It was announced recently that a new common curriculum for incoming NUS dentistry, medicine, nursing and pharmacy students will be introduced (The Straits Times, 16 Aug 23)1.
The Straits Times reported that the aim of the common curriculum covering five modules was to “imbue in students a greater awareness of social issues and their impact on health, as well as cultivate teamwork, communication skills and digital literacy. Students will also learn about working and communicating in multidisciplinary teams, as well as the legal and ethical principles underpinning the practice and delivery of health services”.
“The curriculum combines healthcare, data science, artificial intelligence and information technology to equip students in using data effectively to improve patient outcomes and information flow across healthcare IT systems”
The above stated purposes are indeed laudable. Let’s hope they can achieve what they set out to do. But why stop here? As this hobbit looks back on his medical education received from the local medical school as well as what is happening around him now, he cannot but think that there were some things that the School can do to improve things further.
Here are a few suggestions as to how the curriculum can be improved even more with the introduction of a few more fresh modules….
The IHIS/Synapxe Module
On 27 July 23, the organisation called IHIS (IHIS – Integrated Health Information Systems) was renamed, or to be exact, given “a new identity”, as Synapxe. In his speech on that day, Minister for Health said that IHIS/Synapxe “is a 4000 strong organisation today”2.
IHIS has been in existence since 2008. It is therefore NOT a new organisation, and it is a big organisation that is responsible for providing IT support to the public healthcare system and rolling out the NEHR to the private sector as well. Its influence permeates every aspect of care in the public sector, which consists of the three healthcare clusters that contain 10 restructured hospitals, 23 polyclinics and as well as community hospitals and national specialty centres.
From the many conversations this hobbit has had with quite a few young doctors, they don’t seem to be aware that IHIS/Synapxe exists even though it has been around for 15 years and what it is actually supposed to do. All these young doctors know is that they have to grapple with an EMR that is so important that the restructured hospitals and polyclinics are almost paralysed when the system is down. Even specialists in the public sector don’t know what this organisation is supposed to do. So it is important that we educate our medical students about Synapxe comprehensively and how big and important it is.
To put things in perspective, there are some 4000 people working in Synapxe. From the SMC 2021 Annual Report (the latest available on the SMC website) there were 4,368 specialists employed in the public sector. That means for every public sector specialist providing care to our patients, there is also one Synapxe employee working behind the scenes.
To put things in even bolder relief, according to the 2022 Allied Health Professionals Council Annual Report, there were 1485 diagnostic radiographers, 1003 physiotherapists, 154 radiation therapists, 249 speech and language therapists and 520 occupational therapists working in our restructured hospitals, national specialty centres and polyclinics (i.e. the three public healthcare clusters) in 2022. This makes a grand total of 3411 Allied Health professionals from these five groups employed to deliver important care in the three public healthcare clusters, but this number is still significantly less than the number of people employed by Synapxe! Come to think of it, our medical students should really learn how to work with Synapxe employees since there are more of them than there are allied health professionals.
Medical Law Module: Lawful, Unlawful and Lawless
The aforesaid Straits Times report stated that medical students will learn about the legal and ethical principles underpinning the practice and delivery of healthcare services. Presumably, they will learn about legislation such as the Medical Registration Act, Medicines Act, Healthcare Services Act etc as well as the SMC Ethical Code and Ethical Guidelines (ECEG). This is excellent because this hobbit didn’t think he was taught any of these laws while in medical school. We need to teach medics more than the science and art of medicine, they need to know what is lawful and ethical and what is unlawful and unethical.
But this is also not enough. We need to teach them about what is lawless too. There are organisations such as third-party administrators (TPAs), insurance companies, such as Integrated Shield Plan (IP) providers that can influence, organise and even direct healthcare provision but at the same time do not come under any law that regulates how they do so and ensures that they do not undermine the practice of ethical or lawful clinical medicine.
