Academic Meritocracy and Medical School Admissions

Recently there has been some disquiet about the NUS Faculty of Medicine (sorry, this YLLSOM thingy never quite jelled with an old coot like me. My degree is from Faculty of Medicine, not some guy who gave a lot of money to NUS) accepting students from ‘less than the best academic’ records and more varied sources (read: not just RI and HCI).

A certain Anthony C.H. Leong wrote in The Straits Times (23 July 2019), “What is wrong with the meritocratic old ways of judging by the quality of the candidate’s academic results, further refined through an interview? We tell our children to work hard academically to get the relevant results for the course they wish to pursue in university, only for them to be denied a place by some populist policy. Their parents will have to cough up a fortune to send them overseas. I don’t think those who are unfairly rejected, especially those who do not have the means to go overseas to study, would think very kindly about their country and its professed meritocracy”.

There are quite a few points raised in this quote that needs addressing. First, we need to understand what is the purpose of a medical school, especially a state-funded medical school. The purpose of the NUS Faculty of Medicine or YLLSOM (OK lah, he did give a lot of money to get his name on this school) is to produce the better doctor, or the best doctors it could to serve Singapore. This hobbit emphasises “to serve Singapore” because YLLSOM is largely state-funded (i.e. by taxpayers). To serve Singapore may be of secondary importance if it was privately funded, but it is not.

The primary purpose of YLLSOM is not to fulfil someone’s aspiration to be a doctor, although the individual’s aspiration and the YLLSOM’s primary purpose are not in conflict with each other, philosophically speaking. This may sound somewhat brutal, but that’s  the hard truth. They only come into conflict because of the scarcity of resources – the number of places YLLSOM can take, with the limited resources it has (funding, manpower, space etc), versus the number of people who want to become doctors.

Second, a primer on meritocracy. The word meritocracy comes from the word ‘merit’ obviously. Meritocracy is about putting people in power and/or privilege due to the ability they have, and not due to other factors, such as wealth or social position/inherited titles. We seldom say it, but the people rewarded in a meritocracy, by a meritocracy, are actually the “meritorious” (deserving of merit).

The Cambridge Dictionary describes meritocracy as a “social system, society, or organisation in which people get success or power because of abilities, not because of their money or social position”.

The next point about a meritocracy is that there are many forms and notions about meritocracy. What Mr Anthony Leong has described is academic meritocracy. This concept of meritocracy is widely held by large swathes of society, no thanks  to cultural or even governmental norms. But it is not the only form of meritocracy. For example, when we reward athletes for their performance in competitive sports or highlight citizens for acts of kindness, service to community, valour, or moral fortitude, these are, in a way, also forms of meritocracy, but the norms are different. A National Day Award from the government, such as the Public Service Star, is based on non-academic norms of meritocracy. A person who swims the fastest 100m butterfly in an Olympic Game gets the gold medal and is given S1M. The world and Singapore society have decided that he is “meritorious” and hence deserving of the medal and cash award. But it is another form of meritocracy that is not academic meritocracy. Academic meritocracy is simply a form or meritocracy based on academic ability and performance.

Dynastic and feudal China since  the Sui Dynasty in 6th century AD practised academic meritocracy through the imperial exams. People who excelled in these exams were put in positions of power as officials of the imperial court. Sometimes, the Emperor himself witnessed the final round of these exams himself and marked some of the scripts! Surely this is sponsorship and belief in academic meritocracy of the highest order! Yet one of the main reasons China faded as a superpower in the Qing Dynasty is that it clung to outdated norms of academic meritocracy. People were rewarded and appointed because they excelled in the Classics and Confucian Texts and not on Science and Maths. The world (especially Europe) moved on while China was stuck in backward feudalism. So even as we support and uphold meritocracy, we need to examine and revisit what are the norms of society so that the form and substance of meritocracy remains relevant to the needs of society. Academic meritocracy is no exception.

Back to YLLSOM. As aforesaid, its main aim is to produce the best doctors that it could to serve Singapore. Academic meritocracy is nothing more than an allocative tool to achieve this main aim. Academic meritocracy is not an end in itself.

There are several ways to look at what YLLSOM is trying to achieve by moving slightly away from pure academic criteria for admission into its ranks. First, it is an admission that academic performance is NOT the only meritocratic norm for admission.

