doctors in training - sma physics dr shaun ho shares why he was drawn to the specialty 30 dummies’...

On the Shoulders of Giants

Dummies’ Guide to Residency

Residency Programme – Hits and Misses

Vol. 47 No. 7 July 2015

MCI (P) 154/01/2015

Doctors in Training

CONTENTSVol. 47 No. 7 2015

Editorial

4 A Residency in TransitionDr Jonathan Tan introduces the issue

FEaturE

5 On the Shoulders of Giants Prof P Balasubramaniam continues to impart knowledge

PrEsidENt’s Forum

8 Developing Good Habits in Clinical Practice – Part OneDr Wong Tien Hua discusses the importance of starting right

CouNCil NEws

10 Creating Global ConnectionsDr Benny Loo attends the World Medical Association and Junior Doctors Network meetings

12 SMC’s Response to SMA’s Email Query

iNtErViEw

13 Viewpoints on ResidencyFrom those in the GMEC

ExECutiVE sEriEs

18 Workplace Stress Management for DoctorsA/Prof Calvin Fones looks into the matter

oPiNioN

22 To Through-Train or Not? Dr Tan Li Feng writes about the perks of the residency system

24 Residency Programme – Hits and Misses Dr Tan Ming Yuan touches on the impact and challenges

26 From FM Residency to Sports MedicineDr Wang Mingchang reveals his path to sports medicine

28 Radiation Oncology – A Merging of Biology and PhysicsDr Shaun Ho shares why he was drawn to the specialty

30 Dummies’ Guide to ResidencySK Warrior provides some tips

GP mattErs

32 When Doctors SufferDr Leong Choon Kit speaks about the hardships of being a GP

sma Charity FuNd

34 Running for a Good Cause Relive the exhilaration of Pocari Sweat Run 2015

35 Achieving More TogetherSMACF continues to serve the community

ProFEssioNalism

36 Guide to End-of-life Decision MakingDr Anantham Devanand offers advice on how to view this delicate matter

iNdulGE

38 A Journey through Amsterdam and PragueBryan Koh brings us along for the marvels of his holiday

aNNouNCEmENt

21 Inter-Professional Games 2015

40 MCA Online Training Module - Assessment of Mental Capacity under the Mental Capacity Act

CalENdar

41 SMA Events August – October 2015

aiC says

42 One Patient, One Health RecordGPs, read on!

Opinions expressed in SMA News reflect the views of the individual authors, and do not necessarily represent those of the editorial board of SMA News or the Singapore Medical Association (SMA), unless this is clearly specified. SMA does not, and cannot, accept any responsibility for the veracity, accuracy or completeness of any statement, opinion or advice contained in the text or advertisements published in SMA News. Advertisements of products and services that appear in SMA News do not imply endorsement for the products and services by SMA. All material appearing in SMA News may not be reproduced on any platform including electronic or in print, or transmitted by any means, in whole or in part, without the prior written permission of the Editor of SMA News. Requests for reproduction should be directed to the SMA News editorial office. Written permission must also be obtained before any part of SMA News is stored in any retrieval system of any nature.

EDITORIAL BOARD

Editor

Dr Tan Yia Swam

Deputy Editors

Dr Tina Tan

Dr Tan Tze Lee

Editorial Advisors

A/Prof Daniel Fung

A/Prof Cuthbert Teo

Dr Toh Han Chong

Members

Dr Jayant V Iyer

Dr Natalie Koh

Dr Leong Choon Kit

Dr Jipson Quah

Dr Jonathan Tan

Dr Jimmy Teo

EX-OFFICIOSDr Wong Tien Hua

Dr Daniel Lee Hsien Chieh

EDITORIALOFFICE

Senior Manager

Sarah Lim

Editorial Executives

Sylvia Thay

Donna Cheong

ADVERTISING AND PARTNERSHIP

Li Li Loy

Denise Jia

Tel: (65) 6223 1264

Email: [email protected]

Publisher

Singapore Medical Association

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Level 2, Alumni Medical Centre

Singapore 169850

Tel: (65) 6223 1264

Fax: (65) 6224 7827

Email: [email protected]

URL: http://www.sma.org.sg

UEN No.: S61SS0168EPhotosiStock: 24, 30, 31; Shutterstock: 1, 22, 32, 36

7EDITORIAL

By Dr Jonathan Tan, Guest Editor

“the world is changed…”The merits of the residency programme were the subject of much debate when it was first proposed and

implemented. Would these shorter training programmes with controlled working hours lead to less clinical exposure

and less proficient specialists? Were these new-fangled trainee evaluation forms and feedback sessions truly

necessary? There was much skepticism at first, but one should not judge a tree before seeing its fruits. Perhaps now,

with most of the residency systems in full swing and the first batches of senior residents coming off the production

line, we can take stock of the brave new world of postgraduate medical education in Singapore, a system in transition.

“i feel it in the water. i feel it in the earth. i smell it in the air.”To truly understand a new country, one needs to get one’s boots on the ground. In this edition, we speak to two

groups of people: those who have moulded and nurtured the new residency programmes and the first products

of this far-eastern graft of the Accreditation Council for Graduate Medical Education. I had the privilege to

practise in the departments of the four professors interviewed in this edition and they have kindly agreed to share

their views on their past experiences, the present changes they have effected and their hopes for the residency

programme in the future. I would like to thank Asst Prof Alfred Kow, A/Prof Shirley Ooi and A/Prof Raymond Goy

for so graciously sharing their thoughts, and needless to say, it was a great privilege to interview my programme

director, A/Prof Joseph Thambiah.

We also invited three senior residents to share their personal views as they transitioned to the next stage of

their professional training. They are Dr Tan Li Feng, a medical student who became a resident directly who is now

both a mother and senior resident, Dr Tan Ming Yuan a former basic specialist trainee in general surgery and now a

chief resident and Dr Wang Mingchang, who is completing his family medicine training and is now setting up a new

sports medicine centre.

“much that once was is lost.”To the casual reader, the single institution centeredness of this edition is immediately apparent, and I apologise

for it. Before the residency system, trainees had the opportunity to rotate to various hospitals around the island,

but in this day and age, I doubt I will have much opportunity to see how orthopaedics is practised outside of the

west of Singapore, and I hope this will in some way explain the lack of interviewees from the other clusters.

The last trainees of the old basic specialist training/advanced specialist training trainees are rapidly exiting, and

soon all will be residency. Or maybe not. Dr Shaun Ho describes to us the training that radiation oncology trainees

undergo, one of the last few specialties not part of the residency programme.

“For none now live who remember it”The Chinese have a saying that one who teaches for a day, is like a father for life. Just as our behaviour reflects

our upbringing, our professional life is a reflection of the training we received. When one watches a surgeon

operate, with every quirk and step, one can hear the echoes of mentors past. In the end, it is my opinion that it is the

people and not the system that makes a good training programme. We should never forget the teachers that make

it all possible. Every specialty has its icons and giants, and perhaps in this time of transition, it would do us good

to speak to someone of great experience, who even after retiring from active practice two decades ago has been

active in educating orthopaedic surgeons in Singapore and the region. A tutorial with Prof P Balasubramaniam

has been the stepping stone to passing the FRCS and MMED for many orthopaedic trainees, and his thoughts on

medical education are well worth hearing.

I hope that as we move into the future with the residency programme, we do not forget the past and those who

have helped brought us to where we are today.

Jonathan Tan is currently an orthopaedic resident at the National University Health System. A dwarf in a department of giants, his hobbies include falling asleep while studying, resubmitting rejected journal articles and trying to not stutter during morning teachings. He is grateful for the opportunity to pursue his dreams and hopes to become a good orthopaedic surgeon and help educate future trainees. He is thankful for the love and support of his parents and fiancée without which none of this would be possible.

A Re

siden

cy in

Tra

nsiti

on

4 • sma News July 2015

7 thE First reaction of orthopaedic

trainees, when faced with the

challenges of passing the MMed

(Orthopaedics) and FRCS (Orth), is to

seek a master to prepare them for the

test ahead.

Prof P Balasubramaniam completed

his training in the UK in 1966, and

then joined the University of Malaya

where he was professor and head

of the orthopaedics department. He

joined the then Singapore University

Department of Orthopaedic Surgery in

1981 and was promoted to professor

in 1984. He served as Vice-Dean of the

Faculty of Medicine, Deputy Chairman

of Medical Board and Director of

Medical Affairs, and retired in 1994 at

the age of 65.

Prof Bala’s retirement marked the

beginning of an annual pilgrimage of

orthopaedic trainees to his home for

tutorials. For the next two decades,

successive batches of trainees would

sit around his dining table, moulded

and hardened for the battles ahead.

Even at 86, Prof Bala is still an

oracle of orthopaedic knowledge; a

tutorial with him is a tour de force

through the breadth of orthopaedics,

leaving the trainees wiser but

chastened by the gaps in their own

knowledge. In this era of Accreditation

Council for Graduate Medical

Education (ACGME) and residency,

Prof Bala is unique, separate from the

structured training programmes; he

has taken it upon himself to educate

the next generation of orthopaedic

surgeons.

on teachingDr Jonathan Tan – JT: When did you

first start teaching?

Prof P Balasubramaniam – PB: I began

teaching when I was 19, after the

completion of my A-levels in Sri Lanka.

I worked as a relief teacher in Botany

and Zoology for nine months before

starting medical school. It was my most

memorable teaching experience, since

it was my first teaching assignment.

I started teaching medical students

while I was a medical officer. My boss,

who was too busy to teach, had told me

to stand in for him. That was back in the

1950s where there were no computers

or PowerPoint slides, and lessons were

conducted with “chalk and talk”.

JT: What is your philosophy on

teaching?

PB: My philosophy on teaching is that

every trainee can be trained. To begin

with, every trainee must be a bright

student, one has to be, to pass medical

school and enter higher orthopaedic

training, and I respect that. My style

of teaching has always been to impart

knowledge; the trainees do not need to

know anything at first, but if you impart

your knowledge and set them on the

right track, they will eventually become

good orthopaedic surgeons.

I believe in imparting three things

to my trainees: knowledge, skills and

attitude. I do not just teach from a

textbook, but I also teach based on

my personal experience and what is

important for the trainees in their daily

practice. Training programmes can

change, but they must impart adequate

knowledge to the trainees to enable

them to function in their daily practice.

[At this point, Prof Bala opened one of his notebooks to show me the handwritten notes and illustrations he had prepared beforehand. I could not help but be impressed by the dedication it took to update and compile this set of notes every year for a new batch of trainees.]

I place equal importance on all

clinical skills – at the bedside, in the

clinic and in the operating theatre.

Maintaining proper clinical records

is as important as good clinical work,

because it allows you to learn from

your mistakes and to evolve as a

clinician.

Attitude is part of the unspoken

syllabus, something that you impart

FEATuRE

On the Shoulders of Giants – An interview with Prof P BalasubramaniamConducted by Dr Jonathan Tan, Guest Editor

July 2015 sma News • 5

by personal example to your trainees.

Orthopaedics is not just cutting and

doing.

[Every department has its unspoken culture and some elements of Prof Bala’s influence still permeate mine, even 20 years after he has left. In the same way, the surgical style of each consultant silently reveals his or her past mentors. My department’s culture too speaks of the time when he was still a part of it.]

surgery and orthopaedicsJT: What do you think is the best

way to teach someone to be a good

surgeon?

PB: I believe that surgical trainees

need to operate at least twice a

week. When I was operating, I used

to operate on one side of the spine

and let the trainee operate on the

other. As their experience increases,

I allowed them to work on more and

more of the case. Eventually, I let

them operate alone while I remained

outside the operating theatre, so

that they could consult me if they

needed help.

[A/Prof J Thambiah, my programme director, still speaks fondly of how, at the end of every spinal operation, Prof Bala would instruct him to draw by hand the

vertebrae that he had operated on and colour in the areas that he had removed. It made him a better surgeon and artist, too!]

JT: What do you think is the biggest

change in orthopaedics since you first

started practicing?

PB: In orthopaedics, the volume of

knowledge has increased to such

an extent that most surgeons are

unable to cope. Orthopaedic surgeons

are increasingly subspecialised

and interested only in their areas

of subspecialisation. However, I

maintain a broad interest in the

whole body; it is difficult to do so, but

if one understands the whole body,

one is able to see how the different

subspecialties meet and thus better

understand the patient.

Personally speakingJT: What have you gained from your

years as a teacher?

PB: The most important thing I have

gained is the personal satisfaction of

being able to pass on knowledge to my

students, being able to influence them,

change the way they practise and

ready them for their profession.

JT: Do your students still keep in

touch with you?

PB: Yes, they do! Occasionally, one of

them would call up or invite me out

for a meal. However, I have lost touch

with some of them as their practices

and families grow.

JT: Besides teaching, what do you do

in your free time?

PB: I enjoy going for walks to the

market or shopping centre. These

walks give me much pleasure, as

I enjoy looking at new faces and

watching people interact.

In my younger days, I used to

enjoy cooking. I used to tell my wife

to give me a free day so that I can

cook. Of course, she was a much

better cook then I. When she passed

away, I woke up every morning to

cook for my children, so that lunch

would be ready when they returned

from school, but my maid does not

like it when I interfere in the kitchen,

so I have stopped cooking.

