However, I look at medical education from a more unorthodox but at the same time a more traditional perspective.

 

Let me tell you where I am coming from. Having taught clinical medicine for several decades, I realise that most of what medical students learn are from patients. They are the foundation of learning. To guide the students in this process are teachers and mentors. Below are some of my random disorganized thoughts.

 

Medical Apprenticeship

Medical education is an apprenticeship, where one follows a doctor either individually or with a small group of students. This approach is absolutely essential, especially when it comes to the practical aspects of medicine. It is the ability to interact with patients, to ask astute penetrating questions, to have a sharp eye observing patients, to do an accurate clinical examination, to acquire a good sense of judgement as to the most likely diagnoses, to decide if further investigations are necessary, and to determine what is the optimal treatment strategy. Yes, artificial intelligence can help in any of these steps, but the foundation, in my opinion, should be established by having individualized teaching by experienced clinicians.

 

Learn from Mistakes

We all make mistakes, and we regularly hear about mistakes made by doctors on the news, but it is important to draw lessons from them. For example, there was a tragedy when a patient with severe abdominal pain was seen by a junior doctor and the initial diagnosis of cholecystitis (inflammation of the gall bladder) was actually correct. But when the condition deteriorated because of a ruptured gall bladder, the doctor failed to urgently consult a senior doctor, or refer to a surgeon. The patient died. In this example, there are several problems that need to be addressed.

 

The care of emergency patients needs doctors to lower their threshold in consulting colleagues or referring the patient to another doctor. This problem is encountered quite frequently: doctors seem reluctant to “disturb” their colleagues and they would rather sit on the problem until it becomes an emergency. This behaviour is something that has to be excised in medical school. Students need to be taught that there is no loss of face or shame by acknowledging the limits of their knowledge, and that it is far better to consult someone else early rather than create a tragedy. Humility and teamwork needs to be inculcated in medical education.

 

Technology in Medical Education

Driven by the increasing number of medical students, the falling number of patients, the narrowing of the spectrum of diseases seen in Singapore, medical schools are now turning to technology to teach students. This can take the form of watching videos and animations, doing online courses with testing capabilities, using artificial (plastic) patients, using virtual reality goggles. Nearly all medical textbooks are now available for reading on the computer laptop, tablet, or the handphone. The use of plastic dummies is especially good for teaching cardiopulmonary resuscitation (CPR) because you can make all the mistakes you like without harming anybody. Some of the technological innovations that are already changing educational practices include robotic surgery: students can practice simulated robotic surgery, similar to airline pilots using a flight simulator to learn to fly an airplane.

 

There are good and bad points using technology as a major teaching tool in medical schools. In terms of “book-learning” factual knowledge, it is excellent. Certain practical skills, like CPR and robotic surgery, are also outstanding. However, learning soft skills like how to interact with real patients may not be ideal. Developing logical deductive and inductive reasoning may also be imperfect, and as for creative problem-solving skills, we plunge into an abyss. The solution, I am convinced, is not to decrease the time interacting with peers, teachers, and mentors, and to be challenged by discussing problems and participating in clinical or laboratory research.

 

Information Overload

A universal complaint by current medical students is that they are overloaded with too much information. They do not seem to have a good work-life balance, and many sacrifice their socializing opportunities. A few students are overwhelmed and become depressed and suicidal. This is an important issue and cannot be swept under the carpet. Heads of all departments must meet regularly to decide what is the current core curriculum, and to refrain from overcrowding the medical syllabus.

 

Thinking Skills

Most educationalist claim that they are teaching “critical and creative” thinking skills. They say this so frequently that the phrase is becoming like a vacuous electioneering slogan. I am sometimes asked to give lectures at medical schools, and I always welcome questions. When lecturing in England or the USA, I am inundated by questions both during and after my talk. In contrast, when I give a talk in Singapore, I always ask the students: “Any questions?” and rarely does anyone ask. Silence! So, I surmise that either I am a bad lecturer driving everyone to sleep, or that Singapore students are afraid to ask questions. I suspect it is the latter. Asking questions is one of the most important skills a doctor must learn. Unfortunately, this is not given sufficiently high priority in medical education. I think it is essential for all students, especially medical students to learn to ask questions. "Behind every question is another question, and another question, and another question...."

 

Generalist versus Specialist

Singapore is a tiny red dot and our population of only 5 million is facing difficulties sustaining a large pool of medical specialists and subspecialists. Even with medical tourism, where we attract patients from all over southeast asia, we are currently running into problems with too many specialists. The result is that after we have trained our specialists, we cannot find jobs for them, and this leads to unhappiness. The proposed solution, adopted by some countries, is to train generalists with a deeper grounding in certain specialties. In England and Australia, for example, there has been a movement to produce “General Practitioners with Specialty Interests” or GPSI’s (pronounced “gypsies”). This is still a controversial topic, but I think that maybe Singapore might want to consider a customized version of this concept. Actually you might point to the current polyclinic and group practice system, where you have a collection of different specialists in, say, cardiology, respiratory diseases, gastroenterology, dermatology, psychiatry, etc. and suggest that we are already adopting a version of GPSI's. These specialists have also had generalist training, and can therefore handle the more common medical complaints. The bottom line is that if trainees have a mindset that they are fundamentally general practitioners but are encouraged to deepen their expertise by specialty training, they will not be disappointed if they are not given a pure specialist position in a major institution.

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Are Values Caught, not Taught?

It is commendable that medical education now includes the teaching of ethics, but I have often wondered how effective this really is. Every month we hear about some doctor being suspended or reprimanded for unethical behavior. I realize that all teachers have to set a high moral standard if they are to become the role model for students. They can also discuss ethical issues in small groups. Correct me if I’m wrong, but I have been informed that some Singapore medical students skip organized talks and discussions on medical ethics. I hope I’m wrong.

 

Patients Know a Lot

Many patients have done their homework by scouring the internet before consulting a doctor. They often know a great deal, although their comprehension can sometimes be a bit uneven. We might even find it a bit embarrassing to discover our patients know more than us. This is becoming increasingly common, and we may have to admit: “I didn’t know that!” However, we are now in an era where not everything found on the internet is accurate. How to determine what is “fake news” from valid information is becoming increasingly difficult. Medical students need to be taught this before they get sucked into an alternative universe of untruths.

 

Community Service

One of the strong points in Singapore’s medical education is their devotion to voluntary community service. Students are encouraged to help the less privileged not only in Singapore but also overseas. This is done extensively, and some students render long-term commitments in spite of their busy schedules. While this may not be an official part of the medical curriculum, it is one of the ways of developing compassion, a core component of good doctors.

 

Conclusion

The future of medical education needs to be tackled at several levels. It is inevitable that we are embracing technology passionately, but we need to be acutely aware of their limitations and redress the problems. As for the observation that some students and doctors are reluctant to consult their peers, colleagues, teachers, mentors and others in the healthcare profession, we need to correct this issue. Medical education is an apprenticeship and bedside teaching forms the bedrock of teaching theoretical and practical knowledge, as well as imparting ethical behaviour. Small group teaching is essential especially in teaching criticial and creative thinking skills, discussing moral issues, and learning practical procedures, and therefore class size should not be diluted. Many students complain that the current medical curriculum is a bit overloaded, and their grievances cannot be ignored. With the rapidly changing medical-scientific landscape, doctors need to be prepared to embrace lifelong learning. In the end the priority of medical education should be focused on the patients' care and wellbeing.

 

Professor Yeoh Khay Guan advocated a holistic approach to medical education, and I thoroughly endorse this.

 

 

Kenneth Lyen

11 Nov 2018