Secondly, the correlation between a good doctor and outstanding A level academic performance is not that strong. It is true that you need to have above average academic performance to survive the rigours of medical education. But is a straight As at H2 with three H3 paper distinctions student more likely to make a good doctor than a student with 4As at H2 with no H3 papers? Or will the student with 2A and 1B at H2 necessarily make a worse doctor than a student with straight As at H2 level? The answer is obviously “no” to these questions. Beyond attaining a minimal level of academic achievement necessary to suggest the student has the ability to complete his MBBS, academic performance at A levels does not predict or correlate with his eventual performance as a doctor.

Thirdly, by admitting people from different backgrounds, YLLSOM is perhaps admitting that it is important to have diversity in the medical profession. We need brilliant people to be the next professors of medicine and make scientific breakthroughs. We also need less brilliant (but still intelligent-enough) people to be  the doctors serving patients in the community. Both are equally important, and everyone else in between.

Diversity also prevents groupthink. The risk and downside of groupthink is very real, whether in the medical profession of any organisation. Just look at the Hong Kong government now and the unrest in its society. It is probably a result of groupthink in its highest ranks that prevented them from seeing the grave repercussions that have arisen from trying to push through the now infamous Extradition Bill.

Actually, the policy of choosing people not just based on the best academic performance for Medicine is not new. It is just expressed in a different form. Those of us who entered NUS Medical School in the eighties will remember that the government then had a policy of deliberately trying to shunt the best students to other fields such as Engineering or the Arts because it felt it needed the best academic talent not to be concentrated just in Medicine. There was apparently a PSC officer at the medicine admission interviews (sitting at the extreme left or right of the panel of interviewers) who would offer you “a deal” of sorts – would you want to consider a teaching scholarship? Or a PSC scholarship to Cambridge to read Maths? We never knew whether these offers were real or not, but we were all advised by our seniors to say “no” to show our resolve to become doctors. I know of quite a few people with A level “perfect scores” who did not get into medicine. And while there was no evidence to prove so, people with less than perfect scores seemed to have a better chance of getting into Medicine in the eighties.

In summary, this hobbit thinks:

  • The job of YLLSOM is not to give out places as awards or rewards for academic excellence under the framework of academic meritocracy. It’s main job as a publicly funded medical school is to produce the best doctors it could for Singapore.
  • Academic meritocracy, which is meritocracy based on academic ability, is not the only form of meritocracy. Academic meritocracy is often used as an allocative tool, but it is not an end in itself.
  • The norms of meritocracy are as important as meritocracy itself. The norms determine who is meritorious, and these norms have to be examined and revisited from time to time so that meritocracy remains relevant to the needs of society.
  • Beyond attaining a required level of academic performance that suggests the person can withstand the future rigours of a medical education, there is little correlation between actual performance as a doctor and his A level results.
  • Diversity in a medical school cohort is important, because each cohort has to fulfil different roles in society. Diversity also prevents groupthink.

 

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.

 

Residency Revisited (1)

“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)

Thanksgiving Time

 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:

Residency 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.

 Seasoning

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

 Stuffing

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

 Gravy

A sprig of acceptance

A stem of blissful ignorance

3 tablespoons of cornstarch

2 cups of water

Salt and Pepper to Taste

 Instructions

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.

 

*https://www.moh.gov.sg/content/moh_web/home/pressRoom/speeches_d/2017/speech-by-mr-chee-hong-tat–senior-minister-of-state-for-health-2.html

Hobbit’s Guide to Exams

Ah, it’s that time of the year again.

Sweaty palms, palpitations, a flash of exhilaration when you see his face, or maybe crushing despair.

No, I’m not talking about Choi Siwon, Justin Bieber or even Pornsark Sukhumvit… I’m taking about Examinations. The favourite thing to love/hate by all Singaporeans. We can’t live with it, we can’t live without it. We are well trained since primary school to take examinations, in fact, we love it so much that we now have multiple smaller exams to train and prepare us for the big one. As part of a self-selection process, those who excel in the academics (i.e. Chao muggers who get pristine As) end up in Medicine, where even more exams take place to delight the heart of any kiasu parent.