[Prof Bala’s wife, Ratnadevi Desilva, had a reputation for being an excellent cook. The prospect of a good meal was something every trainee looked forward to after spending hours re-editing a manuscript with Prof Bala. She passed away in 1984, and since then, Prof Bala has balanced the responsibilities of being a professor of orthopaedics and both a father and a mother to his three children. He is now a grandfather and his children have pursued successful careers overseas in the medical and educational fields.]

some thoughtsIt has been a great privilege

for me to interview Prof Bala and

to hear his thoughts on educating

orthopaedic surgeons. It has been

said that teaching is one of the paths

to immortality, as those who inspire

and educate are never forgotten. As

we move into the brave new world

of residency and ACGME, it would

behove us to remember the giants on

whose shoulders we stand.

Prof Bala celebrating his birthday with a group of students


LIFE IN PIXELSSMA NEWS PHOTO COMPETITION

The winner of each theme will take home $50 in CapitaVouchers, a Crumpler camera bag and a Canon Digital Ixus lanyard

with 16GB thumbdrive. The winning photos will also be featured in the pages of SMA News and on the Life in Pixels website.

What’s more, winners of each theme are eligible for a finale readers’ voting contest and stand to win the grand prize, a DSLR

EOS100D Kit sponsored by Canon!

Wait no more and send us your best photos along with your name and MCR/matriculation number at lifeinpixels@sma.

org.sg, with the name of the theme as email subject. All images must be in JPEG format, and sized to at least 2,480 x 3,508

pixels. Include a short descriptive legend (maximum 20 words) with each picture.

This contest is open to SMA members in good standing only. Before submission, check out the contest details at

https://www.sma.org.sg/lifeinpixels.

Calling all photography enthusiasts! To celebrate Singapore’s 50th year of independence, we have released a series of themes which reflect the richness of life on this little red dot.

theme* Closing date release of results

1. “Singapore by Night” – capture the bright lights of our city after the sun goes down

13 September End September

2. “Nation Building” – a play on words: members of the pioneer generation and buildings of historical significance

15 November End November

*SMA will be holding relevant photo workshops in conjunction with each theme. For more info, go to http://goo.gl/6Wg3mv.

In celebration ofOrganised by Imaging partner

PRESIDENT’S FORuM

iN this issue, we focus on doctors in

training. The term “doctors in training”

is interesting to me because, in my

view, doctors never really stop training.

Constant learning and relearning is a

lifelong habit that we develop to keep

ourselves abreast of the changes and

advances in medicine. As doctors,

we want to achieve excellence in our

clinical practice, which is impossible

if we stop learning just because we

have completed a prescribed training

programme.

Aristotle wrote: “We are what we repeatedly do. Excellence, then, is not an act, but a habit.”

Our lives are regulated by habitual

actions, the things that we keep doing

over and over again until they become

automatic. Every morning, we get out

of bed from the same side and stumble

to the washroom to begin our routine.

The amount of toothpaste we use, the

sequence of brushing of teeth, even

the amount of water we fill in the

rinsing cup is more or less consistent.

A cafe manager once told me that the

regular customers who patronise his

establishment typically order the same

item on the menu every time and that

most people like their morning coffee

or tea prepared in a specific way with

very little variation.

Habits are, therefore, very useful

patterns of behaviour that our brains

have developed over time to save

“processing power” and energy. The

term “automaticity” is the ability of

humans to do things without having

to occupy the mind with low-level

details, and we sometimes call this the

“autopilot mode”. In clinical practice, we

often hear doctors commenting that

they carry out their tasks at a “spinal

level”, which means that it has been

repeated so often that the action, akin

to a reflex arc, does not seem to pass

through the brain.

Driving a car is a good example of

automaticity since driving is a very

complex task involving coordination

of sensory and motor function. I recall

my first few driving lessons, where I

struggled in remembering to adjust

the rear view mirror, fasten the seat

belt, ensure that the seat is correctly

positioned and check that the gear

shaft was disengaged – all before even

starting the car. Parking the car was

also a difficult and highly complex

Developing Good Habits in Clinical Practice – Part One

By Dr Wong Tien Hua

Illustration: Dr Kevin Loy


process, requiring presence of mind to

note the surrounding traffic conditions

and a sense of direction of the car’s

movement as it reverses into the

parking lot. If the brain is unable to

adapt and develop an automatic neural

pattern to driving, then every driving

trip will be as stressful and emotionally

draining as the first. Thankfully, this

is not the case because we are able to

drive with relative ease, especially on

familiar routes, while listening to the

radio at the same time.

the good, the bad and the uglyAs doctors, we constantly develop

habits in our daily clinical practice.

Some examples of routine tasks

include:

• Communication – Eliciting a clinical

history from patients, addressing

their ideas, concerns and

expectations, and building rapport.

• Clinical examination – Performing

a focused examination and picking

up clinical signs without missing

important information.

• Medical records – Keeping good

and detailed medical records.

• Medical procedures – These include

performing venepuncture, ECG and

infection control procedures such

as proper handwashing.

Good habits can help us work more

efficiently and effectively. The fact that

doctors are able to excel in every test

and examination, leading to a medical

degree, testifies to our good habits of

discipline, determination and effective

time management.

Good habits in communication

help to establish rapport with patients

and maintain an effective doctor-

patient relationship. Maintaining a

high standard of hygiene and infection

control is a good habit that has a

direct impact on patient safety and

public health. A seasoned medical

officer who can insert an intravenous

cannula smoothly into a neonatal vein

seemingly without thinking is only able

to do so through repeated practice and

the forming of habitual reflexes.

Bad habits, on the other hand, are

professional landmines lying in wait to

sabotage our practice even when we

have the best intentions.

Seemingly innocuous bad habits

such as poor handwriting may lead

to errors that can have serious

consequences to patient safety and

clinical care. In prescribing medicine,

a wrongly placed decimal mark

translates to an incorrect dosage

by a factor of at least ten times. Bad

habits in communication can lead to

misunderstandings with patients and

consequently, dissatisfaction with

the consultation process. We know

the importance of maintaining eye

contact and practising active listening

in patient communication, but the

realities of a busy clinical environment

with computers, phones and other

equipment competing for our attention

can be distracting for the doctor.

Habits form not only in individuals

but also within teams and larger

organisations. For example, as doctors

we work in teams that are part of larger

medical departments or units within a

hospital. How an individual interacts

with others often forms habitual

patterns and result in what we call

“organisational culture”. When there

is poor teamwork or safety culture,

or when team leaders foster a hostile

work environment, communication

may break down, and this can cascade

into catastrophic events that end up as

horror stories in the newspapers. The

accumulation of collective bad habits

can thus snowball into something

rather ugly.

Two recent Singapore Medical

Council cases of wrongful

administration of drugs highlight the

importance of individual responsibility

and the role of teamwork. The first case

was that of a young medical officer

who was censured for administering

chemotherapy intrathecally instead

of intravenously because she failed to

check the route of administration at the

bedside. Such an error could have been

avoided if the steps of administration

were followed and hardwired into

a mental routine. The second case

was that of a cardiothoracic surgeon

who gave undiluted cardioplegic to a

patient. He was initially convicted of

willful neglect, but a court of appeal

later overturned the ruling. The

judges noted that in this case, there

was systemic failure at play, which

contributed to the error. In the above

examples, communication within the

team had broken down and bad habits

were allowed to snowball.

starting rightFor every clinical activity, there is

thus the potential of developing either

good or bad routines. Unfortunately,

our brains do not seem to be able to

distinguish between them; it is as easy

to pick up good habits as it is bad ones,

depending on our frame of mind.

Medical training should not be

confined only to the notion of technical

skill training and accumulation of

medical knowledge. During the course

of our instruction, we are also training

ourselves to develop good habits in

clinical practice. Therefore, we need

to consciously learn good clinical habits

before bad habits seep in and establish

themselves in our subconscious

behaviour. There is no better time to

inculcate a culture of good clinical

habits than at the beginning of one’s

professional career. Senior doctors

have an important role to play as role

models and in setting the standards for

good clinical practice.

For those of us who are keen to

improve our behaviour, change is only

possible if we are aware of how our

habits are formed, as well as what

triggers and rewards fuel them. I will

explore these factors in a separate

article. Watch this space.

Dr Wong Tien Hua is President of the 56th SMA Council. He is a family medicine physician practising in Sengkang. Dr Wong has an interest in primary care, patient communication and medical ethics.


COuNCIL NEwS

i rEPrEsENtEd SMA at the World Medical Association

(WMA) and Junior Doctors Network (JDN) meetings in

Oslo, Norway, from 15 to 18 April this year. It provided me

with a platform to learn the different postgraduate medical

education systems around the world and also speak about

Singapore’s transition to the residency programme.

more about the associationsWMA is an international organisation representing

physicians. It was founded on 17 September 1947 and has

now grown to encompass 111 national medical associations.

The organisation was created to ensure the independence of

physicians and to work for the highest possible standards of

ethical behaviour and care by physicians, at all times.

JDN is made up of junior doctors who are representatives

of the respective national medical associations or associate

members of WMA. It was formed in 2010 to provide a

forum for experience-sharing, policy discussion, project and

resource development on issues of importance to junior

doctors, such as postgraduate medical education, their well-

being and the healthcare workforce.

my experienceJunior doctors from all over the world, including

America, Canada, Spain, Brazil, Turkey, Germany, Nigeria,

Japan and Singapore attended the JDN meeting, hosted

by the Norwegian Medical Association. It was an enriching

experience where I gained insights on various training

systems and difficulties faced by the junior doctors of

the respective countries. Many of the issues raised were

surprisingly similar to those of Singapore’s training system,

such as the appropriate amount of duty hours (and the

challenge of not exceeding it), influx of foreign-trained

doctors and support of junior doctor representations in

national medical bodies (such as postgraduate training

governing groups).

I also realised that the limitations of one system could

be the ideal for another. For instance, the Singapore

system is packed with multiple examinations including

the exit examination (which is a requirement for specialist

accreditation). The lack of an equivalent examination in

more established medical systems, such as the Norwegian

one, was deemed by some to be an inadequacy in ensuring

Creating Global ConnectionsText and photos by Dr Benny Loo


the good quality of specialists trained. This, however, does

not necessarily mean that poor specialists are produced as

it governs the trainees through the training programme and

constant guidance by their supervisors.

The other lesson I learnt was the luxury of being part

of Singapore’s relatively younger medical training system.

We enjoy a robust training system with the benefit (and

burden) of integrating two medical systems and we never

had to fear the collapse of the training infrastructure. The

harsh reality faced by our compatriots in Nigeria is the lack

of investment in medical training from the government and

they are constantly fighting for the survival of their residency

programme. The Nigerian delegates were duly awarded the

best country presentation after sharing with us the grim

plight of their training system.

Thereafter, for the next three days, I observed the WMA

meeting where many issues ranging from membership,

ethics, socio-welfare to education were enthusiastically

discussed. It was a great learning experience as multiple

countries came together to debate for the better cause of

mankind. Issues discussed included environmental health,

support to street children and chemical weapons – which are

fortunately not experienced in Singapore. These problems

faced by many developing, and even some developed

countries, further validated Singapore’s achievements

in 50 years. WMA has also formed closer ties with other

international bodies such as World Federation for Medical

Education and gained more impact in international health

(as evidenced during the Ebola outbreak). I believe that

Singapore will be able to play a bigger role as WMA

continues to strive for better healthcare across the globe.

This experience has broadened my mind on international

healthcare and medical training and I feel very glad to have

met many like-minded friends. I look forward to participation

in future JDN and WMA activities.

Dr Loo is currently training as a senior resident in paediatric medicine at KK Women’s and Children’s Hospital. He likes to look on the bright side of life and always strives to balance his work, family and personal duties.

Clockwise from far leftDr Loo (third from left) with participants of JDN with Dr Xavier Deau (President), Dr Mukesh Haikerwal (Chairperson of Council) and Dr Otmar Kloiber (Secretary-General) of wMADr Loo explaining the Singapore health system and residency programmePhoto taken with Dr L Kayode Obembe (President of Nigeria Medical Association) and Nigerian delegatesGroup photo with the JDN participants


SMC's Response to SMA's Email QueryoN 15 May this year, Dr Daniel Lee wrote an email query letter to the Singapore Medical Council (SMC)

Executive Secretary, on behalf of SMA, enquiring about doctors’ participation in websites that list doctors’

details and services. We herein reproduce the email query and SMC’s response in full.

15 may 2015 sma’s email to smC Executive secretary

Dear Ms Tan,

SMA has been informed by some members that

doctors’ details have been made available through websites

apparently offering appointment services (eg, https://www.

docdoc.sg/, https://www.practo.com/) whether by direct

registration, or by the site entering the details without the

doctor’s permission.

We would like to ask if SMC would consider that the

doctor has contravened the SMC Ethical Code and Ethical

Guidelines if he participates actively, or if he is merely listed

on the website without his expressed agreement.

