From Seniors to Juniors, Re: Clinical Years

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It is the time of the year as each batch transitions into their next year of medical school and as we congratulate our M5s for finishing their MBBS. The nervousness of going into clinical years is natural for many, whilst we wonder how best to handle the jump from the books to the wards. We figured who better to ask for advice and wisdom than our seniors who have walked these years before us. We are thankful to the seniors from both Class of 2020 and 2021 who have given their invaluable suggestions for this article (we apologise for not being able to include all of it in detail!). All the responses were deeply meaningful and we will try to sum it up as best as we can here.

The Academic Side of Clinical Life

The first question frequently asked would be what study resources to use. Some are commonly used, such as the Oxford Handbook of Clinical Medicine for Internal Medicine or the Clinical Practice Guidelines for Family Medicine or MedBear for General Surgery. Yet, asking different people would yield different answers on what works best for them. Eventually, whether it be textbooks or seniors’ notes, it is alright to take the time to find what suits your studying style the most.

With clinical life, theory becomes a companion to clinical skills. Besides reading up and building our theoretical knowledge, seniors (and doctors) have always encouraged us to keep practising. After all, it is not the same reading about a physical examination, performing it on a real patient, and eventually translating the signs seen into a differential diagnosis.

In the wards and clinics, one other aspect to observe would be the communication between both healthcare staff and patients. With every clinical experience, it is essential to learn how to handle various situations with respect and empathy. Breaking bad news, angry patients, conflicts among a team—though these are not everyday situations, they are instances we must learn to handle with professionalism. It is never too early to watch and learn from the doctors around us on how they communicate to reach solutions. These are intangible skills that also come in useful when we might have to counsel patients in the future as we exit medical school.

And our seniors’ essential advice: stay humble to learn. It is a vast world of knowledge out there but it is crucial to not let this daunt our desire to learn. Instead, actively asking questions and making the most out of every learning opportunity, will help to achieve consistency in our learning.

The Non-Academic Side of Clinical Life

Whilst we may sometimes focus on the new academic expectations of clinical life, our seniors have also reminded us that academics is not all there is to our clinical years. For example: pursuing a hobby outside of medicine. Some might find that several doctors might open a conversation with what hobbies you enjoy as well. Having something you enjoy outside of medicine does not mean having to choose one over the other; they can certainly co-exist and hobbies can help to relieve some stress from the increased rigor in our clinical years.

Ultimately, our seniors’ words of wisdom: one must remember that Medicine is also about the people you journey with. Although entering clinical life will not be an easy ride ahead, supporting one another is both intangible and invaluable. Learning together, being kind to and looking out for each other are no less important than seeing an additional sign. For many, it is not just about completing medical school, but to emerge on the other side with precious friendships—with those who have walked alongside them to be where they are today.

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Careers Magazine would again like to thank the seniors who have given us their advice and lent their words of wisdom to this article. We wish you all the best in your future work as well!

The Evolution of Singapore's Healthcare Industry Under COVID-19

Anyone who has lived through the past year and a half will have a story to tell about COVID-19. The pandemic has upended the world, causing massive death, injury, unemployment and more; it's hard to imagine a more globally impactful event in recent memory. On a personal level, all of our lives have ground to a halt, as work-from-home and social distancing have necessarily become our new normal. With this upheaval, however, has come an opportunity to examine more closely the industry in which we will all work someday, and identify the changes catalysed by such an unprecedented crisis.

Our experience with SARS was retrospectively a boon during COVID-19, as it provided us insight on the holes in our healthcare system we needed to fill. As we students approach the end of our academic year, and our M5s prepare to graduate, it seems an appropriate time to be cognizant of the lessons learned from this pandemic, take stock of the paradigm shifts happening in healthcare and speculate on how they might impact the Singaporean medical scene in the near and distant future.

Telemedicine and Digitalisation

The movement towards telemedicine and the digitalisation of care is arguably the greatest – and definitely the most obvious – effect of the pandemic on healthcare so far. Digital health consults were, in many places, on the precipice of being implemented by healthcare institutions (1), but COVID-19 has accelerated that timeline. With the urgent need for social distancing to quell the spread of the virus, many non-critical treatments and consultations were put off until a less precarious time (2). However, in areas which had the resources and infrastructure to adopt alternative means of connecting patients and healthcare workers, telemedicine became the new standard (3). Where they could, countries introduced online consultations, virtual health screenings and socially-distanced check-ups to completely replace face-to-face interactions (4).