From M1 to M5, there are end-of-posting tests, MBBS part I, part II, part III. Then whichever sub-speciality you choose, more exams to take, part I, part IIa, IIb, IIIx, Vz etc. In fact, because of the higher fail rates, some doctors have to retake these exams several times. Isn’t it a strange observation that these exams are rather expensive, and can be held overseas; and some doctors are so dead-set on passing them that they would fly all over to re-take the exams anywhere? So maybe there must be a set percentage of failures per year so that there’ll be returning customers? After all, the overseas colleges charge a fee, the organising committee charge a fee, and our own Singapore JCST charge a fee, even if the exam is not held here! But, this is a groundless comment, just my own flight of fancy. Of course, there are some strange doctors out there who have too much time and money on their hands, and are known to have sat for all the available sub-specialty exams available. These are the Professional Examinees. One famous example is Prof Chee Yam Cheng who passed Part 1 of MRCP, FRCS and MRCOG just for kicks. Then he became a hospital administrator, which does not require even a MBBS. Talk about irony. (Prof, in case you are wondering, I am the short squirt who is walking around your hospital with hairy feet and without a tie, and I am NOT one of the housekeeping staff)

The Hobbit is a simple doctor – I don’t have those fancy letters after my name. But I do know many people, oh the great and powerful, who have achieved greatness and success in their chosen fields. Let me put together some pearls of wisdom, and share this guide to passing the examination with you (without having to pay S$23.99 or subscribe to my blog; as many enterprising American residents have done to guarantee plus double-confirm “Success in ABSITE”.)

In studying:

1. Use short simple textbooks (preferably with lots of colourful pictures- for example, do you remember the full text of Lord of the Rings? No right? You only remember the spiffy quotes like, “You shall not pass!” (sorry. Bad example.). One such textbook is “The Black Book of Clinical Examination” by Tey Hong Liang and Erle Lim, two of the most pre-eminent examination sadists of our times.

2. Avoid using seniors’ notes (nice for revision purposes, but a bit silly to use this as your main textbook. Especially if said senior is now a part-time GP with interest in cosmesis- do you really, really want to use his notes from 2000?)

3. Start early – this is no problem for most of you medical students, because mugging is in your blood. Unlike the Wizarding World, we are very proud of our Mugger blood. But there are a few brilliant, talented ones- eh, whose talents probably lie NOT in studying- who continue to be very active in sports and the Arts. Trust me, MBBS or MRCS or MRCP – hard to wing it last minute and squeeze years of learning into 1 week of hard core revision. Can be done, but rather stressful. I do not recommend it.). For postgraduate exams, it is important that you can start early with examination sadists/gurus to get into the scheme of things from the onset. Long ago, the ultimate exam guru were folks like Prof Ng Han Seong and Prof Rajasoorya. Now there are still folks like Erle Lim who can destroy your ego and confidence in 47 seconds. Better now than in the exam later.

Exam technique:

1. Spot questions (seniors have traditionally handed down a TYS- ten year series- where examination questions are committed to their formidable memories all throughout that 3h of essay, and then transcribed and circulated for future batches. Worthwhile to look through and know what are the common perennial topics- “What are the structures in the T1 plane? Course of facial nerve? Classical signs in SLE and scleroderma? Signs of chronic liver disease?”)

2. Train for the right arena – If essay- bring in nice pens with smooth action and ink that doesn’t smudge. If MCQs- if the past 15 answers were D, something is wrong. If oral exam- practise to talk well. More on this later.

3. Know thy enemy, know thyself (There are a few feared examiners locally, and the myth and legend surrounding them has grown over the years, as they become more senior and their own seniors and peers who know them personally have either gone into private practice or passed on. I have heard that medical students nowadays practice presentation to a life-size poster of Prof W, so that they can get used to the sense of panic and fear in case they encounter him in real exam. Bollocks. Everyone started out as medical students, and everyone has made novice mistakes sometime in their career. Yes we should respect these bastions and giants of our field, but to fear them like some tyrannical dictator is not necessary.

The clinical examination:

This merits a separate section because most of the failures are from this component, rather than the written. At the speciality examination, most sub-specs have a viva component as well, and it takes a different kind of skill set. No point knowing all the textbooks and journals in the world but cannot articulate your thoughts.

1. Dress well – For the men, that means shirt +/- tie; cufflinks may be excessive. Ladies- while looking sexy and helpless works in some fields- probably not in ours, but there have been cases. There was this one girl with- her skirt, her erm, chest- never mind- stories for another time. Conservative is always good. Leave the fashion statements of purple hair, shaven heads, multiple piercings and rings for personal time please. I have nothing against that- I dye my feet hair blue sometimes. I just like the colour. And I’ve got piercings in places you probably don’t want to know about. For both: An ironed, spotless white coat (splotches of curry or other more personal fluids are a definite no-no.