Yours sincerely,

Dr Daniel Lee

Honorary Secretary


smC’s reply

Dear Mr Lee,

We refer to your email dated 15 May 2015 enclosing an

email from Dr Daniel Lee.

The email in question raises the matter of whether

there has been a contravention of the Ethical Code and

Ethical Guidelines (ECEG) by active involvement in either

of the two portals listed. As is the case with advertising on

any platform, the concern would be more on the quality

and standards of information than the availability of the

platform itself. For that reason, to the extent either portal

provides only factual information on the doctors (eg, factual

information on the specialisation of a doctor, contact

details and opening hours), this is unproblematic as the

ECEG explicitly allows factual information on doctors to

be provided to the public (Sections 4.4.1 and 4.4.2 of the

ECEG).

However, where the doctor actively provides

information that can be used in a misleading fashion, or

otherwise participates actively in any website that they

know may use such information in a manner which is

comparative in nature, or would otherwise be used in a

manner inconsistent with the principles set out in Section

4.4.1, such acts may amount to a contravention of the ECEG.

Though not exhaustive, this would include the provision of

special discounts, or gifts, or any other financial incentive

to the patient for using such platform, or involvement in

platforms where testimonials are used as part of a doctor’s

listing or advertisement. Furthermore, while paying for

advertising one’s practice is allowed, the ECEG disallows

doctors from being involved in “fee-sharing” arrangements

with third parties, including such websites.

On those fronts, it would appear to us that participation

in a directory-like structured website is not inappropriate,

while active participation in any website providing

“ranking-table” like frameworks (based on parameters

that may not be objectively based on factual matters),

where doctors can be involved in special “promotions” or

provide other inducements for use of services or where

patient testimonials are utilised, may contravene the ECEG.

As it may be inappropriate for us to make determinative

pronouncements on individual websites, especially in the

absence of a complete understanding of the website’s listing

methodologies and their financial arrangements (if any)

with the medical community, doctors may wish to consider

for themselves how the application of such principles might

apply to each of these websites.

Kind regards

Selven Sadanadom

Deputy Head (Corporate Communications),

Administration Division

Singapore Medical Council

COuNCIL NEwS


it has been almost five years since the residency programme was introduced to Singapore’s healthcare

landscape. Just how different is the residency programme from the previous system and what is its impact on

the residents? We interviewed four professors who are actively involved in the Graduate Medical Education

Committee to find out more about their perspective on the programme.

a/Prof Joseph

thambiah

is a senior

consultant and

head of the

Musculoskeletal

Trauma division,

Department of

Orthopaedic Surgery,

National University Hospital (NUH).

He is both a fellowship-trained spine

surgeon and trauma surgeon. A/Prof

Thambiah is actively involved in

undergraduate and postgraduate

education, and has been the

programme director (PD) of the

National University Health System

(NUHS) orthopaedics residency

programme since its inception.

To him, medicine is more than a

profession; he currently leads bi-

monthly medical missions to Batam

and organises weekly mobile medical

clinics that provide free healthcare

to foreign workers and the elderly

poor living in one-room HDB flats.

Now that the first residents accepted into the residency programme have become

registrars, how do you feel their performance compares to that of trainees from the old system?

In my opinion, the performance

of the current senior residents is

equivalent to that of their predecessors.

“

onViewpoints INTERVIEw

Residency

A/Prof Thambiah (second from left, standing) posing at the photo booth


“

One of the pluses of the residency

programme is that we have a clear

idea of the quality of work expected

from the residents when they turn

registrars. A negative is the decreased

amount of time spent gaining

experience due to the regulation of

duty hours, though this is balanced by

a reduction in resident fatigue.

However, whether the residents

have the requisite amount of time to

gain clinical experience and are ready

for greater responsibilities is still a

concern. We try to overcome this by

getting the residents to do tag-on calls

with senior residents and registrars

six months before they become senior

residents themselves. We also make

sure that there is always an additional

level of supervision for them to turn

to. I think one trait of the old system

was that we threw the new registrars

into the deep end and allowed them

to sink or swim; more often than

not, they swam and learned from the

experience, but this is not optimal.

We aim to provide more consistent

training in the swimming process

so that they can keep their noses

above water for far longer. However,

I sometimes worry that this method

may be too much molly-coddling,

and as we all know, too much stress

shielding is not good for fracture

healing!

what do you think are the challenges faced by your residency programme?

When I first started as a

programme director, I thought I was

being punished, since I had to learn the

language of the Accreditation Council

for Graduate Medical Education

(ACGME) from scratch. I had to

complete the programme information

form and go through it word for word,

as the ACGME would fault us if even

a comma was out of place. (Thankfully

I was well trained by my mentor

Prof Balasubramaniam.) The other

challenge was getting the faculty to

accept that the paradigm had shifted

and that the ACGME is the new reality.

Another challenge we face

is contextualising the training

programme for our own national

purposes. With the replacement of the

old training programme, we may have

thrown the baby out with the bath

water, as there was much good that

we could have retained. Personally, I

see no reason why we have to slavishly

follow everything the ACGME requires

of us. We should have the confidence

as a nation to develop our own colleges

for orthopaedics. Scotland, with a

smaller population than Singapore,

has two Royal Colleges of Surgery.

Perhaps, this is what we should aim for

in the future; a national system that

combines the best of both worlds.

We may also be forcing our junior

residents to choose their specialties

too early. Perhaps, there should be a

Ministry of Health (MOH) directive

that all graduates must go through

mandatory housemanship and a year

as a medical officer (MO) before

appearing for interviews. By that time,

they may be better able to make a

sound decision concerning what will

affect them for the next 40 years of

their lives.

Similarly, medical students are

choosing their specialties far too

early. In my opinion, each cohort of

residents should have some degree

of homogeneity in their postgraduate

experience. However, when we select

residents too early on, we may end

up placing an undue amount of stress

on them to catch up with their more

experienced fellow residents. If such

an MOH directive is in place, it may

discourage the various programmes

from “poaching” medical students

early for fear of losing them to other

programmes.

asst Prof alfred Kow is

currently the Assistant

Dean of Education in

Yong Loo Lin School

of Medicine. He is

actively involved in

undergraduate education

in surgery in NUS. In

addition, he is also a core faculty

member of the NUHS general surgery

residency programme. He was

previously the associate programme

director for NHG-AHPL general

surgery residency program at Tan

Tock Seng Hospital and Khoo Teck

Puat Hospital. He is truly excited

to participate in improving surgical

education in Singapore.

Now that the first residents accepted into the residency programme have become registrars, how do you feel their performance compares to that of the trainees from the old system?

Much preparation was put in

place to ensure that the residents

are well supervised and that they

mount the learning curve safely and

smoothly. Simulation training, more

focused on-the-job training, as well

as better organised and intensive

education activities allow the senior

residents to better understand surgical

practices. We also crafted the float

systems to comply with the work

hour restriction and at the same time,

allow the residents more focused

training in emergency surgery. This

has helped them to concentrate their

learning in emergency surgeries (eg,

appendicectomies, hernias, simple

laparotomies). By the time they turn

registrars, they are well prepared

to handle the role. We have also

scheduled them to shadow registrars

on call from as early as the beginning

of the third year residency, to prepare

them to step up to the job when the

time comes. The residents are very

motivated and I am extremely pleased

with their performance. While the

younger senior residents may not be

able to handle complex operations on

their own, the faculty members are


readily available to help. That is the

beauty of the training system – ease of

consultation and better supervision.

what are the benefits of the residency programme?

A structured teaching system

with focused outcome is the key to a

successful residency system. It has also

created a pro-teaching environment

for the residents to learn, instead of

a “work-oriented” routine. There is a

great paradigm shift in the mentality

of the trainers and faculty members

as well. Personalised supervision is

an important feature in the residency

system. Mentees can explore their full

potential with the faculty members

and their mentors to gain as much

as possible from the training system.

Work hours are controlled and there

are fewer issues with fatigue in the

residency system. Some may argue

that this might compromise training

quality, but I would say that, if the

system is crafted properly, it should

be a win-win situation for both the

faculty and the residents. Resident

satisfaction is very high (but I hope

it will not lead to complacency and

over-demanding behaviour from the

residents).

what do you think is the future of your residency programme?

It is still a new and evolving system.

We went through some growing pains

in the beginning, but it is now slowly

entering a stable state. The system

should get better as long as the whole

fraternity of surgeons in Singapore

(as trainers and faculty members)

put in effort to make surgical training

better for the next generation of

surgical residents. Of course, this is

only possible with the administrators

and leaders in MOH working hand-in-

hand with the faculty members on the

ground.

a/Prof shirley ooi

is a senior consultant

and former chief

of the Emergency

Medicine (EM)

Department

at NUH. She has

been the Designated

Institutional Official (DIO) of

the NUHS residency programme since

2009 and was the chairperson of the

Emergency Medicine Specialist Training

Committee from 2009 to 2011. She has

won multiple teaching and mentoring

awards, with the most prestigious being

the National Outstanding Clinician

Educator Award 2013. She was also

the winner of the National Medical

Excellence Team award in 2011.

how is the training of the current residents different from that which you received when you were a trainee?

It is definitely very different. As

one of the pioneers of EM in Singapore,

there was hardly any structured

training. Though we had guidelines

on what the relevant postings were in

order to qualify for our FRCS (A&E)

exams, we basically rotated from one

posting to another with hardly any goals

or objectives for each of our postings.

There were also no dedicated mentor

or posting supervisor to guide us during

the basic specialist training (BST) phase,

and we depended on opportunistic

learning and tutorials from our seniors

to prepare for our exams. The gaps in

our knowledge were sometimes only

revealed when we were taking the high-

stakes FRCS (A&E) exams in Edinburgh,

as there were no local exams then!

In contrast, the current EM

residency programme is well structured

and administered by a programme

director with 0.5 full-time equivalent

(FTE) protected time and a core faculty

with 0.2 FTE protected time. The

programme is externally accredited

by the ACGME-I, and has a curriculum

with clear goals and objectives. Uniform

training is in place and learning is no

longer left to the “luck” of the trainees.

Each resident has a dedicated mentor

who follows them through the full five-

year period of residency and there are

rotation supervisors as well. Formative

feedback is emphasised so that the

residents know how they are doing.

There are also annual in-training exams

to help residents identify where their

gaps in knowledge are. As the residents

belong to a sponsoring institution

(SI) under the leadership of a DIO

who oversees the Graduate Medical

Education Committee, each SI takes

ownership of its residents’ training.

Another key difference is that the

current EM residents can start their

training as early as in their house

officer (HO) year, whereas we could

“

Dr Alfred Kow and his family


“

start our training only after completing

housemanship.

Now that the first residents accepted into the residency programme have become registrars, how do you feel their performance compares to that of trainees from the old system?

To answer this question objectively,

comparison should be made between

similar scenarios. For residents who

enter the EM residency as MOs, the

product is just as good, if not better.

This is because the training that they

receive is more comprehensive and

holistic. Residents who entered the

EM programme as HOs should not be

compared with the registrars during

my time; who at the earliest would have

been in their fifth or sixth postgraduate

year. Rather, they should be compared

to their peers of

equivalent clinical

experience in the

previous system

whose performance

they definitely

surpass.

As a DIO, I

have asked senior

clinicians from

different specialties

about how they

view the current

senior residents

compared to the

registrars from the

former training system. Unanimously,

they concurred that these senior

residents, although more junior in

terms of age, are just as competent. In

fact, one senior clinician opined that

current senior residents can function

at a level that is one year ahead of

previous ASTs! They also felt that the

competence level of the residents as

a whole is more uniformed compared

to the past. Previously, there were

excellent and motivated ones who

were able to fend for themselves, but

there were also those who were very

weak even after they exited from the

training programme. They attributed

this improvement to a better selection

system, a more structured programme

and the closer monitoring given. In

addition, the senior residents have

demonstrated better pass rates in their

exams.

Therefore, despite the shorter

training period, I would still appeal to

those comparing the two systems to

remove the seniority factor from the

equation. Only then can we assess the

real impact of the residency system.


In the past, trainees were virtually

guaranteed a job upon completion

of their training in a particular

department. In the current situation,

the aim of the residency programme,

as set out by MOH, is for each of the

three SIs to train specialists for the

whole country and not only for their

individual institution. Thus, residents

need to have this mindset or they may

be greatly disappointed!

Allowing residents to start training

as early as their HO year may pose

a challenge, because the experience

of life in a particular specialty as a

medical student may be different

from that as a working doctor. It is

probably better for junior doctors

to choose their specialty after

gaining some working experience. In

addition, nothing beats real clinical

experience. I think a win-win situation

would be a slightly delayed entry

into the residency programme, after

the completion of housemanship,

combined with a well-structured

residency programme. Then, we will

have the best of both worlds!

A/Prof Ooi (centre), as DIO, at her 11th run of the NuHS Residency Orientation at Outward Bound Singapore in July 2015 after completing 18 km kayaking round Pulau ubin with her residents, senior management and faculty!

a/Prof raymond Goy

was the programme

director of the NUHS

Anaesthesiology

Residency Programme

from 2010-2015. He

was awarded the NUH

Teaching Excellence Awards

for three consecutive years

(2012-2014) and the NUHS Residency

Award in 2014. A/Prof Goy firmly

believes that the ACGME-I system

(with appropriate adaptations to the

Singapore healthcare system) is the

best change our Ministry of Health

has made to our postgraduate training

in Singapore. He is passionate about

mentoring residents from all specialties.

