December 2016 | Issue 27
Learning beyond the classroom to deliver patient-centred care

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By Sean Firoz, Senior Executive, Communications & External Relations 


LKCMedicine student Koh Jin Kiat assumed that the patients he was going to see required close attention and care. But a big surprise was in store for him on his first visit to their home at the Asian Women’s Welfare Association (AWWA).

Mr L, an elderly man who is wheelchair-bound from a diabetes-related amputation, was zipping around his room cleaning as quick as an able-bodied person, while Madam E was determined to enjoy life’s little moments despite her back injury and hypertension. Both chose to live at AWWA to enable them to continue living their lives independently and not to burden their families.

“A lot of us went in with the impression that Mr L’s ability would be quite limited because of the amputation,” said Jin Kiat.

“Most of us would have this stereotype that a person with an amputated leg is handicapped and bitter at life. Instead, here we have a gentleman who was able to do all that he could, just like before the amputation, and still have a positive outlook.”

This was one of the key observations Jin Kiat made from his Long-Term Patient Project (LTPP). This community-based module spans the first two years of medical school and puts students in the shoes of young and old patients with chronic illnesses to learn more about their lives once they have been discharged from hospital and what kind of support they need or want.

LKCMedicine Vice-Dean for Education Associate Professor Naomi Low-Beer said, “When we conceptualised the curriculum, we recognised that students must learn to care holistically for patients, many of whom are elderly and living with multiple medical problems. The Long-Term Patient Project provides students with a patient-centred experience that takes them outside the classroom, helping them to develop as caring empathetic medical professionals.”
Lead of the LTPP Assistant Dean for Year 4 & Family Medicine Associate Professor Wong Teck Yee added, “One of the things I wanted to capture was a learning experience for the students to bring with them into their residency and beyond. So each time they look back, they would see the experience in a new light, offering up new insights as they go along.”

Caring for an ageing population

At the National Seminar on Productivity in Healthcare 2016 back in October, Minister for Health Mr Gan Kim Yong introduced the Healthcare Manpower Plan 2020, to sustain a high quality and affordable healthcare system in the face of Singapore’s ageing population by changing the way the healthcare sector delivers care.

“We need to move the centre of gravity of healthcare delivery, from the hospital to the home within the community,” said Mr Gan.
With the focus shifting from acute care to nursing and rehabilitation homes, closer integration between different institutions is key to supporting patients.

To help students understand both what patients want and the types of care available outside of hospitals, the LTPP assigns all Year 1 students to a patient, whom they then follow up with until the end of their second year. These patients may receive home care visits, live in assisted-care living, be long-term residents at nursing homes or in the midst of completing community-based rehabilitation, like Richard Chan and Tan Khee Ming’s patient.

The pair of Year 2 students visited a patient who had suffered multiple strokes and was going through rehabilitation at the Ang Mo Kio Thye Hwa Kwan Hospital.

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Year 2 students Tan Khee Ming (left) and Richard Chan (right) visited Mr E at the Thye Hwa Kwan Hospital

“There is a sense of continuity when we do the LTPP; it involves a more holistic view of what a patient’s recovery is like and their progress. We also see a snapshot of which phase of recovery they are at,” said Richard.

At LKCMedicine, the LTPP complements the School’s innovative curriculum that prepares students for the healthcare realities of tomorrow. The rigorous curriculum not only ensures students become competent doctors, it also instils in them softer skills such as effective teamwork, life-long learning habits and a patient-centred approach to delivering care.

In talking to their patient, Richard and Khee Ming learnt how the doctors and nurses helped him manage his condition, trying their best to make him feel comfortable through the transition from surgery to rehabilitation. Needing space and time to come to terms with his condition, their patient didn’t want much support beyond the rehabilitation offered at the hospital. Similar to Jin Kiat’s patients, being able to lead an independent life was a top priority for this patient.

Experiencing some of the different kinds of care and support available early on in their training provides insights to students that will be particularly valuable once they graduate and are actively involved in discharging patient from their care back home or to one of the many step-down care facilities.

Integrated care has already been introduced in some parts of the healthcare sector, such as transitioning patients who require nursing care after their acute condition is stabilised from hospitals to nursing homes. This has resulted in reducing the time from referral to admission by more than 50 per cent.

But to get patients, many of whom want to be as independent as they are able to, into the right care setting that minimises the risk of repeat admissions, healthcare professionals have to have a good understanding of all the options available.

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Thya Hwa Kwan Hospital, one of the community hospitals that LKCMedicine students visit during their LTPP

Assoc Prof Wong, a family physician at Tan Tock Seng Hospital (TTSH), said, “When the students become junior doctors, the ageing population would have a lot less social support. When they work as junior doctors they have an appreciation of what happens when a patient goes into a community hospital as well.” Assoc Prof Wong went on to explain how homes such as the AWWA have nurses to help with patients’ medication, but there are limitations to the care they are allowed to provide.

Taking this into consideration when planning a patient’s discharge is important to ensure that they are able to adhere and manage the follow-up care necessary for their recovery.

The LTPP also requires students to be independent and develop a resourcefulness that will stay with them throughout their career. Interacting with patients and their carers with little supervision, the students come up against challenges such as language barriers. While these are scenarios they would have faced in their training, encountering these in real life forces students to think on the go without support from faculty.

Assoc Prof Wong said, “There was a case where the patient could only speak in a dialect, and the pair of students attached to her had issues understanding. So, they actually went around and found a classmate who can speak the same dialect and help them. This is one of the things I want our students to learn; how to navigate the system.”

One step at a time

Sending students out to meet patients, the LTPP exposes them to the real-world challenges faced by patients with chronic illnesses and their families. It does this at a time when students have had little interaction with the healthcare system in the hope that this will enable them to focus on the patient experience and retain these impressions throughout their working lives.

Assoc Prof Wong still recalls his LTPP experience some 20 years ago. Even today, while seeing patients at TTSH, he reflects on his medical student experience visiting his patient in a nursing home.

While some of the insights will only become apparent later on, both Richard and Jin Kiat have had more immediate learnings.

For Richard, this experience has driven home the need to keep a broad base and holistic approach to caring for patients. “In an era where medicine is becoming increasingly specialised, the worry is that doctors do not have the necessary skill set to integrate across specialities in order to better meet the healthcare needs of our rapidly ageing population.

“As medical students entering the healthcare system, we will be able to adapt to society's changing needs from the very beginning of our medical career, forging our identity towards being more holistic in our medical approach to society,” said Richard.

Jin Kiat, now a Year 3 student, feels his passion for family medicine has been reaffirmed after meeting Mr L and Madam E and how the doctors and carers at AWWA treat them.

Jin Kiat said, “I have personal experience of how important it is for doctors to make you feel better without giving you any medicine. It is very important for that personal interaction to make you feel safe and feel cared for, and I’ve experienced what a world of difference it makes when a doctor takes his time to explain to you what is going to happen.”

As Singapore’s population ages, the patients of tomorrow will be more educated, tech-savvy and empowered over their health, said Assoc Prof Wong. With the head and the heart for medicine, LKCMedicine students will be equipped to contribute meaningfully to the transformation of the healthcare system.

As Mr Gan said in his speech at this year’s healthcare productivity seminar, “Only if we all share the same vision of what a good healthcare system for tomorrow is and what the important skills and career choices are can we build a healthcare system that will serve Singaporeans well for the years to come.”