In Singapore, the pandemic prompted a rapid escalation in adopting new and relatively innovative models of care. Tamping down on community spread was and still is a significant priority, and one way to do that was to prevent hospitals and clinics from becoming hotspots for infections by cutting back on non-essential interactions. For instance, the National Kidney Foundation and the National University Hospital coordinated an effort to cease in-person dialysis rounds in February 2020, replacing them with remote reviews of patient records and online communications with on-site dialysis nurses (5). The Ministry of Health further encouraged the digital healthcare boom by approving video and phone consultations with some limited and conditional coverage from Medisave (6).

It is difficult to tell precisely how and how permanently telemedicine will be integrated into existing healthcare platforms, and the role it will play alongside in-person consultations in the future. However, it is not an unreasonable assumption that it will be more extensively implemented following its widespread use and relative success in delivering adequate care during this pandemic (7), and we can likely expect telemedicine to be a routine part of healthcare in the future.

A Shifted Focus to Holistic Healthcare

One of the more notable trends in healthcare in the 21st century is the push for a greater emphasis on non-physical health issues. Mental health was a key theme in the Sustainable Development Goals and was thus brought to the forefront of the recent unified global agenda (8). COVID-19 has now thrown these illnesses into even sharper focus – while it may be a respiratory virus, it has also triggered a mental health epidemic, with reported cases of anxiety and depression approximately quadrupling in the last year alone (9).

The context of near-total isolation has become almost universal as a majority of people are forced to stay home and avoid interaction to contain the spread of the virus. This has led to an avalanche of mental health issues stemming from the inherent loneliness of work-from-home and social distancing (10) and the existential loss and fear created by a spike in unemployment and the generally dismal state of world affairs (11). Moreover, many people now lack their typical emotional outlets e.g. sports or travel, leading to a build-up of stress and emotion without catharsis, which exacerbates the issue (12). The pandemic has created a perfect storm for mental illnesses and caused many to spiral downward into anxiety, depression and more (13), and this problem is affecting every section of society. There has been a significant rise in those seeking help for mental health issues in Singapore across all age groups since the pandemic began (14).

In response, many communities have been calling for a greater emphasis on mental health in national health strategies to combat these trends, although there have yet to be any national guidelines on specifically supporting the mental health outbreak during COVID-19 in Singapore (15). However, mental health will continue be a predominant issue in the healthcare arena, both globally and locally, as this wave of mental illness will endure even years downstream of the pandemic (16). Healthcare workers in the future will need a solid grasp of how to navigate mental as well as physical illnesses in patients in order to address these increasingly prevalent health issues.

Medical Tourism

In keeping with the trends of globalisation and greater international collaboration, medical tourism has become a major industry in the last few decades. Singapore is one of the world’s top destinations for medical tourism – we rank #2 globally on the Medical Tourism Index (17). In recent years, the practice of encouraging citizens of other nations to travel to Singapore has been somewhat controversial, at least in the public sector; 2019 saw the Ministry of Health cracking down on public healthcare institution contracts with foreign agents who facilitate visits by foreign patients (18). In the same year, the Singapore Tourism Board confirmed it was no longer pursuing medical tourism as a travel strategy (19).

While medical tourism was in the process of being weaned down in the public sector even prior to COVID-19 (20), it was still a popular practice in private healthcare institutions (21). The near-total shutdown of the travel industry following the pandemic means that medical tourism has temporarily but completely ceased. Many private healthcare institutions were more heavily impacted by this as some have lost a majority of their overseas patients (22).

It is possible that the last year without business will kill both the private and public medical tourism industries permanently and make Singapore a far less common destination for foreigners seeking treatment. Whereas this may be a relatively minor impact on public healthcare, it could be quite a drastic change for some private healthcare institutions which cater to this clientele. However, conjecture on the eventual outcome of medical tourism as a niche industry in Singapore is still wholly speculative – medical tourism could pick up again when borders reopen, but in the meantime, it is a significant adjustment for many healthcare institutions.

