April 2016 | Issue 23
Embracing the clinical years




By Nicole Lim
Assistant Director, Communications & External Relations

“This is it. We’re finally doing what we have signed up for!” With palpable excitement and a bit of anxiety, Chew Yirong and Brenton Sio, along with their classmates from LKCMedicine’s inaugural cohort, donned their white coats and entered one of Singapore’s busiest hospitals for the first of their three clinical learning years.

Split into three streams, the students are rotating through medicine, surgery and six specially-selected short postings during their year at Tan Tock Seng Hospital (TTSH).

And getting stuck in didn’t take long. Brenton was soon scrubbed into theatre to observe a complicated tumour resection and reconstruction. Still buzzing from the experience, he recalled, “I got to help with retraction, suction, and even tie some stitches. I stayed until 3am to see the surgery through.”

Students examine a patient on the ward

This excitement and eagerness to learn are among the factors that have distinguished the LKCMedicine students in the eyes of the healthcare professionals they work with.

Senior resident in general surgery at TTSH and clinical core tutor Dr Caroline Siew said, “The students are proactive in their learning and come well prepared for tutorials.”

LKCMedicine Lead for Surgery and Consultant with TTSH’s Department of General Surgery Assistant Professor Glenn Tan agreed. “They often think outside the box, raising questions that really challenge us.”

Students are also adapting well to their new environment. From getting and returning case notes to knowing when to stay out of the way in a busy operating theatre and even when to lend assistance during a sudden cardiac arrest, LKCMedicine students are making a name for themselves through their situational awareness.

Advanced Practice Nurse at TTSH Ms Jamie Lim said, “After their first week on the wards, I had nursing colleagues come up to me saying they were surprised and delighted by students introducing themselves on their first day.”

Mind the gap?

But it is not just their softer skills that have impressed. With the School’s focus on principles and application, one of the concerns raised by some healthcare professionals was whether the students would know enough basic science and anatomy to keep up, a worry that turned out to be unfounded.

“The only way to tell them apart is by looking at the school name stitched on their lab coats,” said Asst Prof Tan, who added that many of his colleagues fed back that they were impressed with the students.

The students, too, felt ready. “The School did prepare us very well with scientific knowledge and practical skills, like clinical communications training. Although it is a huge learning curve in Year 3, I keep falling back on my foundation knowledge from Year 1 and 2,” said Brenton.

Doctors and students review patient notes and discuss care plans

Added Yirong, “I find myself going back to revise my Year 1 and 2 content to make sense of what I am learning in Year 3.”

There are, of course, occasions when the students do not know the answer. Then it is time to hit the books when they get home, so that they have the answer ready the next day. But both Brenton and Yirong are not overly stressed by this. “There is always more to learn in medicine,” said Brenton.

Yirong agrees. “Sometimes if our NUS friends know something we don’t, we can get a bit uptight. But our Schools just have different teaching philosophies,” she said. Something that none of them has let get in the way of the spirit of friendly collegiality.

In fact, for Yirong and her team, it was the Year 5 NUS Yong Loo Lin School of Medicine students who helped them find their feet at the beginning of their surgical posting. And the holy grail of the clinical years – the MedBear notes – was readily shared with the newcomers from LKCMedicine.

Clinical learning tailored to needs of Singapore

Starting with a blank slate, the curriculum team at LKCMedicine had the unique opportunity to review the full structure of the clinical years – from a realignment of the postings to dedicated mentorship from core tutors, campus teaching weeks and regular formative work-based assessments. Vice-Dean for Education Associate Professor Naomi Low-Beer said, “We’ve developed a curriculum structure that nurtures students’ professional development, clinical skills and knowledge. Crosscutting themes such as professionalism, clinical communication, ethics and patient safety are incorporated into their campus teaching weeks and run throughout their clinical years.”

With Singapore’s ageing population, chronic conditions such as musculoskeletal and skin conditions are on the rise. Building an early awareness in students of how these conditions present and affect patients’ quality of life prepares them for their future postings in specialties such as family medicine and geriatrics.