Many residents have benefited from his

guidance or received “homework” at

the end of a day in theatre.

how is the training of current residents different from that which you received when you were a trainee?

In the past, anaesthesia trainees

were allowed to plan and dictate

their own BST rotations. This was

advantageous, as it promoted self-

guided learning. Motivated trainees

could pick rotations in hospitals where

subspecialty training was available to fill

up the gaps in their training. However,

this system had several disadvantages.

If a trainee was not cognizant of the

gaps in his training, he may not choose

the appropriate rotations and could

end up with deficiencies in his learning.


A/Prof Raymond Goy (first from left) with his pioneer batch of NuHS anesthesiology residents at Outward Bound School

Furthermore, the Medical Officers

Posting Exercise (MOPEX) system

was manpower-driven rather than

education-driven. Even if the trainees

were keen to do the required rotations,

the vagaries of the manpower

requirements and administrative

divide of the different hospitals may

occasionally result in them not getting

their desired postings.

The ACGME-I residency

programme replaces the opportunistic

learning of the BST/AST system. All

subspecialty training in anaesthesia is

now uniformly administered based on

the curriculum and educational needs

of each trainee. With this system in

place, each trainee will get hands-on

experience in the full spectrum of

anaesthesia practice. The elements

of formative resident and faculty

evaluation and feedback are also

enhanced. There are also competency

milestones that the trainees have

to work towards in their route to

specialisation.

Importantly, it is no longer just

about the teaching and receiving of

information. It is also about educators

taking ownership of a resident’s

successes, challenges and professional

and ethical development.

what are the benefits of the residency programme?

The residency programme offers

numerous benefits for the learners,

educators, hospitals and Singapore, if

we are patient and allow the system to

mature.

I believe that the more structured

curriculum and the closer monitoring of

residents will enable us to consistently

produce well-rounded doctors. The

more objective system of evaluations

and feedback also ensures that the

residents are kept abreast of their

progress and allows the faculty to step

in, when needed, to assist them.

We also make sure that the

residents’ feedback on the programme

are heard and acted upon by the

faculty. I particularly enjoyed the

“Meet the Residents” sessions with

my DIO, which allowed us to identify

areas of improvement in the training

programmes, the hospital work

processes and areas that affect patient

outcomes.


There are multiple challenges,

past and present. These challenges

help make our PDs more resilient and

determined to overcome them for the

sake of their residents.

Current medical students and

young doctors are entering specialty

training earlier and are thus less aware

of the rigours and demands of each

specialty compared to before. Medical

students are placed in an unnecessarily

stressful situation of having to

decide on a career track without the

opportunity of caring for patients

and becoming great doctors first; this

is the so-called “residency rat race”.

My advice to young medical students

and doctors is this – unless you are

certain of your career choice, it would

be prudent to take a step back and try

out new options before embarking on

a residency track; a career has to be

driven by passion not obligation, so take

your time to explore and embark on a

specialty that ignites your passion.

A possible solution is to allow

doctors to apply for residency training

only in the second post-graduation year

so that they would have the opportunity

to rotate through more specialties

as MOs. PDs must have the foresight

and discipline to look at the Singapore

system as a holistic national training

unit and allow applicants to mature in

their outlook before matching them

to the specialty. We must also provide

active career counselling to our medical

students to learn to be good holistic

doctors first before specialist training,

and dissuade them from joining the rat

race before they are ready.

At the same time, the increasing

number of residents in our

programme has led to fewer spaces

available for MOPEX MOs to work

in our department, preventing us

from evaluating their suitability

for residency. We overcame this

by performing swaps with our

participating sites, giving MOs from

their departments the opportunity to

work in our programme to prove their

worth, while our residents spend time

at these partner sites. We hope that

this will give MOs who are not yet

part of the residency programme the

chance to become residents.


EXECuTIVE SERIES

PraCtisiNG mEdiCiNE can

be stressful. Conversations with

colleagues invariably drift to

anecdotes that illustrate how

and why stress is inherent to our

profession. Research evidence also

suggests that doctors are vulnerable

to stress at work and that we are

highly susceptible to the ill effects of

work stress, including an increased

incidence of psychological distress and

psychiatric morbidity.

While we readily endorse its

ubiquitous presence, a simple

definition of “stress” remains

elusive. Broadly, stress refers to

the psychological and physiological

reactions that occur when we perceive

an imbalance in the level of demand

placed upon us versus the capacity to

meet that demand. In the workplace, it

refers to the times when we are simply

not sure if we have what it takes to

meet the challenges faced.

why are doctors stressed?A combination of factors

contributes to why doctors may be

especially vulnerable.

Some personality traits that make

us good as professionals (eg. obsessive,

perfectionistic, conscientious,

approval-seeking) may cause us to

be more prone to emotional distress.

Doctors like to be in control but may

harbour chronic self-doubt.

The nature of the job – long hours

and heavy patient loads – is an obvious

source of stress. At the outset of our

careers, we have learnt to deal with

difficult patients and relatives, often

in hectic and trying environments.

Dealing with issues of death, dying

and suffering may take an emotional

toll. Engaging in the “noble” mission of

Workplace Stress Management for Doctors

By A/Prof Calvin Fones

healing ostensibly makes sacrificing

personal life acceptable, or even

expected. The skewed emphasis

on work may then contribute to

poor family/social relationships and

support.

The types of stress may be

unique to the practice environments.

Doctors in public service may feel a

lack of control over factors like work

schedules or workloads, or having

to cope with a lack of resources.

Dysfunctional workplace dynamics

such as bullying or feeling undermined

or unrecognised are often cited by

doctors in training. On the other

hand, those in private practice may

face isolation, both physically and

psychologically.

Various factors pertaining to

the culture and organisation of the

workplace may also engender more

stress for the doctor working there

(Table 1).

table 1. organisational factors that affect work stress

Lack of autonomy and control

Work schedule (eg, call rosters and clinic schedule)

Work load (eg, patient load and administrative duties)

Lack of resources to work effectively and safely

Manpower constraints

Fear of mistakes and litigation

Risk management

Administrative ineptitude and bureaucratic bottlenecks

Career expectations

Uncertainty about authority and responsibilities

Balancing clinical load, administrative, research and teaching

Unclear/unrealistic targets

Career development/advancement and training opportunities

Job fit

Different personal values from the workplace environment,

(eg, generatinprofessional fees vs financial/social needs of patients)

Congruence with interests, training and skills

Dysfunctional workplace dynamics

Hierarchy

Promotions and recognition

Rivalries and peer pressure

Bullying, feeling undermined and harassment

work environment

Monotonous, routine

Chaotic and disorganised

Safety, workplace violence and risks

Organisational support

When patients complain or threaten litigation

Leave/holiday coverage


why does stress matter?Stress in doctors matters because it

leads to “casualties” among colleagues,

including burnout, emotional

exhaustion, disillusionment, a lack of

personal accomplishment, depression,

anxiety and drug/alcohol abuse or

dependence.

Stress may manifest as

psychological/emotional changes,

physical symptoms, behavioural issues

or organisational problems (Table 2).

Occupational stress affects

hospitals and organisations in terms of

productivity and performance. Loyalty

and commitment may suffer, ultimately

affecting recruitment and retention

of medical staff. A stressful work

environment invariably leads to poor

morale and motivation.

Simultaneously, stress matters to

patients as well. Surveys on doctors in

the UK reveal that stress negatively

affected patient care. Clinical

judgement and decision-making may

also be affected. A study of National

Health Service hospital consultants

found that those with poor mental

health reported reduced levels of care

towards patients.

On a more positive note, a

case-control study found that the

introduction of stress management

courses to 22 hospitals led to a

substantial reduction in the rate of

malpractice claims compared with that

in control hospitals. Patient satisfaction,

improved safety and better clinical

outcomes may result from reducing

stress and improving the practice

environments for doctors.

Challenges to tackling the problem

Unfortunately, some doctors can

be very resistant to the idea of seeking

help for themselves, particularly for

emotional or psychological distress.

Many hold an unrealistic expectation

that somehow doctors are not

supposed to be ill, that we should cure

ourselves or just “suck it up”. There is a

potentially dangerous stigma attached

to seeking help for psychological

problems. Some may fear a lack of

confidentiality or that their fitness

to practise may become jeopardised.

Even among those who recognise

their problem or access help, there

is often a reluctance to take time off

to recuperate, even when medically

advised. Thus, there can be an element

of collusion within our medical “culture”

that allows the ill-effects of stress to go

unchecked.

Casualties of work stressAlthough there are rare instances

when doctors may become impaired in

their ability to practise safely because

of the extreme effects of stress (usually

due to the development of major

psychiatric illness or drug and alcohol

problems), the Medical Registration Act

has regulations relating to Unfitness

to Practise through illness and the

need to voluntarily stop practice if we

realise our ability to practise is affected.

Indeed, the Act requires us to inform

the Singapore Medical Council if we

believe a colleague may be unfit to

practise. A health committee may then

be appointed to inquire into the case.

In practice, however, it is sensitive

and difficult to report colleagues. We

are usually able to persuade impaired

colleagues to voluntarily stop practice

and seek treatment without having to

resort to such drastic measures. Our

profession’s principle of self-regulation

means that we have a responsibility,

both to our patients and colleagues,

to ensure that a doctor who becomes

impaired by illness should temporarily

stop practice. Our colleagues should, in

turn, be treated in a confidential, caring

and non-judgmental manner.

Overseas, impaired physician

programmes that emphasise

early, proactive identification and

confidentiality have been set up to

encourage voluntary self-disclosure

by impaired doctors. Treatment,

support and follow-up are provided.

Disciplinary and coercive actions

should always be the last resort, with

the goal being reinstatement and

resumption of practice, but with patient

care and the interests of the profession

being paramount.

what can be done about stress in the profession?

Efforts to prevent the ill-effects

of stress should begin at the earliest

stages of medical training.

Mentoring and peer support

networks, occurring in both formal

and informal manners, should begin

in medical school. Thus, students can

become aware of the importance of

maintaining their own physical and

emotional health at the onset of their

career. This type of early intervention

may have the added benefit of

lessening the stigma associated with

seeking help. For junior doctors,

adequate supervision and support,

along with realistic working hours and

healthy work-life balance, ought to be

table 2: manifestations of work stress

Psychological/emotional changes

Poor concentration and memory

Insomnia

Fatigue

Anxiety, depression

Guilt, denial

Anger, aggression, irritability

Resentment, cynicism

Poor appetite, over-eating

Behavioural changes

Indecision

Resistance to change, being

uncooperative

Social withdrawal and isolation

Apathy, avoidance

Alcohol and drug abuse

Physical changes

Chest Pain, palpitations

Shortness of breath

Headaches, dizziness

Bowel symptoms

Muscle tensions

Organisational problems

Absenteeism

Decline in productivity

Resignations and poor retention

of talent


“The young doctor should look about early for an avocation, a pastime, that will take him away from patients, pills, and potions…” – William Osler

encouraged. Medical training should

include helping doctors recognise their

own limitations and develop skills to

better track how stress affects their

well-being and professional practice.

what can you do to help yourself?Awareness

Awareness of the sources of

stress and how one reacts to different

stressors is a crucial first step.

Individuals differ in the nature and

intensity of the stress that they are

susceptible to.

Acceptance

Coming to terms with one’s own

vulnerabilities is not always easy. The

stringent standards and rigorous nature

of medical training sometimes inculcates

a distorted message that not pushing

ourselves to the limit amounts to

personal “weakness”.

The competitive nature of medical

school and residency may spill over to

professional rivalry, and this culture of

competitiveness can be a major source

of stress. Striving to be “the best” may

demand a high emotional cost. Perhaps

an attitude more aligned with simply

doing our professional best is healthier,

both for the patients and doctors.

Attitude

Along with the inherent need to

“compete”, certain mental attitudes

serve to perpetuate workplace stress.

The notions of service, sacrifice

and putting the needs of patients

first, which are “noble” attributes of

the profession, may easily become

distorted to unhealthy proportions.

Some doctors, while appearing to

lament their extended work hours and

lengthy appointment lists, may derive

gratification from the same; their

popularity as the most widely sought-

out specialist, therefore, justifies what

is actually an imbalanced and stressful

practice.

Nevertheless, acquiring a healthy

work-life balance is not easy to achieve,

but prioritising the basics of rest,

relationships, relaxation and recreation

go a long way to preventing the ill-

effects of stress.

Stress-reduction techniques include

elements of deep breathing, muscle

relaxation, mindfulness and meditation.

Exercise and physical activity stimulate

the production of endorphins and

counter the deleterious effects that

stress has on the immune system.

Coping stylesHaving negotiated the rigours of

many years of medical education and

training, most doctors would have

developed their own repertoire of

strategies to cope with stress. Their

effectiveness depends on the type of

stressor, the particular individual and

circumstances. There are two types

of coping responses: emotion- and

problem-focused.