2. Speak well – If English is not your first language there is a natural disadvantage. For those with Singlish as a first language/mother tongue – Singlish is not such a great idea in the exams, “This 60 year-old auntie say that she got stomach pain, and then hor, she like, went to see her doctor, and then like, took something and then she was ok lor.” But please don’t put up an accent; it is a touch incongruous for Student 127 Tan Ah Hock to have perfect Queen’s English. It would also be pretentious for student 128 Aloysius Amadeus Tan A.K. to have perfect Queen’s English. *names above are fictitious. Any resemblance to real persons, living or dead, are purely coincidental* For those with serious stutters or confidence issues, can get lessons from speech therapists, toastmasters, etc.

3. Carry yourself well – You know how in a Beauty Competition, every contestant looks gorgeous – dressing sometimes irrelevant as they are skimpily dressed, those who speak well score better than those who messed up the Q&A (“Australia? You spell wrong, it is A-U-S-T-R-I-A!”). But the winner is some graceful creature who has this lovely, indefinable air about them- great composure, great stage presence, great charisma. Now that, my dear boys and girls, is what will make you shine in the clinical exam. Trust me, your seasoned examiners, and your seasoned patients (don’t forget, some of them are veteran patients returning year after year, you know, the ones that hold a glass of water in hand and know how to hold water in their mouth, THEN swallow; or the ones who know to breathe in-out-hold their breaths and lean forward JUST SO for you to hear that elusive murmur) – they know when you know what you are doing; or not.

My final tip for you, our minds work best by remembering no more than three things. You do notice that I have classified my advice accordingly. The long-standing success of trilogies stand as evidence to this observation ☺

The Desolation of Smug – Hobbit’s Guide to Being a Good Resident

“Residents”.
When I first heard this term, I thought, “As in, Permanent Resident versus Citizen?” or as in the game and movie “Resident Evil”? I also thought itmeant that the resident RESIDES in house 24-7, otherwise why the term? That first one year of rolling out Residency Program, there was chaos. It used to be that call rosters are straightforward, and hierarchy is clear.

The houseman clerks the patient (ie. talks to the patient, fills in something calling a “clerking sheet”, sets a plug, draws blood, does an ECG, orders a CXR). The good houseman gets all these done, steps ahead of the rest of his team. The bad houseman asks his MO to help, because having 2 admissions at one time is too hard to manage.

The medical officer then reviews the patient (by checking that the clerking was done properly, orders more stuff to try to impress the registrar; maybe tell patient things like “kiv CT”, “kiv “PFO”). The good MO functions as a top-notch HO as well as effective registrar. The bad MO hides in the call room and claims all the credit for the HO’s work.

There are different grades of HO/MO. The best ones are hardworking and smart of course; of the rest, they may be classified into:

Grade 1: lazy but smart- “Slacker”
Grade 2: hardworking but stupid- “Blur cock”
Grade 3: lazy and stupid- “Space cadet”
Grade 4: lazy and stupid but think they are God’s gift to Medicine- “Consultoid”

Consultoids actually aspire to greatness when they do not have any of the required ingredients; similar to current Mediacorp serial: “The Journey: a Voyage”. For those of you who have not watched this (which I reckon is about 99% of the profession), the serial is about 3 ASTs kena jammed by the residency system and now have to complete their specialty training overseas in strange foreign lands.

Treatment:
Grade 1: no need to do anything, they will drift into their chosen subspeciality or locum-land
Grade 2: keep teaching and hope that eventually something sinks in
Grade 3: leave alone- hope that they drift off out of medicine and never be in a position to do harm
Grade 4: no cure- they grow up to be bad registrars and bad consultants

The registrar does the final review on call, and makes the tough decisions (eg. What shall I get the team for dinner? Bak Kut Teh or Zi-char or pizza? BTW, YLLSOM graduates do NOT eat pizzas when on-call. These are reserved for those with posh-nosh foreign degrees)

Seriously though, in most disciplines, the most senior person who stays in-house is a registrar. He must make the right balance; manage sick patients independently without compromising patient safety. If everything call consultant, will be seen as useless; if everything don’t call consultant, may be seen as reckless. The good registrar knows his work, escalates to the consultant appropriately (rather than a phone call to say, “eh, sorry boss, should have called you earlier before patient went into asystole…” and looks after the junior team well. The bad registrar is the consultant’s worse nightmare. The smart con soon learns to be friends with the roster planner to avoid having a bad registrar on call for him.