For example, IP providers are regulated to ensure they are sound financially, but there is no law that can stop or punish an IP provider from suddenly stopping coverage for something as fundamental as a colonoscope, or for denying coverage to a policyholder for colon cancer because he had bleeding from piles 10 years ago. These are the lawless aspects of our healthcare environment that every medical student should learn early – the sordid facts of life that a doctor will face sooner or later as a doctor.
Patient Confidentiality and Privacy Module
We always talk about patient confidentiality in our medical ethics lessons and when teaching our students and young doctors about the dos and don’ts when accessing and using EMR and NEHR. But we never talk about patient privacy rights. In fact, there is nothing on patient privacy and their privacy rights in official documents that this hobbit is aware of. Hence, there are also no established standards to articulate what is a patient’s right to privacy.
Which is kind of incredible for a first-world country such as ours.
Every ethicist worth his salt will tell you that it is almost impossible to define a patient’s confidentiality rights well before we have some clear idea about what are the patient’s privacy rights. How does one define a patient’s confidentiality rights when there are no privacy rights standards and therefore he has no established and expressed rights to information privacy in healthcare? Confidentiality is built on the foundation of privacy. But somehow, we have been able to talk about ensuring patient confidentiality by suspending it in thin air without anchoring it to the principle of privacy.
This hobbit wonders how much longer can we continue to ignore teaching the principles of patient privacy and privacy rights to our medical students (and for that matter, to all healthcare professionals as well) and just continue to harp on only ensuring patient confidentiality. Its like trying to teach medical students histopathology without first getting the student to learn histology and anatomy
The Expectation Module
We really need to educate our medical students that they have to moderate their expectations of the good material life that they think they will have. This should be done right after matriculation.
Here are the numbers. As of 2021, there were 16,044 doctors licensed to practise medicine in Singapore, of which 6,431 were specialists. The number of doctors increased by 776 over the previous year.
Twenty years ago, in 2001 (SMC Annual Report 2001), there were 5,922 doctors in Singapore, of which 1930 were specialists. The number of doctors increased by 345 from 2000.
Over 20 years (2001 to 2021), the number of doctors increased by 2.7 times and the number of specialists increased by 3.33 times.
The doctor-population ratio in 2001 was 1: 678. In 2021, the ratio had fallen to 1:3693.
Our medical profession is growing a lot faster than the general population. The population in Singapore hasn’t increased by 2.7 times in 20 years, even though they have aged and should consume more health care per capita. But the fact remains that doctors are fast losing any rarity effect that they used to enjoy.
Unfortunately, the number of freehold housing properties and Certificate of Entitlement (COEs) have not increased as quickly as the number of doctors here. In fact, the vehicular population is now at almost zero-growth. The end result is that most doctors of the future will not be able to enjoy the so-called finer things in life that their predecessors did: large cars, freehold condominiums and landed properties, golf club memberships etc.
Going forward, the median income of doctors will move more and more towards the median income of the general population. The end result is that things that can only be afforded by say, the top 5 to 15% of income earners will be out of reach of many doctors unless they have parental assistance to purchase these things or they are at the top of their game in terms of earnings. This would include private housing and it won’t be long before we see large segments of the profession staying in HDB flats. Hopefully, doctors in the future should still be able to afford HDB Prime and Plus HDB flats.
Our medical students need to know that given the numbers, this scenario is all but a certainty due to the inevitability of statistics. And we should really tell them the whole truth as early as possible. Of course, there will be still be a very few within each cohort that can end up in big houses and own very expensive sports cars, but these will get rarer and rarer as long as the doctor population is growing at a much faster rate than the general population.
Don’t get this hobbit wrong, there is nothing wrong with staying in HDB flats like 80 to 85% of the population. This hobbit grew up in a HDB-shire and thoroughly enjoyed his 30 years living there. He may yet return to one when he gets older to enjoy the amenities and subsidies that HDB dwellers enjoy. But he is worried that many young doctors and medical students may set out with material expectations which are misaligned with the eventual reality that many of them will experience.
3https://www.moh.gov.sg/resources-statistics/singapore-health-facts/health-manpower
hobbitsma 