Emotion-focused coping

This involves trying to reduce the

negative emotional responses (eg,

fear, anxiety, depression, frustration or

embarrassment) associated with stress.

Emotion-focused coping techniques

include distraction and suppressing

emotions or experiencing them through

talking about how they feel. These

strategies may be ineffective, as they

ignore the root cause of stress or delays

the dealing of the specific problem.

However, it can be a good strategy if the

source of stress is beyond the person’s

control.

Problem-focused coping

This targets the causes of stress

in practical ways by tackling the

problem or situation that is causing

stress, consequently directly reducing

the stress level. These strategies,

which include problem-solving, time-

management and accessing instrumental

social support, aim to remove the

stressor or reduce the cause of stress.

They deal with the root cause, thus

providing a long-term solution. It is

the default strategy employed in our

professional approach to tackling our

patients’ problems. However, it is not

always possible to use these strategies

such as when dealing with loss and

bereavement, which requires emotion-

focused coping.

making the choice of less stress For some doctors, a stressful

professional life has become a

longstanding and deeply ingrained

habit. Others seem resigned to the view

that stress itself is an inevitable part

of life as a doctor. The reality is that

there are proactive choices that we can

make, especially when we realise that

negative effects have already begun

to set in. Making a decision to take the

necessary steps to better manage and

control work stress can be tremendously

empowering. Change may not come

easily, but the patience, persistence

and commitment required would be

worthwhile across all areas of life.

Dr Calvin Fones is a consultant psychiatrist in private practice who assesses patients who are stressed every day. He also listens to stressed colleagues who vent their angst in hospitals’ doctors’ lounges and occasionally helps stressed

medical colleagues in a clinical setting. Not immune to workplace stress himself, he tries to follow the advice he dispenses.



For Doctors, For Patients

at this year’s Inter-Professional Games (IPG) from August to October!

For more than one-and-a-half decades, SMA has joined forces with five other professional bodies,

namely the accountants, architects, engineers, lawyers and surveyors to organise the annual IPG.

If you wish to find out the complete list of games and take part in IPG 2015,

please visit https://goo.gl/5AWUhX.

dr Chia yih woEi

ChairmaN

sma sPorts & GamEs CommittEE

BRING YOuR GAME ON

OPINION

or Not?

i bEloNGEd to the second last

A-Level batch that missed the much

feted through-train scheme by a

whisker. So I thought I should count it

fortuitous to be the second batch to

enter the residency “through-train”

programme.

Much like the A-Level through-

train, the residency “through-train”

has also been greeted with much

controversy. The pros and cons of

either system are bounteous. The

former system was more flexible

(or laissez-faire) and self-directed

(or unstructured); while the new

promised more structure (or greater

bureaucracy) and greater certainty (or

less flexibility).

As I had always wanted to do

geriatrics, it was not a difficult

choice for me to jump onto the kiasu

Singaporean student bandwagon to

sign up for the internal medicine (IM)

residency programme straight out of

medical school. It also helped that IM

was not a complete lock-in either, as

I knew that if I did not find geriatrics

appealing after a while, there were

many other IM subspecialties available

to choose from. In that way, I got the

best of both worlds – a guaranteed

By Dr Tan Li Feng

{

{To Through-Train


Li Feng is a first year senior resident from the Department of Geriatrics, National University Health System (NUHS). She first wrote an article for SMA News in 2007 (http://news.sma.org.sg/3905/MedSoc.pdf), in her first year of medical school as

the class representative. In it, she stated that she wanted to do Geriatrics and eight years down the road that is what she is doing today.

training spot and some flexibility for

manoeuvring. I am not sure if other

specialties enjoy this advantage as

well.

However, as IM residents came

to learn soon after, there was also

a price to pay for such flexibility.

Senior residency subspecialty spots

are not guaranteed. The chances of

landing a senior residency spot seem

at times as random as the vagaries

of the wind, dependent on the year

that you are scheduled to apply in

and the competition you face in that

particular cohort. Neither was there

an option of waiting a year to apply in

a less competitive cohort. The budding

cardiologist who daily holds onto his or

her aspirations to get by every arduous

medicine call might very well end up

doing general medicine or being lost

at the end of junior residency, due to

factors that are at times beyond the

resident’s control. Some flexibility

has since been introduced to the

senior residency matching process,

but certainly the promise of turning

consultant in six years upon graduation

is unfulfilled for a selected group of

residents.

Thankfully, I did not have to go

through that disappointment as a

resident. If anything, the residency

system’s certainty and push to “churn

out” specialists helped me move on

despite having my training disrupted

by a happy bundle of joy – the birth

of my son. I am certain that without

the residency programme, I would not

have been able to keep to the schedule

of completing my junior residency

programme within the stipulated 36

months. Thanks to supportive and

enlightened programme directors who

helped mould my schedule in an “infant

residency programme”, I was able to

be matched to my senior residency

programme of choice before I had even

attempted my registrar exams. This

would have been impossible in the

old system. I passed my exams within

months of starting senior residency.

As a new mother, moving on to

senior residency sooner, rather than

later, has certain advantages and was

definitely a factor in my decision to

continue training rather than dropping

out as the light at the end of the tunnel

seems closer within reach. The only

downside so far has been that because

I never got the chance to do any

paediatrics, as breadth of training was

sacrificed for intensity and relevance,

I am no wiser when it comes to little

ailments that my infant gets.

The residency system is assuredly

not for everyone. Unlike the old system

where junior doctors were not given

dedicated guidance, the residency

system benefits some, potentially

at the expense of others, but it can

also ensnare some. It is expeditious

but should not be rashly undertaken.

Perhaps it can be likened to marriage.

If one is ready for commitment,

accommodation, loss of some

autonomy and in-laws (one big, fixed

residency family), then take the plunge.

However, if marriage is undertaken

merely to escape singlehood and not be

left on the shelf, then it is a dangerous

commitment with possibly painful

outcomes for all involved.

Not everyone is suited for marriage,

and not all would enter into one at

the same time in life. But thankfully,

residency is not marriage. It is only one

part of a doctor’s journey. Sometimes

it is a highway, other times a blip or

a detour. But in the grand scheme of

things, what does it matter if you take

six, ten or 15 years to train? It is simply

a matter of perspective – something we

doctors need in all that we do.

...the residency system benefits

some, potentially at the expense of others, but it can

also ensnare some.”

“



OPINION

residency Programme – Hits and Misses

By Dr Tan Ming Yuan

loNG hours, busy calls and

punishing schedules – these are some

characteristics often associated with

general surgery training all over

the world. Nonetheless, they are a

necessary evil to achieve craft and

mastery in our field of practice. In

recent times, surgery training, as well

as the specialist training community

as a whole, has undergone a huge

change with the introduction of the

residency programme in Singapore.

What prompted the change was

the success of the US residency

programme and the need to increase

the specialist population in Singapore

to meet the demands of the future.

transitioning from old to newI am part of this transition phase

and am currently witnessing its

evolution. Upon graduation and

completion of my house officer year,

prior to serving my two-year National

Service in the Singapore Armed

Forces, I found myself on the brink of

the transition between the old and

new systems. As a pre-selected basic

specialist trainee traversing into the

new realm of residency and having

experienced both, I was able to see

the differences between these two

unique systems and how the change

has impacted local training.

{ {

Dr Tan Ming Yuan is chief resident with the NHG-AHPL General Surgery Residency. He believes that there is more to life than work and is thankful to have great friends at work, not just colleagues.

“…in order for the residency programme to reach its

full potential, an entire

generation will have to change.”


Residency is a form of graduate

medical training that originated

from the US and took root in the

19th century. Pioneered by Sir

William Osler and William Stewart

Halsted at the Johns Hopkins

Hospital, residency is a formalised

and regulated training programme

that has evolved over the years

to its current state – rigorous

and structured in its training

methodology and outcomes.

With the change from the time-

proven, “survival of the fittest”

basic specialist training/advanced

specialist training system to the

new structured, competency-

based residency system, there is

a push for the implementation of

new pedagogies and education

methods. In addition to the

workload of service provision, the

resident now faces an increase in

number of assessments, in-training

examinations and other demands,

which were hitherto given far

less attention. An all-rounded

resident is expected to perform

well in each of these realms – from

clinical medicine, operative skills to

scholarly activities and involvement

in institutional or national

administrative commitments.

Considering the challengesAlthough the concept and

eventual aim of residency is good,

many would agree that there is

much room for improvement. The

residency programme is still at its

infancy stage of development and

will continue to grow and evolve in

order to meet the challenges of the

future.

Like a cup that is already filled

with water, we cannot continue

adding more water without first

removing some, or else the cup will

simply overflow. Similarly for the

residency programme, we need to

be cognizant about what additional

tasks and aims are added, as well as

where compromises can be made

based on what is relevant and critical

for achieving what is deemed a

competent specialist of the future.

There is also a need for a

paradigm shift in the methods of

administering such a programme.

This starts with the top management

and flows down to the faculty, who

are on the ground mentoring the

new generation of trainees. We

need to rethink the methods that

have served us well in the past and

consider if they are still relevant and

efficient in achieving our targets, or

perhaps we need to embrace a new

methodology.

There has been much flak on

the concepts of restricted duty

hours, protected time for formalised

teaching and in the case of surgical

disciplines, case logs. These concepts

should be viewed not only in its

execution (which may have caused

some inconvenience to individuals

and institutions), but also the intent

and reasons they are in place.

Perhaps, with greater understanding,

these changes may be more readily

embraced.

For a long time, we have assumed

that a doctor is also a teacher, but

this may not be the case. Faculty

must be educators, not just by

chance or talent, but through

nurturing. There is now much

knowledge available on the science

of education, and we should not

ignore the necessary development

of our teachers in this regard. Thus,

the faculty for residency ought to be

trained specifically for this role.

Despite these challenges, I

remain optimistic about the future.

This transition is a good opportunity

to discard some of the preconceived

notions of what used to work, to

shape the training programme

for our future generation, and to

remind ourselves of the importance

of continual evolvement and

improvements. Certainly, there

will be some hits and misses

along the way, but in order for the

residency programme to reach its

full potential, an entire generation

will have to change. We must stay

focused on our mission, which is to

train competent future medical and

surgical specialists who will excel

and surpass their predecessors. Only

when that happens will we have truly

succeeded.

OPINION

why Fm in Nuhs?Family medicine (FM) was not

the initial choice for my first medical

officer posting exercise (MOPEX). I

had applied for anaesthesia but got

a polyclinic posting instead. Though I

struggled with the polyclinic workload,

I found myself enjoying the variety

of cases that spanned different body

systems, age groups and genders,

as well as the continuity of care and

relationships forged with patients.

After rotating through other

MOPEX postings, I realised that shift

work and overnight calls are not for

me. All things considered, I decided

on FM as a specialty. My application

under the old basic specialist training

programme in 2010 was rejected.

Fortuitously, I reapplied the following

year and was accepted into the

inaugural intake of the FM residency.

I chose National University Health

System (NUHS), as it offered a unique

programme, including block postings

to private GP clinics. I was also bowled

over by the sincerity of its faculty,

especially when the programme

director, A/Prof Tan Boon Yeow,

telephoned personally to address my

concerns point-by-point. Later on, the

faculty also supported my intention to

subspecialise in sports medicine.

Fm residency journeyThe inaugural batch of NUHS FM

residents experienced many teething

problems. The learning curve for

inpatient rotations was steep. Even

though the postings were short, the

residents were expected to get up

to speed fast and to perform like

other members of the department

in order to fulfil service needs.

Also, the style of assessment of the

Accreditation Council for Graduate

Medical Education (ACGME) and

the concept of hosting FM residents

were new to most departments,

leading to confusion on the ground

regarding how best to manage our

learning needs. In departments with

high service loads and manpower

shortages, educational needs

sometimes took a back seat and taking

time off to attend FM continuity

clinics and teaching sessions was often

difficult. In 2011, the programme

failed the ACGME audit, leading to

uncertainty over our future.

I am glad to say that all that is in

the past now. The programme has

since gone on to achieve full ACGME

accreditation. Host departments

have also become more mindful of

FM residents’ unique learning needs

By Dr Wang Mingchang

From FM Residency to Sports Medicine


and are thus more accommodative

towards us. They also recognise FM

residents’ contribution to their teams,

for instance in ensuring holistic patient

care beyond the focus of a specialty on

a specific organ system or region.

why sports medicine?Having served as an instructor

in the health and fitness club during

my junior college days, I had found

it rewarding to teach about exercise

safety, to give injured students

rehabilitation advice, and to help

others meet their weight loss and

fitness goals. During my university

days, I continued to do so and

cherished the hope that I could

someday incorporate this aspect in my

career.