The consultant on call is the final bastion. His word is law, his will be done. Except when there is a VVIP patient in which the consultant (especially a young one) will be reduced to standing around in the corridor until the Head of Department, Division Chairman, CMB, CEO, GCEO appear to make a collective decision on anything from performing major surgery to whether the VVIP gets fish or chicken porridge for breakfast. Otherwise, the good consultant is a master of his craft, a teacher, a good administrator, a good researcher and a healer. The bad consultant doesn’t really know his work, does not know how his hospital systems work, has forgotten (or maybe never knew) basic medicine and surgery. He was probably a consultoid in his younger days. The good consultant is well loved and well respected by his juniors and peers. The bad consultant is hated, being the cause of a lot of unnecessary work. (Refer endocrine for hypocount 14, refer GS for Hb 12->9 after hip replacement, refer CVM to start medicine for hypertension or fitness for OGD when it is obvious the bleeding peptic ulcer patient is going to die if an OGD is not done…)

Nurses used to know clearly whom to call to do certain things- actually, everything call housemen first. Housemen are the magical elves who make things happen. But over the years, as more and more duties get taken away from housemen- eg, phlebotomists take blood; nurses do ECGs, check blood before transfusion, etc; consents are taken by at least an MO and above… housemanship seems to become more and more about clerical work.

Now, back to RESIDENTS. Different programs take in residents at different years post-grad. Residents are a varied bunch- some have just graduated medical school, some are medical officers of varying seniority, a few are foreign grads who might not have working experience in Singapore, and some are trainees in the old system who got played out and had no choice but to change to the new. You can recognize them because they walk around with a look on the face that screams “Screw me harder – I can take it!!”. [machiam Leonidas from “300”]

So, a team of 3 HOs and 3 MOs may have 1 HO-resident, and 2 MO-residents- and the roster reflects them as “residents” instead of the traditional HO/MO. What this means on the ground is that, nurses were not sure who call to do changes sometimes! It didn’t help that some departments appointed HO-residents to tag on MO calls, without actually doing MO work because of the P-number, but also not doing HO work. While this may seem superficially to be beneficial for the HO-resident, it actually is detrimental! This HO may not learn enough skills as a HO to be effective at a MO level; and when he turns into an actual MO, can he perform his tasks? Anyway, the key message is that the clarity we had in the HO/MO days is now a royal mess.
A good resident is expected to be a super high achiever. The student who applied would firstly, have to have good grades; secondly, the compassion of Mother Theresa; thirdly, a national sports champion and finally, Friend to all. Continuing this self-fulfilling pattern, he then goes on having to live up to expectations of being in the 100th percentile for ABSITE, win President’s Charity Award, complete training in 4-6 years, get good feedback in the “360 feedback”, publish 10 papers a year and be the next DeBakey.

This Hobbit has noticed that more and more “junior” people are looking down on him. Not just because Hobbit is short. Residents seem to be uncertain how to behave- confidence comes across as cockiness; humility is a forgotten virtue. Yet, how many of them feel pressured to act confident because they fear showing any signs of weakness? Confiding in your peers may be the last mistake you make because you don’t know who will betray you to the PD (program director). No way is any resident going to confide in a senior. So how? Just hide behind a facade and try to juggle everything.

Please let this Hobbit reassure you, dear resident. Have faith (not just confidence, but faith)- you were chosen because you are good. Do not let anything distract you from being the best doctor you can be, and that comes back to the heart of what makes you a good doctor- your initial passion and empathy to want to help the sick.
You must have been a “hardworking and smart” HO/MO to get to where you are. Resist slipping and becoming lazy- being smart can only take you so far. Keep reading and studying and operating to stay “smart”- and not just book knowledge, but be an all-rounder- build up teaching, research and leadership skills. Don’t neglect interpersonal relationships- truly be friends with your peers, seniors, allied health; don’t be friends just to get them to do things for you. Be friends because you do want a good working environment and a second family. Remember to still invest time in your first family, whether it’s your spouse, your parents, your sibs, etc.

Find good role models, and aspire to be like them, or even better than them. Be a master in our craft- how did this consultant KNOW that patient had aortic dissection just by LOOKING? How did this consultant manage to “NEVER” have a perioperative morbidity? How did this consultant become so well loved by everyone? How can this consultant have >200 publications? Admittedly, role model consultants are getting rarer with each passing year as the old legends retire and the younger ones leave for private practice to escape the system that you are in now.

But then, what do I know? I just live in a hole in the ground.