In Singapore, the light at the end of the tunnel is dim but visible. The progression to Phase 3 and the reopening of most in-person businesses has allowed us to return to a fragile new normal. It's ordinary to be pessimistic about the ramifications of a pandemic when we only recently passed the peak of this healthcare crisis, but upheaval catalyses radical change, and not all of it is bad. Discerning the positives from the negatives will require more hindsight than we have at present, but we should be aware of the rapid evolution of the medical industry during and following this pandemic. The next pandemic could very likely happen while most of us are still practicing, but hopefully this experience has prepared us adequately for that.

By Beth Jacob-Chow (M3)

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References

1. Wootton R, Craig J, Patterson V. Introduction To Telemedicine. 2nd ed.

2. Masroor S. Collateral damage of COVID‐19 pandemic: Delayed medical care. J Card Surg. 2020;35(6):1345-1347. doi:10.1111/jocs.14638

3. Portnoy J, Waller M, Elliott T. Telemedicine in the Era of COVID-19. The Journal of Allergy and Clinical Immunology: In Practice. 2020;8(5):1489-1491. doi:10.1016/j.jaip.2020.03.008

4. Ohannessian R, Duong T, Odone A. Global Telemedicine Implementation and Integration Within Health Systems to Fight the COVID-19 Pandemic: A Call to Action. JMIR Public Health Surveill. 2020;6(2):e18810. doi:10.2196/18810

5. Lee C, Weng K, Cheang C, Thong T, Behram Ali K. Rapid Transition to a Telemedicine Service at Singapore Community Dialysis Centers During Covid-19. NEJM Catalyst: Innovations in Care Delivery. 2020. doi:10.1056/cat.20.0145

6. Ministry of Health, Singapore. TIME-LIMITED EXTENSION OF CHAS SUBSIDY AND USE OF MEDISAVE FOR FOLLOW UP OF CHRONIC CONDITIONS THROUGH VIDEO CONSULTATIONS IN VIEW OF COVID-19.; 2020. https://www.moh.gov.sg/covid-19/vc. 

7. Bashshur R, Doarn C, Frenk J, Kvedar J, Woolliscroft J. Telemedicine and the COVID-19 Pandemic, Lessons for the Future. Telemedicine and e-Health. 2020;26(5):571-573. doi:10.1089/tmj.2020.29040.rb

8. Dybdahl R, Lien L. Mental health is an integral part of the sustainable development goals. Prev Med Community Health. 2018;1(1). doi:10.15761/pmch.1000104

9. Panchal N, Kamal R, Cox C, Garfield R. The Implications Of COVID-19 For Mental Health And Substance Use. Kaiser Family Foundation; 2021. https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/.

10. COVID-19 Measures, Loneliness and Depression. https://adelphipsych.sg/covid-19-measures-loneliness-and-depression/. Published 2020..

11. Blustein D, Guarino P. Work and Unemployment in the Time of COVID-19: The Existential Experience of Loss and Fear. J Humanist Psychol. 2020;60(5):702-709. doi:10.1177/0022167820934229

12. Sarner M. Maintaining mental health in the time of coronavirus. New Scientist. 2020;246(3279):40-46. doi:10.1016/s0262-4079(20)30819-8

13. Reger M, Stanley I, Joiner T. Suicide Mortality and Coronavirus Disease 2019—A Perfect Storm?. JAMA Psychiatry. 2020;77(11):1093. doi:10.1001/jamapsychiatry.2020.1060

14. GOH T. More in Singapore seek help for mental health issues amid Covid-19 pandemic. The Straits Times. https://www.straitstimes.com/singapore/health/more-seek-help-for-mental-health-issues-amid-pandemic. Published 2020. 

15. Ho C, Chee C, Ho R. Mental Health Strategies to Combat the Psychological Impact of COVID-19 Beyond Paranoia and Panic. Article in Press | ‘Online First’ Access. 2021. https://www.annals.edu.sg/pdf/special/COM20043_HoCSH_2.pdf. 

16. Gold J. Covid-19 Might Lead To A ‘Mental Health Pandemic’. Forbes. https://www.forbes.com/sites/jessicagold/2020/08/06/covid-19-might-lead-to-a-mental-health-pandemic/?sh=4577e2b7706f. Published 2021. 

17. Medical Tourism in Singapore l Pacific Prime Insurance Brokers. Pacificprime.sg. https://www.pacificprime.sg/medical-tourism-in-singapore/. 

18. Lim J, Soeriaatmadja W. World News Day: Health Ministry clamps down on medical tourism in public hospitals. The Straits Times. https://www.straitstimes.com/world/health-ministry-clamps-down-on-medical-tourism-in-public-hospitals. Published 2019. 