I first heard about sports medicine

in my second year of medical school,

and subsequently did my electives at

the Changi Sports Medicine Centre

(CSMC) and Singapore Sports Council,

and also served six months as a medical

officer at CSMC. One of the routes to

subspecialisation in sports medicine

was via the Master of Medicine in

Family Medicine examination. This was

a natural choice for me since I have

an interest in both family and sports

medicine.

meeting dr lingaraj Krishna My first rotation in National

University Hospital (NUH) in 2011 was

with the orthopaedics department. At

that time, I did not work directly with

Dr Lingaraj Krishna (current director

of NUH Sports Centre), but he had

found out about my interest in sports

medicine. Three years later, towards

the tail-end of my residency training,

Dr Lingaraj, having been tasked to set

up the NUH Sports Centre, invited me

to be a part of it and I agreed without

hesitation.

building up the serviceDr Lingaraj worked tirelessly

to engage staff within and outside

of NUH, and to put together a

multidisciplinary sports medicine

Dr Wang Mingchang is a family physician and sports medicine registrar with the NUH Sports Centre. He is hydrophobic but is trying hard to overcome this, and hopes to complete a 1.5-km open water swim someday.

and surgery

team comprising

orthopaedic surgeons,

sports physicians,

physiotherapists,

podiatrists,

radiologists, sports

scientists and others.

He also liaised with

senior management,

administrative staff

and contractors to

set up the physical

premises of the Sports

Centre, as well as

implement operational

and billing protocols.

My roles

included setting up

pre-participation

screening protocols

for events supported

by the Sports Centre

and drafting disclaimer

statements on the advice of the

hospital’s legal counsel. I also had the

opportunity to network with National

University of Singapore’s (NUS) staff

and partner institutions on projects

jointly organised with the Sports

Centre, as well as assist with article

requests from the mainstream media.

The biggest challenge was getting

NUH accredited as a sports medicine

training site. Upon rejection by the

Joint Committee for Specialty Training

(JCST) on the first attempt, we sought

the advice of other successfully

accredited sports medicine

departments, to come up with a

training programme that met JCST

training requirements. Personally, the

process was challenging as the above

responsibilities were in addition to my

pre-existing FM work commitments

at St Luke’s Hospital and the NUH

Transitional Care Team. You can

imagine the amount of free time I had

left over!

All our efforts finally came to

fruition when NUH received its

accreditation as a sports medicine

training site. As for me, I will be starting

full-time sports medicine training

from July 2015. Clinics have already

started at the Sports Centre, and we

hold regular multidisciplinary team

meetings to discuss challenging cases.

We are also collaborating with Team

NUS in looking after NUS athletes

with sports injuries and coming up

with injury prevention programmes for

high-risk sports.

Final thoughtsFrom the family medicine’s point

of view, sports and exercise play a vital

role in chronic disease management.

Knowledge of sports medicine is also

important, as more Singaporeans are

participating in exercises, resulting in

increasing rates of sports injury. As we

manage a rapidly ageing population,

physical exercise will play a key role in

functional and healthy ageing.

Above Dr wang Mingchang (right) with Dr Lingaraj Krishna, the director of NuH Sports CentreFacing Faculty and residents of NuHS FM residency programme at an orientation dinner in July 2014


what is radiation oncology?Radiation oncology has

traditionally been one of the best

kept secrets in medicine. Even

though this specialty is becoming

increasingly popular overseas, it is

still relatively unknown locally due

to limited exposure to it in medical

school, despite the important role it

plays in the treatment of cancer. It

is estimated that more than half of

all patients diagnosed with cancer

will undergo radiotherapy during the

course of their illness, whether it is in

the curative, palliative, neoadjuvant

or adjuvant setting.

Friends and family, even those

in healthcare, have little idea what

radiation oncology is about. It is often

confused with diagnostic imaging,

Text and photos by Dr Shaun Ho

OPINION

Radiation Oncology – A Merging of Biology

and Physics

interventional radiology, nuclear

medicine or medical oncology. In

radiation oncology, we use ionising

radiation in the form of photons,

electrons and even protons to treat

patients with cancer or other benign

conditions such as thyroid eye

disease, keloids, acoustic neuromas,

arteriovenous malformations and

trigeminal neuralgia.

Radiotherapy has come a long

way since its therapeutic potential

was discovered more than a hundred

years ago. It has developed rapidly,

especially over the last 20 years,

from simple 2D techniques to

3D conformal radiation therapy

(RT), to intensity-modulated RT

and stereotactic radiosurgery. As

technology continues to advance, so

does our ability to deliver radiation

to a target with greater accuracy and

higher dosage while sparing as much

normal tissue as possible.

why i chose to specialise in radiation oncology

Radiation oncology was not what

I had planned on specialising in – I

stumbled upon it unexpectedly. In

fact, I was initially drawn to surgery

because I was fascinated with its

interplay of anatomy, pathology

and technique. However, during

my surgical posting, I met a fellow

medical officer (MO) who was a

radiation oncology trainee rotating

through general surgery. That was

when I first learnt about this field

and the intriguing nature of its work,

which seemed to share similarities

with surgery minus the invasiveness.

Later, I did a posting in radiation

oncology and decided to stay put.

Radiation oncology appeals to

me in several ways. The first is our

patients – as every oncology patient

we meet in the clinic faces a serious

disease, it is a privilege to be part

of the treatment process to cure or

palliate our patients and it is also

very rewarding. Furthermore, many

consultants are able to build close

relationships with the patients and

their families because patients who

receive RT are often on long-term

follow-up after the completion of

treatment.

Another factor that draws me to

radiation oncology is the colleagues

in the department – fellow doctors,

radiation therapists, nurses, physicists

and dosimetrists – who work closely

together. From healthcare staff who

go the extra mile for patients, to

fellow trainees who help and support

each other, to senior doctors who

are always ready to provide help and

advice, everyone is passionate about

their work and caring towards the

patients.

Several incidents left a lasting

impression on me. One was a

consultant who had travelled to a

{

{

patient’s house to pass him some

medication when he found out that

the patient had significant side

effects from RT. Another colleague

recently fetched a deaf patient who

was uncontactable by phone to the

hospital because the patient’s CT scan

was suggestive of a retropharyngeal

abscess. Such colleagues who

genuinely care and go the extra mile

for their patients remind me daily why

I chose to practise medicine.

Unfortunately, radiation

oncologists are often subjected to

button-pushing witticisms due to the

perceived one dimensional nature of

our work, but nothing can be further

from the truth. Another aspect of

radiation oncology that appeals to me

is the broad knowledge base and skill

sets required in this field. Not only

do radiation oncologists need to be

familiar with reading CT scans, MRIs

and nuclear imaging, we must also

have a good understanding of surgical

procedures and anatomy, as it helps

guide target volume contouring. Due

to the many patients with terminal

disease that we manage, we also

need to have a basic understanding

of chemotherapy and the systemic

treatment options available, and be

familiar with palliative care.

A day in the clinic could involve

performing a nasendoscopy for one

patient, a vaginal examination and Pap

smear for another patient, followed

by a depot injection of goserelin for

a patient with metastatic prostate

cancer while titrating his pain

medications and having a discussion

about future care plans, and finally,

interpreting the radiological films

of another patient . While the initial

learning curve can be steep, the

multifaceted aspect of our work helps

to keep things interesting.

Radiation oncologists have

fairly predictable schedules, which

is uncommon in medicine. While

weekdays can get quite packed, we

do not have night calls and most

weekends are free. This allows for

good work-life harmony, giving us

sufficient time for our families and

hobbies.

radiation oncology trainingRadiation oncology is one of the

remaining training programmes not

yet under the residency system. It

consists of five years of seamless

training, of which one year is spent in

relevant non-radiation postings of our

choice. We work towards attaining

the UK FRCR (Clinical Oncology) or

the FRANZCR (Radiation Oncology),

the Australian/New Zealand

equivalent. The former qualifies

physicians in the UK to be clinical

oncologists who can prescribe both

chemotherapy and radiotherapy, but

it can be quite challenging to clear

the exams as we do not prescribe

chemotherapy in Singapore. Besides

clinical oncology, the exams also cover

subjects such as physics, statistics,

pharmacology, cancer biology and

radiobiology. As some of these topics

are not covered in medical school, it

takes some effort to learn them from

scratch.

To help us in our training, we have

weekly combined tutorials across

institutions. In-training assessments

are conducted through regular

mini-Clinical Evaluation Exercises,

case-based discussions and Direct

Observation of Radiotherapy

Planning Skills (DORPS). We also

have six monthly end-of-posting

assessments, comprising multiple

choice questions and vivas. During

our training, MOs and registrars

rotate through various firms in the

department to gain exposure to the

different oncology subsites such

as neuro-oncology, head and neck,

thoracic, breast, gastrointestinal,

urology, gynaecology, lymphoma,

paediatrics and sarcomas. The

department is also generally

supportive of trainees who wish to

broaden their knowledge beyond

radiation oncology.

Overall, radiation oncology is a

very interesting field, incorporating

technology and imaging with patient

care and contact. I am fortunate to

have stumbled into this field and am

thankful to be training in a specialty

that I enjoy.

Shaun is a radiation oncology registrar at National Cancer Centre Singapore. A lover of the outdoors, he can be found jogging through park connectors across Singapore on weekends. He enjoys discovering new places and learning new

things. Spending time with his friends and family brings him lots of joy and laughter.


OPINION

EVErybody KNows how to become a resident… or do

they? Good grades, publications, community service and

excellent clinical acumen are all helpful, but are they all that

matter? Are the rumours that blue blood, good looks and

medical school of origin play a part true? Are all candidates

for residency equal or are some more equal than others?

Maybe yes, maybe no, but you can’t change your parents

(although you can choose your godmother or godfather),

and in this age of Facebook, it is getting increasingly hard to

pass off your plastic surgeons’ handiwork as a makeover or

targeted weight loss/gain. But fear not, with this short guide

to basic residency requirements and specialty-specific

traits, you’ll be filling out survey forms and hounding faculty

members to complete your evaluations in no time.

basic residency requirements Knowledge

It’s difficult to get that general surgery residency if

you think the epiploic foramen of Winslow is in the brain.

Neither will you impress your endocrine consultant if you

think a sliding scale is something you use in the kitchen.

Time to stop sailing the uncharted seas and open a

book, plus even if you publish ten papers for your future

programme director, you still have to pass medical school

before you can start residency.

Clinical acumen

Appearing in the firing line at multiple morbidity and

mortality meetings does not a resident make. Clinical

acumen is an integration of knowledge, experience and

the art of medicine. The only way to get more of it is to

set out to sea more often, hopefully with a chart. For the

non-resident senior medical officer or service registrar

wandering in the desert, have faith because the time for

you to cross the river into your promised land (ie, specialty)

is at hand, especially for the good clinician. For the medical

student applying for residency, perhaps possessing clinical

acumen is a bit too much to ask, but it’s never too early to

start mastering the specialty of your choice.

Research

How do you differentiate between each candidate? For

some programmes, a PubMed search for the prospective

candidate’s publications may be a surrogate marker, but

dummies’ Guide to residencyBy SK Warrior

research

is not for

research’s

sake. If you’re

going to be doing

something for the

rest of your life, it helps

that it’s an intellectually

stimulating subject worth

investigating. But still,

you shouldn’t overdo it

and neglect your clinical

work; all the publications

in the world are of little

use if you can’t tie off that

bleeder in the middle of

the night.

Attitude

No one

wants a

resident who

pulls a long face

every time the clinic goes past 5 pm or turns off the phone

after midnight while on call. Remember you have to earn

the right to perform those total knee replacements and

cataracts, so put on your happiest smile and say, “Yes

Prof, I’m ok!” and then continue holding that retractor

throughout the rest of that Whipple procedure. Remember,

pain is weakness leaving your body. What we do in life

echoes through eternity… and the next residency interview.

Grooming

You have to look the part – if you want internal

medicine, look neat and intelligent; general surgery or

neurosurgery, look as though you’ve not slept in days.

And if you want to do a residency that begins with the

letter “O” or “D”, it’s time to buy those heels and invest

in some branded accessories; but try not to overdo it –

perfect makeup, initialed bespoke clothing, fancy shoes

and Bahasa Indonesia instead of Bahasa Melayu classes

may raise suspicions of “mountain climbing” private sector

tendencies, not kosher in residency programmes meant to

train doctors for the public sector.


traits of the specialty However, those are but general

attributes of a resident. Below are some

specialty-specific traits that you must

demonstrate to get your residency.

Anaesthesiology

Be OCD! That sticker can only be

pasted lengthwise on the syringe. Helps

to have an overdeveloped hippocampus

(I think?) for all those drug dosages and

half-lives, and the nerves of a fighter pilot when the patient

crashes on you.

Internal medicine

Why have one differential when you can have 15? Refer

as needed to disprove said differentials. Be the last true

generalist in a world of subspecialists.

Geriatric medicine

Be both gentle and patient and have the ability to

move at a glacial pace. A flair for dialects is helpful but not

compulsory. After all, the caregivers of the elderly tend to

be foreign maids who can speak some basic English.

Diagnostic radiology

Love office hours and life spent in darkness. Love

shades of grey, literally. A photographic memory and the

ability to hedge help (“please correlate clinically”).

Pathology

Love office hours and a life spent staring down

microscopes. Love shades of purple and pink, literally. A

photographic memory and the ability not to hedge help.

Emergency medicine

Hate office hours and love

unpredictability. Work is like a box of

chocolates (you never know what you’re

going to get!). Save lives and be like

the Night’s Watch, overstretched and

misunderstood. Be prepared to override

your friends, as necessary, to admit

to the correct specialty (ideal, but not

compulsory).