Hobbit’s Guide to Being a Houseman: An Unexpected Admission

I have not been on call in years, so some of you may wonder- am I qualified to be writing a guide to housemanship. Uncle B had the misfortune to be admitted recently for severe abdominal pain- most likely from overeating or food poisoning from orcal-fecal contamination. You know how these disgusting orcs just poop everywhere. And what with our fondness for food and beer, good or otherwise – especially during Oktoberfest. Anyway, from where I was sitting at the emergency department where Uncle B was waiting for attention, I can observe many of the young doctors on the ground bustling around doing their changes, and what a heart-warming sight it is!

After hours of waiting in the P2 area in the emergency department, kept fasted because no one can exclude an acute abdomen, xrays done were unable to see free air or bowel gas because there was too much adipose tissue … anyway- we finally got a bed in the subsidized ward where we waited for a CT scan. Nowadays, a CT scan is ordered to diagnose anything from acute appendicitis to chronic ingrown toenail.

He had a precarious blue plug on his left hand- after many failed attempts… of course, our hairy feet precluded any chance of plug setting there. The drip was finishing- the trace of blood back-flowing up was mildly disturbing to him as a layperson.

A fresh-faced young lass came up to him and started clerking. Interestingly, she has already filled in much of the clerking sheet. The questioning went something like this,” So, Mr B? You know what you have? Pain right? Ok. Don’t eat until my senior comes and sees you. Thanks, bye.” Apparently, she has already obtained the history and physical examination from what was already available from online. The rest of the night was uneventful, except for my Uncle B making a fuss about to eat, and me secretly sneaking in a vending machine sandwich for him. He was discharged well the next day.

Being the good nephew that I am, I kept him company the whole night, and it was an interesting experience being the patient’s family, rather than being the managing doctor! From what I can see, housemanship has changed a lot since my time. For one thing, there’s a lot more of them! It used to be one houseman looking after 30-40 patients, now it seems like there are more doctors on a ward round then patients sometimes! Of course- in my time, policemen wore shorts, the television network was called SBC and most importantly, Britney Spears was still a virgin on the Mickey Mouse Club (OK I exaggerate on the last point. I actually meant Madonna).

Housemen nowadays are a mixed group, maybe one-third are “out-of-phase” doctors from foreign universities; some are post-grad doctors- most of them are “residents”, already pre-selected into a specialty training program, and some display this in a few ways:

1. Bochap-ness when it’s a condition outside of their chosen specialty

2. Confidence, bordering on arrogance when it comes to a topic that comes under their specialty (never mind that they are 2 weeks fresh out of medical school; all full of book knowledge but no clinical experience.)

3. Talking back to their registrars or consultants (it used to be, when my boss said jump, I asked how high? And just do it. Even if I can’t really jump, what with my bad knees. Now, residents will argue that there is no need to jump, if you want, go ahead and jump yourself.). Some even call their registrars and consultants by name (which in my time, along with buying McDonalds for supper, was a crime punishable by death or exile into the Phantom Zone).

However, this doesn’t mean it is all bad. We are still getting the best and brightest into medical school, so they must be the best and brightest young doctors. In fact, now that they have structured, protected training, they are even better than the current registrars and consultants. I bet, if the current Regs and Cons have to do the ABSITE, the scores will be dismal. So maybe they are entitled to their hubris. After all, residents’ and students’ complaints and feedback are taken so seriously that Registrars and Consultants get penalized; while it is near to impossible to fail a HO/MO, no matter what a lousy doctor he/she is.

Skills and job requisites for housemen have changed a lot as well. I think the key skills needed now are:

1. Proficiency with computers- with the rollout of electronic platforms for EVERYTHING, a good doctor must be one with the computer. Tracking patient’s location, ordering investigations, getting consent, tracing notes from other institutions, looking at imaging, changing settings, reviewing medications, etc. Naming these programs Sunrise and Aurora may be misnomers. More appropriate names are “Hangman”, “Crashes” and “Error loading”.

2. Fluent in Acronyms- SOOB, BIBA, TOC, ERx, CPSS, C-DOC, OTRS, OOTS, CPACS, AIC, CMIS, ROSC. OMG, LOL.

3. Diploma in printer repair- a good doctor must know how to unjam paper, replace toner, replace ink; change printer settings from single to double page; must know how to print things from a remote location because the printer in your ward just won’t work, especially when there’s an emergency OT chit to be printed out before the porter & nurse can bring patient down to the OT.

4. Certificate of competency in Whatsapp-ing (SMS is so ‘90s)- the convenience of chat groups for a generation raised in this media age is a welcome escape from actually having to talk to a colleague to hand over cases. If clinic reviews may be done via Facebook or Snapchat, it’ll be embraced. An example:

Postcall HO: “Hey Team 3 HO, pls note ytd adm 1 perf PDU, for EOT, chit n consent up. Tq. ☺”

Team 3 HO: “g8t, thx!”