19. Medical tourism in Singapore “no longer a priority” - LaingBuisson News. LaingBuisson News. https://www.laingbuissonnews.com/imtj/medical-tourism-in-singapore-no-longer-a-priority/. Published 2019. 

20. Lim J, Soeriaatmadja W. Singapore government clamps down on medical tourism in public hospitals - World News Day. World News Day. https://worldnewsday.org/singapore-government-clamps-down-on-medical-tourism-in-public-hospitals/. Published 2019. 

21. Chee H. Medical tourism and the state in Malaysia and Singapore. Global Social Policy: An Interdisciplinary Journal of Public Policy and Social Development. 2010;10(3):336-357. doi:10.1177/1468018110379978

22. Goh C. COVID-19 border closures impact Singapore medical tourism sector | Video. CNA. https://www.channelnewsasia.com/news/business/covid-19-border-closures-impact-singapore-medical-tourism-sector-13885542. Published 2021. 

6 Books to Read This Year on Wellness and Becoming a Better Doctor

With the dawn of a new year, the time has come for us to refresh and start anew. As part of Career Directorate’s aim to promote work-life balance and self-care, here are some books that allow us to reflect and focus on our own well-being, and help us become better doctors. All of these books are also applicable for meaningful reading even after we have graduated and become practicing doctors.

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1. When Breath Becomes Air by Paul Kalanthi

Why you should read this: This book follows Paul Kalanthi, who is diagnosed with terminal lung cancer at the age of thirty-six and in his final year of neurosurgery residency. Having to transition from doctor to patient, he approaches the issues related to death with grace, posing thought-provoking questions about the meaning of life. As medical students and future doctors, we can learn from how he tried to live each day to the best of his ability, and the importance of the patient-doctor relationship. We also learn the importance of explaining illness and death to our future patients, and how morality is important in our practice of medicine as well.


 2. In Shock by Rana Awdish

Why you should read this: This is a first-person account of how Dr Rana Awdish finds herself becoming a patient fighting for her life in a span of a night after developing HELLP syndrome. During her months-long ordeal, she faces disconnect and indifference from her fellow doctors who are involved in her care, illuminating the mistakes doctors frequently make. Rather than merely treating patients, she reminds us that doctors should embrace connecting with patients. Her discoveries will help you shed light on the importance of kindness, support and communication in our interactions with patients.


 3. The Upside of Stress by Kelly McGonigal

Why you should read this: It is common knowledge that medical school is stressful, and I think all of us can easily recall a time when we were drowning in our stress, to the extent that it affected our daily lives. That is why it is so important for us to learn how to deal with it. There are many methods frequently cited to get rid of stress, ranging from meditation to exercise, but as this book writes, it is also possible to embrace stress. Kelly McGonigal, PhD, turns the conventional wisdom of stress being harmful on its head and teaches us how to use stress to our benefit, rather than getting overwhelmed by it.


 4. Why We Sleep by Matthew Walker

Why you should read this: As medical students, we frequently have to pull all-nighters to get our work done, and we hear of legends who manage to survive on a mere 3 hours of sleep each night. Some of us may suffer from insomnia as well. Yet, as author Matthew Walker PhD writes, all of this may be detrimental to our well-being. In his book, he sheds light on the importance of sleep to various functions, ranging from improving our learning and mood to hormone regulation, and teaches us how we can make use of sleep to achieve the above benefits.


 5. The Daily Stoic by Ryan Holiday and Stephen Hanselman

Why you should read this: This book provides 366 quotations and life lessons on living a better life from famous philosophers, which lends itself well to daily reading and reflection, making it a good way to unwind at the end of a long and stressful day. As we slow down and reflect on the words of those who have lived before us, we can learn how we can live a better life and improve our own mental well-being over the course of the year.


 6. Ikigai by Hector Garcia and Francesc Miralles

Why you should read this: This book introduces the Japanese concept of ikigai -- the satisfaction of living a meaningful life -- through interviews with residents of a Japanese village with the highest percentage of 100-year-olds. We learn about their sense of gratitude, peace and joy, and how to incorporate these into our own lives to find our own satisfaction. The tips here are highly applicable whenever we feel burnt out or lose sight of what is truly important -- finding meaning in our careers, even when the going gets tough and we think we can find none.