Cardiology

Can read squiggly lines and enjoy life

at 1,000 miles per hour? Welcome!

Neurosurgery

Can read CT brains and enjoy life at 1,000 miles per

hour? Welcome!

“SK Warrior” is the alter ego in each of us who has to regularly face challenges in our work, and gracefully overcome obstacles of all forms, with a smile. May the SK warrior live on in you forever and to continue to do SK work for the betterment of your patients.

“Ours not to reason why, ours but to do and die.”

General surgery

Male: Have good hands and be able to withstand

pain and hard work. Looking good or speaking well is not

necessary.

Female: Pretend to be one of the men and be ready to

give up the best years of your life proving yourself.

Ophthalmology, otolaryngology, dermatology and plastic

surgery

Top of the class and good-looking to boot (some people

have all the luck). Let me guess, you can get

through a night call with perfect makeup, hair

and clothing, too.

Paediatrics

Chronic Dean’s lister with a deep

affinity for complex syndromes? Enjoy

calculating dosages with a calculator? Of

course, it helps if you actually enjoy working

with kids.

Obstetrics and gynaecology

Be the kind of person that women love, yet never

seen as a potential romantic rival by the husbands. Enjoy

occasional awkward conversations.

urology

Be sympathetic about leaks, unpeeled and peeled

bananas and malfunctioning machinery. Enjoy awkward

conversations.

Psychiatry

Be a father/mother figure or confidant that the patient

never had. Must be wary of erotic transference. Must enjoy

awkward conversations.

Orthopaedics

Enjoy working with power tools.

Know everything about only one thing.

Don’t be hurt if people think you know

nothing.

Family medicine

Enjoy working with people. Know

something about everything. Don’t be

hurt if people think you know nothing.

Remember Jon Snow became Lord

Commander.


i FrEquENtly receive distressed

SMSes from fellow GPs. Many of us are

solo practitioners who enjoy autonomy

as doctors and businesspeople. There

are certainly beauty and benefits in

solo practices. However, life is not

always smooth sailing; often, it springs

surprises on us in unexpected ways.

Like our patients, we face all kinds of

life challenges – personal health, family

problems, emotional issues, practice

difficulties, even perceived unfairness

and injustice. The list is endless.

Physical well-beingBeing in the frontline of the

healthcare system, GPs are constantly

bombarded with all kinds of viruses.

We are seasoned warriors against

influenza, hand, foot and mouth

disease, dengue, shingles and

chickenpox. We get knocked down,

rest a day and are back on our feet,

albeit with the loss of a day’s worth of

income.

From time to time, we hear

remotely about some new outbreaks

like the MERS. Many of us have

volunteered as Public Health

Preparedness Clinics and have

been promised supplies of personal

protective equipment and antiviral

medicines. Despite the support, we still

feel the jitters.

Some of the older GPs may suffer

from chronic diseases. A few may have

strokes. While we can still comfortably

practise as GPs, our emotional strength

and stamina would have diminished.

We may not be able to last an entire

day of clinic.

Financial well-beingMany young GPs are struggling

to make ends meet because of the

high rental of their commercial units.

They may still be servicing their study,

housing or car loan. At the other end

of the scale, patients are deterred by

the perceived higher GP fees. These

GPs are stuck between a rock and a

hard place.

“Hey, bad news! My neighbour has just rented his unit to a young, new GP.”“Hi, my landlord wants to increase my rental from $3k to $8k. How?”“Oui, the GP behind my clinic has just gotten CHAS. Should I apply too?”“Hi bro, just received a letter from a management company wanting to introduce a penalty system. How?”

All these SMSes reflect the very

dynamic and hostile environment in

which GPs operate. The bottom line is

money. At the forefront of our minds is

how to survive, or is it even worth the

effort continuing?

When Doctors Suffer

By Dr Leong Choon Kit, Editorial Board Member

“Hel

p, m

y family just left me...”

“Feeling depressed...”“I’m

so lost! ”


GP MATTERS

Dr Leong Choon Kit is a GP in the private sector. He feels strongly about doctors contributing back to society. As a result, he tries to lend a voice to the silent majority in every issue he has come across, particularly those in healthcare, educational and other social concerns.

Psychological well-beingGPs undergo multiple stresses

daily, and over time, they can

certainly wear us down.

“Look, Choon Kit, being a GP can be very bipolar. If your clinic is empty, you are stressed by the fear of no income. If the clinic is too full, you are stressed by not being able to finish seeing the patients, or missing potentially life-threatening conditions and complaints from patients.”

A senior GP had warned me

when I first started my clinic. I can

understand that perfectly well now.

social well-beingI have heard of colleagues who

work so hard that they have hardly

any time to socialise. I have also

tried counselling fellow colleagues

whose spouses have left them.

To a lesser extent, I sometimes

feel stressed when my patients

ask about my children’s academic

performance, or lack thereof. I

also feel stressed when my friends

and relatives stop me in church, at

weddings or funerals to ask about

their medical conditions. It seems

rude to avoid them and it is difficult

to explain to laypersons about our

ethical obligation regarding kerbside

consultation.

where will help come from? A few years ago, while holidaying

on Phillip Island, Melbourne, my

family stopped at a quiet restaurant

by the quay for lunch. I found out

from the restaurant staff that it

is an establishment set up by a

fishermen’s co-operative to help ill

fishermen who could not go out to

sea – an interesting concept. Their

self-help spirit is admirable. The

chef, waiters and waitresses worked

tirelessly and always wore a smile.

They knew that their work supports

one another to bring collective good

to their community.

Similarly, in mission work, it

is recognised that missionaries

experience all kinds of stresses. Not

all return from the field unscathed.

Many of them need regular doses of

tender loving care, which is provided

by the member care department of

the mission agencies.

Doctors too are human – we

get bombarded by all kinds of

stresses and get wounded physically,

emotionally and psychologically.

Despite that, we are supposed to

carry out our duty to care for others

and in the name of professionalism,

hide our hurts while doing so.

It is about time that our

professional bodies look into a

formal structure to look after our

kind. We should learn from the

fishermen on Phillip Island and the

mission agencies. We should not

expect others to take pity on us or

look after our welfare, nor should we

expect a hand-out.

I am familiar with the GP scene.

Chat groups and regular meetings to

share industrial knowledge can be

therapeutic. These platforms allow

GPs to openly discuss problems

faced in the different phases of our

lives and practice, and enable us to

learn from one another.

Another useful and practical

help would be for GPs to cross

cover one another during periods

of unavailability. For smaller clinics,

employing a locum may not be

feasible. We can help to look after

patients from neighbouring clinics,

allowing our colleagues to take leave

for holidays, mission trip or medical

follow-up at hospitals.

There is so much we can do for

one another; the time to act is now…

or maybe yesterday?

“Hey, CK, do you have a moment? I’ve just received a letter from a management company and I am disturbed by the new clauses they have added in. Can you help?”

Looks like it’s time to help again.

I will share what I learn from this

friend in the next issue…

There is so much we can do for one

another; the time to act is now… or maybe yesterday?”“


By Jennifer Lee, Deputy Manager, SMA Charity Fund

thE PoCari Sweat Run 2015 was held on 12 July 2015 at

Kallang Practice Track. SMA Charity Fund (SMACF) was one

of the selected beneficiaries of the run that attracted a total of

10,000 runners, with 53 runners registered under SMA.

Dr Wong Tien Hua, President of SMA, flagged off the 10-km

run in the morning before joining the crowd as a fellow runner.

Staff from the SMA Secretariat also took part in the race to

support the SMACF.

In his speech, Dr Wong thanked Pocari Sweat Singapore and

the runners for their support towards SMACF and its causes,

which include providing financial support for future doctors

from underprivileged families. With the bursary, they will not

need to find other means to supplement their family income at

the expense of their medical education and training. Dr Wong

went on to congratulate Pocari Sweat Singapore for a successful

event, with a good turnout.

The donations received from the race will be used to fund

the SMA Medical Students’ Assistance Fund (SMA-MSAF), a

programme managed by SMACF, which provides bursaries to

needy medical students to support their living expenses so that

they can concentrate on their medical education.

Mr Yoshihiro Bando, operating officer of Otsuka

Pharmaceuticals Japan, commented, “POCARI SWEAT was

developed by Otsuka Pharmaceuticals Co. Ltd, Japan, with the

philosophy to create new products for better health worldwide.

We also recognise medical doctors as one of the key players in

creating and impacting health through their medical knowledge

and training. We are pleased to have the SMA Charity

Fund, which helps ensure that needy medical students can

concentrate in their medical training and become good medical

doctors, as one of our beneficiaries!”

Running for a Good Cause

Ph

oto

: Po

cari

Sw

eat

Sin

gap

ore

Ph

oto

: Po

cari

Sw

eat

Sin

gap

ore

Ph

oto

: Po

cari

Sw

eat

Sin

gap

ore


achieving more together

Full member of National Council of social service SMA Charity Fund (SMACF) is now a full member of

the National Council of Social Service (NCSS).

NCSS is the coordinating body for some 400

voluntary welfare organisations (VWOs) in Singapore. It

is a statutory body established by an Act of Parliament

(The NCSS Act) on 1 May 1992, with the charter to

improve the lives of the disadvantaged in Singapore,

taking over the functions of the former Singapore

Council of Social Service and Community Chest of

Singapore. It works closely with many government

ministries, as well as the people and private sectors.

NCSS leads and coordinates the social service sector

in Singapore with the purpose of ensuring that every

person has the opportunity to live a life of dignity to his

or her fullest potential within society.

There are two types of membership under NCSS:

full and associate. Full membership is granted to an

organisation whose primary function is to provide a bona

fide direct social service that helps to meet the existing

needs of the community.

As the SMACF is a young charity, being awarded

a full membership is a testament to the quality of our

programmes. We can now collaborate with the council as

well as network with other VWOs to address needs that

may not have been covered, thus deepening our impact

on the medical fraternity. In addition, SMACF will also

be eligible for consideration for various funding schemes

under NCSS.

Care & share movement

SMACF has been accepted as a member of the Care &

Share Movement.

Care & Share is a national fund-raising and

volunteerism movement led by Community Chest for the

social service sector, in celebration of SG50 this year.

It aims to bring the nation together to show care and

concern for the needy, and to recognise the contributions

made by VWOs. Eligible donations raised by participating

VWOs from now till 31 March 2016 will be matched

dollar-for-dollar by the government. The matched

amount will go towards building the capabilities and

capacities of the social service sector, and supporting

social services to meet rising needs.

Your support is critical in helping us to advance our

cause, and create ripples through society. Donation to

SMACF can be made online at the SG Gives website

(https://www.sggives.org/smacf) or by cheque (donation

forms can be downloaded from our website). Donation

made this year will enjoy 300% tax deductions.

By Jennifer Lee, Deputy Manager, SMA Charity Fund

SMA CHARITY FuND

Bursary application for the SMA-MSAF is now open

for medical students from Lee Kong Chian School of

Medicine and Yong Loo Lin School of Medicine. Medical

students who are interested in applying for this bursary

can approach the schools directly on the bursary

application. For further enquiries, please contact SMACF

at [email protected]


introductionEnd-of-life decisions can

prove to be especially challenging

to doctors because protecting

our patients’ health is a central

tenet of the profession. However,

respecting life includes supporting

quality of life right to its very end

and there is no absolute obligation

to prolong life indefinitely without

regard for consequences such

as burden of care.1 To tread this

delicate balance, the ethical principle

of respect (both for patients and for

human life) provides the foundation

on which doctor-patient trust is built.

There should be no doubt that care

provided at the end of life is of the same

standard as the treatment provided to

any other patient. This trust provides

dying patients and their loved ones

with the confidence that they will

always receive the best care possible

and that their choices and values will be

honoured.

All medical treatment imposes

burdens on patients. The trade-off

with benefits diminishes with frailty,

co-morbidities, progressive disease and

incurable conditions. Burdens include

treatment-related side-effects, cognitive

impairment, loss of independence and costs

both in terms of time and finances. There may be

a misconception that palliative care should be reserved

until the last days of life. On the contrary, the control of

physical and psychological symptoms should always be

a priority and palliation can be initiated at any stage of

illness. Inappropriate treatment also results in a misuse of

limited healthcare resources that may be directed away

from other patients who may benefit from them.

Ambiguity arises because there is no universally

By Dr Anantham Devanand

accepted definition of a patient who is approaching the

end of life. The General Medical Council in the UK has

proposed to include all patients who are likely to die

within the next 12 months and not limit to those who are

imminently dying. This broad definition would encompass

patients with terminal disease, those with existing

conditions with a risk of dying from an acute crisis and the

physiologically frail who have multiple co-morbidities.1

This informs us of the range of patients to whom end-of-

life decision making may be applicable.

making an end-of-life decisionThe process begins with a comprehensive evaluation

of the patient to clarify concerns, diagnoses, prognoses

and available treatment options. Patients who retain

decision-making capacity should be respected and

allowed to make their own decisions including the option

to refuse life-saving treatment. This process should not

be reduced to doing whatever the patient wants.2 Instead,

doctors have an obligation to help patients come to terms

with their illness, understand what can be meaningfully

achieved and make decisions that are consistent with

personal values.