Despite the years between us, some things never change. The good houseman must still be like an octopus- multitasking and getting things done, because they are the invaluable ground team and mini-miracle workers who get things done. Many have used the minions from Despicable Me as their FB photo. I can still relate to that!

The good houseman/resident must still be able to:

1. Create a patient list (no matter what computer program is used)

2. Engage in bovine-worship (In ancient Biblical times, there was the golden calf, now there is bowing at least 4 hours a day before the ubiquitous COWs – computer on wheels)

3. Lie through the teeth to get an urgent review or scan done

4. Convince a social over-stayer to go home/ convince MSW to hasten application to nursing home

5. Trace changes, order meds (done in the comfort of the aircon lounge because it’s all online!)

6. Look after patients when their seniors have disappeared to clinics/OTs/snake temple

7. Take a good history (with more foreign patients nowadays, good thing we have more foreign nurses and doctors to help with translation. Unless it just so happens that the combination is not ideal- eg. PRC patient, clerked by a Singaporean overseas grad who speaks only Queen’s English, with a Fillipino staff nurse, and a Tamil speaking assistant nurse.)

In fact, while housemen nowadays seem to my old, jaded eyes to be less well-trained; is it the fault of the system which has made them so? I won’t be able to function as a houseman nowadays; I type with both index fingers. I can take bloods, set plugs, do hypocounts, insert NGTs, do ECGs, put up drip; but I can’t type fast. The modern houseman has more help from nurses and allied healthcare to help with the physical changes; to the point that some perhaps, have not quite learnt how to do them. More importantly, there is this surreal expectation from policy makers practicing zero-risk medical administration that once you pass housemanship, you can miraculously take on new and additional responsibilities like sign a death cert and take consent for simple procedures.

Moving forward, how can we improve the training system for doctors, and specialists so that we won’t face a shortage of generalists in 10 years’ time? That is a topic for another day; The Hobbit II “The Isolation of Smug”. I need to go have lunch with my Uncle B

Guide to Medical School Admission Selection

It’s that time of the year again when something important happens. You can feel it in the air which is pregnant with tension. We are not talking about filing tax returns, the Hougang bi-election, or even the very exciting SMA AGM, which last year lasted all of forty minutes.

 

The column strictly speaking is not targeted at doctors. This note is targeted at folks that still have a chance to step away from the abyss, avert disaster and escape calamity. No, I am not asking you to not take the MRT. I am asking you not to become a doctor.

 

If you are already a doctor, well too bad. Try reincarnation.

 

There are basically two kinds of folks who want to be a doctor. You may think the two categories are those that succeed and those that don’t. You can’t be more wrong than that. The two categories are simply those that can afford an overseas medical education and those that can only afford a local university like YLLSOM, Duke and Imperial.

 

If you can afford to go overseas, you have nothing to worry about. Please leave this note and go back to playing Farmville or some mindless FB game.

 

But then again, this is Singapore, and the rich and poor have equal access to subsidized education. I once know a doctor who bought a Porsche for himself when his son got into YLLSOM. His logic was that the savings from staying in Singapore can fund the purchase of the Porsche. Brilliant logic.

 

If you are the poor chap who happens to aspire to be a doctor but can only afford YLLSOM, here are the basic criteria that may just qualify you for consideration to be considered for a flicker of a chance to be interviewed for possible consideration to be given entry to this very prestigious medical school:

 

a) IQ of 150 and above

b) Represented your country in some sport and has broken some age-group national record

c) Looks better than Angelina Jolie AND Brad Pitt

d) Speaks like Obama

e) Has perfect A levels or IB scores

f) Fly a plane or a helicopter

g) Demonstrate at least one special trait or ability like telekinesis or walking on water

 

Please note that having all these traits ONLY gives you a chance to be to be perhaps interviewed by the panel of sadists at the Admissions Interview. Other traits you think may matter, actually do not matter. These include

 

a) Empathy and ability to communicate with fellow human beings

b) Parent is VVIP like Cabinet Minister, SMA President

c) Being a RI/RJC student

 

Now, if you happen to have the traits the local medical schools want, you will next have to prepare your “portfolio”. It is merely an account of what are the properties, stocks and bonds your family owns that will come in handy financing your education as well as the clinic suite at Mount Elizabeth@Novena and Mount Elizabeth@Mount Elizabeth. At the rate things are going, by the time you are ready for private practice, we may well have Mount Elizabeth@Pulau Tekong.

