e. bias?). Multiple assessors in different departments and hospitals will diminish the effect of bias on the part of one or two assessors/supervisors.

Feedback #5

Choosing a specialty should not be rushed

The decision to allow final year students to apply and get residency positions was perhaps the single most erroneous and unwise aspect of the residency system.

Most of our graduates come from the undergraduate system. They may not have the maturity to choose a specialty that truly suits them. In the past, almost all our professors told us to take our time to choose a specialty. Because it was important that we truly knew what we wanted before we make that choice.

In addition, it distracted final year students from doing what they needed to do most, help one another and study hard to pass the final exams. Instead, anecdotal evidence suggests that kiasu-ism came to the fore as final year students jostled for popular residency positions with one another even before they took their final exams.

The new training system should remove the option of final year students (and even house officers) being allowed to apply for training positions. Waiting a bit is good for everyone.

Feedback #6

In a small country, do not delink training from employment

In America, you can train in Minnesota and work in Florida or train in California and work in New Jersey. When the country is so huge and numbers are so big, delinking training and employment is necessary and central planning and control is unnecessary, maybe even undesirable and impossible.

It is different for a country/city-state with a population of 5M spread over 700 square miles. Example – NUH’s problem becomes CGH’s problem and CGH’s problems become TTSH’s rather quickly before it becomes a national (i.e. “MOH”) problem.

Feedback #7

The world does not rotate around Singapore. In the war for talent, a small country cannot have a rigid system that limits entry of talent that is in demand. As long as we maintain exit quality, multiple entry points are OK.

The residency system dictated that specialist training must have the same start and ending point. Many good people from overseas who had received some training and already with qualifications such as MRCP, MRCS etc were deterred from coming to further their training in Singapore because they had to start their training all over again at R1 (first year). In the past, Singapore could recruit registrars and they come in as ASTs (Advanced Specialty Trainees). Now this is not possible.

If you are a superpower like USA, you can dictate terms like this. But people are NOT going to lose seniority like that just to train in the Little Red Dot. In the global war for talent, this is a non-starter.

We should maintain strict exit standards, while entry points should be made flexible.

Feedback #8

Train for reality. Workload caps are surreal at best.

Reality as a specialist is that there are hardly any workload caps. You cannot limit a resident to say 8 patients a session under heavy supervision and then once he becomes a specialist, you load him with 30 patients and he is expected to make tough decisions the very next day. A few junior specialists have told me that life is hard to adapt to as a qualified specialist. The transition from senior resident to associate consultant is too sharp.

The new training system must train for reality, and the reality is that a specialist sees many patients and make independent decisions. Transiting them abruptly is doing them and their patients a disservice.

Feedback #9

Understand the context of the system you are trying to follow.

Is the American ACGME system bad? Not necessarily so. The American system was designed for a big country of more than 300 million people spending 16 to 18% of GDP on healthcare. Maybe it suits them well.

Can we adopt 80 to 90% of this system for a country of 5 million people spending 4% of GDP on healthcare?

Let this Hobbit frame it this way, 16 to 18% of GDP is what the ENTIRE Singapore Government lives on for all functions: defence, education, transport, housing and health.

We need contextual and reality checks before and when we plan and design the new system and if and when we decide to follow a foreign system.

Feedback #10

Listen to the professional bodies. Ignore them at your own peril.

When the residency was first mooted, all the big professional bodies (PBs) expressed serious reservations. We can only hope the minutes of the meetings then reflected this accurately and the feedback was likewise accurately passed on to the politicians. They need to avoid being ill-advised and they have to know the hard truths when they make decisions. In any case, MOH does not have a good record when it comes to ignoring PBs’ feedback and advice. Here are a few examples:

• SMA told MOH Night Polyclinics was a bad idea. MOH went ahead. In the end after several years, Night Polyclinic service had to be terminated.
• College of Family Physicians (CFPS) actually said letting GPs prescribe Subutex was a bad idea. This was ignored, which led to the huge Subutex problem later on.
• The PBs also said loosening regulations on medical advertising was not to be embarked on hastily and so comprehensively. Look at the medical advertising scene now.
• SMA also stated unequivocally that withdrawing of the SMA Guidelines of Fees (GOF) was against public interest. But hey, all the relevant authorities let the GOF die and SMA had to reluctantly withdraw the GOF. That’s why we are in this mess now.

The current residency system is just another example of MOH ignoring PBs’ feedback and most stakeholders ending up worse-off.