The Mental Capacity Act (MCA) clarifies that every

adult is assumed to have decision-making capacity until

it is proven otherwise.3 Mental incapacity is assessed

using a two-stage test: (1) Is the person suffering from an

impairment of mental function and; (2) Does the impairment

prevent the person from making the required decision.

Anyone is deemed incapable of making a specific decision

when he/she cannot understand information related to

the decision, remember the provided information, weigh

up information or communicate any decision that has

been made. Doctors are obligated to maximise capacity

by either improving one’s understanding and aiding

communication or delaying decisions until acute medical

conditions that cause temporary incapacity are treated.

Anticipatory decisions help extend the autonomy of

those who have lost decision-making capacity. An advance

directive and the appointment of a lasting power of

attorney are examples of such decisions. It is imperative

Guide to End-of-life Decision Making


PROFESSIONALISM

Dr Anantham Devanand is a senior consultant in Department of Respiratory and Critical Care Medicine, Singapore General Hospital, an assistant professor at Duke-NUS Graduate Medical School and the deputy director of SMA Centre for Medical Ethics and Professionalism.

to ensure the validity and applicability of any available

anticipatory decisions.1 Valid decisions are informed and

made when mental capacity was intact without undue

external pressure. The Advance Medical Directive Act

allows adults who are terminally ill to reject life-sustaining

treatment when they become mentally incapacitated.4

If patients meet such criteria, a search for an advance

directive should be made with the Registry of Advance

Medical Directives at the Ministry of Health.

A Lasting Power of Attorney (LPA) registered at the

Office of Public Guardian is a legal proxy authorised

to make decisions on behalf of the patient (“doner”).3

However, the proxy’s scope of decision-making must

also be checked because he or she can be authorised to

make decisions on the donor’s personal welfare, property/

affairs, or both. In medical decisions, the proxy’s role

is further restricted by the statute to exclude refusal of

life-sustaining treatment and any other treatment that

the doctor believes to be necessary to prevent significant

deterioration in the patient’s condition.

If a patient without decision-making capacity has not

made any anticipatory decision, then doctors have the

responsibility to make decisions based on the patient’s

best interests. This is defined by the MCA to consider not

only the medical best interests, but also the patient’s past

wishes, values and beliefs.3 The decision should be least

restrictive of the patient’s future choices and cannot be

motivated by a desire to bring about death. Although

responsibility ultimately rests with the doctor, the law

requires that relevant legal proxies, caregivers and family

members should be consulted and not just be told what

has been decided.

When consulting with families, they must not be given

the impression that they are being asked to make any

decision.1 Instead, it must be made clear that they are

advising the healthcare team on the patient’s values and

likely preferences. Phrases such as “doing everything”

should be avoided because of the mistaken inference that

“everything” equates to better care.2 Ideally, an identified

doctor should take responsibility for the communication

with the family. Multiple doctors across different shifts

and subspecialties will struggle to build the necessary

trust to guide family members through the patient’s

critical illness.

advance care planningRegardless of the safeguards, making a best interests

decision in a medical crisis remains a less than ideal

solution. Advance care planning is a voluntary discussion

between patients, care providers and family to clarify

care preferences (including location of care).5 It extends

beyond end-of-life decisions to long-term care needs

as well. Although advance care plans are not as legally

binding as an advance medical directive or designating a

LPA, they create a record of patient’s wishes and decisions

to facilitate the future delivery of treatment. The advance

care planning process itself assists patients to understand

their medical condition and treatment options, motivates

them to reflect on values and beliefs, and facilitates a

discussion with caregivers and family on choices at the end

of life. Instead of being a box-ticking exercise, it should be

an information sharing and reflective experience that can

be re-visited.5

End-of-life decision making should not be reduced to a

single “life-or-death” decision.2 It comprises a process by

which patients understand their own medical condition,

come to terms with the prognosis, clarify personal goals

and communicate with those closest to them. This journey

is often fraught with grief, denial, ambivalence and hope.

Helping them navigate this journey with minimal distress,

as well as a genuine respect for life and human dignity is

the doctor’s contribution.

References1. General Medical Council. Treatment and care towards the

end of life: good practice in decision making. Available at http://www.gmc-uk.org/Treatment_and_care_towards_the_end_of_life___English_0515.pdf_48902105.pdf. Accessed 27 June 2015.

2. Berlinger N, Jennings B, Wolf SM. The Hastings Center Guidelines for Decisions on Life-Sustaining Treatment and Care Near the End of Life. Oxford University Press, 2013.

3. Singapore Statues Online. Mental Capacity Act. Available at:http://statutes.agc.gov.sg/aol/search/display/view.w3p;query=DocId%3A7f933c47-8a34-47d1-8d0a-0 a 4 5 7 d 6 f a 1 c 2 % 2 0 % 2 0 S t a t u s % 3 A i n f o r c e % 2 0Depth%3A0;rec=0;whole=yes.

4. Singapore Statues Online. Advance Medical Directive Act. Available at: http://statutes.agc.gov.sg/aol/search/display/view.w3p;query=DocId%3Ac3137d32-215d-4bd1-a935-fc4770fc5850%20%20Status%3Ainforce%20Depth%3A0;rec=0.

5. Singapore National Medical Ethics Committee. Guide for healthcare professionals on the ethical handling of communication in advance care planning. Available at:https://www.moh.gov.sg/content/dam/moh_web/Publications/Guidel ines/National%20Medical%20Ethics%20Committee%20Guidelines/2010/NMEC%20Guide%20for%20Comms%20in%20ACP.pdf. Accessed 24 June 2015.


INDuLGE

iN most of my travels, I try to fit in one or

two good meals to round up the trip. Sights,

attractions, museums and history – they

are like the staple, the expected and bland

experience that is highly recommended on

TripAdvisor but would be neither spectacular

nor mind-blowing. Worse, it may just lead

you to busloads of tourists and a handful of

pickpockets on weekends.

Food is different. Food gives you a glimpse

into the complex dynamics that shape a society,

on a plate, which you can taste. It tells you a

story – its history, the disparity in social class,

the blend of different cultures, the influence

of colonisation and the fertility of the lands.

It may or may not be on TripAdvisor’s top 100

list of must-do, but it is always an experience that

you can reflect on, to which people can relate.

My travels this summer brought me to two very

contrasting places geographically, socially and politically.

Holland, a coastal province in Netherlands, was a colonial

superpower ruled by a King, while Czech Republic, previously

a colony and communist, is landlocked.

the dutch capitalWhen we think of Holland, Amsterdam comes to mind.

I had the privilege of spending two nights there, and the

experience was unexpected but enjoyable. I always imagined

Amsterdam to be a place of vice, where teenagers get high on

amphetamines and retirees smoke weed while playing chess

by the canal. I imagined it to be a place where couples spend

their honeymoons just so they can feel closer to the brink of

danger. But I couldn’t be more wrong.

I checked into a very quaint and charming hotel and was

given, what I believe, the best room available. Occupying

the entire attic, the room was clean, decently sized and

overlooked the canal. It prodded my imagination and gave

Text and photos by Bryan Koh

A Journey Through

&PRAGUE

AMSTERDAM

me a sense of how Anne Frank might have lived half a century

ago, even though that vision was rather farfetched. I wasted

no time and made my way to the Anne Frank House only to

Clockwise from topThe quaint room at Ambassade Hotel, AmsterdamMouth-watering dishes enjoyed in AmsterdamLong wait to visit the Anne Frank House


find a queue snaking more than a hundred metres long. Not

wishing to waste time queuing, I booked myself on a river

cruise instead.

The river cruise turned out to be an extremely entertaining

experience that celebrated the magnificence and architectural

genius of the Dutch in their heyday. The organisation of the

canal ring area, the engineering of dunes, dikes and dams to

channel water away from the third of Holland that sat under

sea level, not to mention Golden Age artists like Rembrandt

and impressionists like Van Gogh – such orchestral brilliance

is often forgotten, but they ought to be remembered when we

think of Amsterdam.

Then the sun set and it was time for dinner. Dry-aged Dutch

ribeye steak, Dutch white asparagus with morel mushrooms

(seasonal), and cod from the Dutch coast paired with amazing

wine. The freshness of the produce, the intricate presentation,

the delicate taste and balance of flavours all reflect Holland as

a province – precise, passionate and dedicated to their art.

the journey continuesAfter Amsterdam, my next stop was Prague, the capital

city of Czech Republic, known for its baroque buildings,

Gothic churches and Astronomical Clock. I stayed at the Jalta

Boutique Hotel, which used to be a nuclear fallout shelter and

the military base of the Warsaw Pact countries during the

Cold War. It is right smack in the centre of Wenceslas Square,

next to the National Museum. The city of Prague is starkly

different from Amsterdam. The people are more wary, cold

and unwelcoming of tourists. This is understandable given

that the Velvet Revolution happened only recently in 1989.

The Bone Church in Kutna Hora, with skeletons of at

least 40,000 adults decorating its walls and halls, reminded

me of the Black Death and Hussite Wars. Even the

Astronomical Clock in the Old Town Square told the story

of a clockmaker, Master Hanus, who had his eyes gorged out

by the city councilmen just so he could not repeat his work.

Similar stories were told about Gothic churches and Jewish

synagogues. Living in this century in a place like Singapore,

I find it difficult to imagine the tumultuous life that people

have led in such a place for centuries. As I marvelled at the

beautiful architectural structures and the stories behind

them, I couldn’t help but pause for a moment to appreciate

the country that I grew up in.

As my journey through the two cities came to a close, I

sat with my mum, atop the Prague Castle Gardens, in Terasa

u Zlate Studne, the best restaurant in Czech Republic.

Taking in the scenic landscape, we talked about the history

of Czechoslovakia, the mechanics of the Astronomical Clock

and the poor quality of seafood in Czech Republic.

Bryan Koh is a final year medical Student at Yong Loo Lin School of Medicine. When not with his books or at the hospital, he spends time pursuing his interests in sport, food and horology. He had wished to be a rugby coach, chef or watchmaker but settled for his best option – being a doctor.

Clockwise from top leftCanal view of Amsterdam at nightAstronomical Clock in PragueHuman skeletons decorate the walls of the Bone Church, Kutna Hora, PragueThe fine cuisine savoured in PragueMum and I posing for the camera as we dinedThe crowd taking in the Nightwatch by Rembrandt


Contents• Topic 1: Overview of Mental Capacity Act (MCA)

• Topic 2: Code of practice

• Topic 3: Overview of incapacity

• Topic 4: How to assess mental capacity and when to

refer

• Topic 5: Writing a mental capacity assessment report for

purposes under the MCA

• Appendix

learning objectives• Understanding the principles and application of the

MCA in the assessment of mental capacity.

• Appreciating the importance in Lasting Power of

Attorney Certificate issuance.

• Understanding the requirements in preparing a mental

capacity report for the purposes specified in the MCA

MCA Online Training ModuleAssessment of Mental Capacity under the Mental Capacity Act

For enquiries, please contact the sma secretariat by phone at 6223 1264 or via email at [email protected].

Register online

• Visit SMA website

(www.sma.org.sg)

• Click on MCA

Online Training

Module

• Click on “Get this

course”

Account signup

• Sign up as a user

• Fill in the required

details

• Create an account

MCA online training

module

• An email will be

sent to you once

your account is

activated

• You are ready to

start

DATE EVENT VENUE CME POINTS WHO SHOULD ATTEND? CONTACT

CME Activities

16 AugustSunday

BCLS CourseAlumni Medical Centre

TBCFamily Medicine and All Specialties

Lin Shirong 6223 [email protected]

5 SeptemberSaturday

MPS-SMA Conference – The Changing Medicolegal Landscape: Rising to the Challenge

One Farrer Hotel & Spa

TBCDoctors and Healthcare Professionals

Denise Tan 6223 [email protected]

13 SeptemberSunday

BCLS CourseAlumni Medical Centre

TBCFamily Medicine and All Specialties

Lin Shirong 6223 [email protected]

24 - 25 OctoberSaturday - Sunday

The Annual National MedicoLegal Seminar 2015

Fairmont Singapore, Raffles City Convention Centre and Swissotel Stamford


Denise Tan 6223 [email protected]

31 OctoberSaturday

Cancer Education Series 2015: Prostate Cancer

Health Promotion Board


Carina Lee 6223 [email protected]

Non-CME Activities

August - October Inter-Professional Games 2015 Various Venues NA SMA MembersAzliena Samhudi 6223 [email protected]

1 AugustSaturday

SMA Intermediate Photography Course (Night Photography – Fireworks Edition)

Esplanade NASMA Members and Guests

Mellissa Ang 6223 [email protected]

19 AugustWednesday

SMA Annual Golf TournamentSembawang Country Club

NASMA Members and Guests

Azliena Samhudi 6223 [email protected]

SMA EVENTS AUGUST - OCTOBER 2015

CALENDAR

AIC SAYS


doctors in training - sma physics dr shaun ho shares why he was drawn to the specialty 30 dummies’...

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