 

Just kidding. The portfolio is a collection of the things you want the folks at the medical school to know about you. I once met a female applicant who had 4 papers in her name, one as first author in a peer-review scientific journal. I am not making this up. And guess what, I was told later she did NOT make it into the medical school. That’s because she couldn’t summon her purported powers of clairvoyance as demanded by the interviewers. She should have seen this coming…..poor girl

 

The portfolio also includes a short essay about why you want to be a doctor. The typical 19 year old will write something like:

 

a) When I was young, I was very troubled when my grandparents/parents fell ill

b) I was so inspired by the professionals who tended to them

c) I am a person with great personal attributes like empathy, commitment, perseverance, honesty and sincerity.

d) I want to be a clinician scientist to help people, and save the world

 

These are all great stuff. But seriously, this Hobbit thinks the interviewers would be happier if some wise guy just wrote the truth – doctors get paid to work like maids, come home feeling half dead and obviously have no time or energy to get laid (with their spouse or otherwise).

 

You are also required to write an essay together with the other applicants one day in a large room. The purpose of this is to test your ability to do something that is completely unrelated to the task at hand (such as whether you are suited to being a doctor), which is important as we doctors all know are part and parcel of our everyday lives. Especially for doctors working in public institutions. These unrelated tasks include

 

a) Attending annual hospital retreats

b) Understanding service quality data

c) Passing ACGME audits

d) Passing JCI audits

e) Giving ridiculous performances onstage in Public Hospital X Annual Dinner and Dance

 

Finally, if after all the abovementioned abuse, for some miraculous reason, you are still alive and have been called up for interview, there are some things you should never do during the interview:

 

a) Burp

b) Dig your nose

c) Display armpit hair, and

d) Display honesty

 

Despite all your doubts and misgivings you have to show your sincerity (which is different from honesty) about wanting to be a doctor.

 

You may think that the interviews are conducted by experienced doctors and there are certain answers that will be better received than others. You cannot be more wrong. The people on the panels may include some or all of the following

 

a) Old RI boys that hate candidates from ACS

b) Old ACS boys that hate candidates from RI

c) Nurses that like doctors (especially when doctors are dead)

d) Disgruntled GPs

e) Disgruntled Specialists

f) Frustrated academics

g) The Dean

 

Of course, occasionally, you may meet one interviewer who is generally not frustrated, not disgruntled and who didn’t come from RI or ACS. Good luck. The Dean may ask you “who is the Dean?”. Giving the wrong answer is not a wise thing to do under such circumstances. The other thing is never show any doubt when interviewers offer you other career options like Dentistry, Pharmacy or Nursing. You must tell the panel you are prepared to kill your grandmother, pawn your gonads and sell your soul just to be a doctor. And if you are an overseas candidate, you will swear a solemn oath never to insult Singaporeans or criticise Singapore online, offline or anywhere in between.

 

Finally, the above process largely refers to the admission selection process for NUS. Now if you are applying to the NTU-Imperial College Medical School, you would have to take the BMAT (Biomedical Admission Test) which is different from the UKCAT (United Kingdom Clinical Aptitude Test) and which is also held at about the same time as A levels. Someone should really complain to the Queen about this. It makes you wonder how the Kingdom is going to stay United when they can’t even get their act together on how to select medical students in one standardised way. In addition to the BMAT, you get to have mini-interviews with 8 interviewers sequentially. A bit like one of those tacky social events that feature speed-dating…..

 

As for the Duke Graduate Medical School, because it is a very “atas” and “boutique” medical school where all things are American, this Hobbit actually has absolutely no clue how admission selection is done except that it’s for graduates, cost twice as much YLLSOM and takes one year less than an undergraduate course. It is supposed to better prepare a student for the rigours of the American Residency system which this country has adopted for reasons that are unfathomable.

 

Whatever the case, should you be selected into one of these medical schools, please do remember that becoming a doctor demands the greatest of commitment, hardship and discipline. But there are some perks to the job. These include

 

a) Free parking in hospitals and the mortuary

b) Free medical consultation from your colleagues

c) Your parent’s undying gratitude and pride for bringing honour to your family and clan (unless they are also doctors) even though their other investment banker offspring gives them three times more money than you do

d) Being named in patients’ obituaries (this perk is NOT enjoyed by lawyers, investment bankers and accountants, so there!)