In the clinical years, formal classroom teaching is combined with apprenticeship-style learning

As well as rheumatology and dermatology, short postings include infectious diseases; anaesthesiology, which goes hand-in-hand with surgery; as well as postings with the departments of ophthalmology and ear, nose and throat (ENT). The medicine posting, too, has been lengthened from the standard eight weeks to 14 weeks as patients tend to present with more and complex medical problems.

This restructuring also presented an opportunity for the School’s clinical faculty to refine their teaching materials. Asst Prof Tan, who is also the Head of TTSH’s Vascular Diagnostic Laboratory, said, “It has given me the chance to review my entire set of teaching materials, and adapt and improve it for the benefit of all my students.”

Apart from ensuring students have a strong clinical foundation, Year 3 is a time when students develop key skills, including routine clinical tasks and clinical needs assessment skills. For the former, other healthcare professionals have been roped in to teach and assess students in skills such as IV cannulation and blood drawing. For the latter, students learn how to gather and analyse information from patients and how to use this information to make broad differential diagnoses.

Class of 2018 student Eugene Leong performs a physical exam on a patient during a routine clinic appointment

To enable students to spend more time in the hospital, the School has also decided to consolidate its main assessment into one year-end exam. “We have end-of-posting formative quizzes to give the students an idea of what to expect from the year-end exam, but we don’t want to take away [time] from their clinical learning,” said Assistant Dean for then-Year 3 & Year 5 Associate Professor Tham Kum Ying, who is also a Senior Consultant in the Department of Emergency Medicine at TTSH.

Encouraged to spend time on the wards and in clinics, the students had to adapt to a much more dynamic and unpredictable learning environment. With a huge range of opportunities to pursue, prioritising and finding the most valuable learning opportunities is a skill the students are developing. “There are so many things to do in one day that it’s hard to achieve everything. So it is important to set yourself a list of objectives each day, and do your best to stick to it. Save some time for consolidation [of what you have learnt]. Anything more is a bonus,” said Brenton.

Without their own seniors, Dr Siew observed that the students rely on tutors to help point out interesting cases. She said, “They need to learn to use ward rounds and case files to independently identify cases, a skill they are slowly developing.”

Fellow clinical core tutor and senior resident in vascular surgery at TTSH Dr Joseph Lo agreed. “From their interactions with patients in both clinic and ward settings, it is clear that the students have good communication skills. Learning may be further maximised by presenting these cases to their tutors, following up on the outcomes of patients and supplementary textbook reading on patients’ conditions. Ultimately, patients are the hangers on which we hang our medical knowledge,” said Dr Lo. 

Keeping the patient at the heart

Advice for juniors

Without seniors in their own School to look to, both Brenton and Yirong are grateful to all the other medical students, junior doctors and other healthcare professionals who have taken them under their wing.

Now keen to pay it forward, here are their top tips for their juniors:

1. Remember you’re part of a team

2. Share openly with each other

3. Manage your time

4. Be proactive

5. Find a senior to help you settle in (and 
    learn quickly when’s a good time to
    ask for help!)

6. Take time to understand the patient’s

7. Patient service associates can help to
    identify interesting patients

8. Set out what you want to achieve each
    day, so that you can make the most
    of your time at the hospital and if
    you’re done early, go home and study!

Medical students’ transition from books to wards has been documented to trigger a drop in empathy. To help manage this, LKCMedicine developed a curriculum built on the twin goals of academic excellence and humanity in medicine. The Long-Term Patient Project, and the Hospital and Polyclinic Weeks are just some of the initiatives that the School put in place to nurture students’ awareness of the patient’s perspective during the preclinical years, efforts that are now bearing fruit.

One of Brenton’s most memorable encounters was with a patient who was partially paralysed by a stroke. After Brenton’s physical examination, the patient told him that he uses every assessment as an opportunity to measure his progress. “This middle-aged man started pouring out his concerns. He felt dejected because he couldn’t see any improvement. It really got me, that with just a small stroke in a crucial part of your brain, everything you take for granted is gone,” said Brenton.

Alongside this, students learn about professionalism, ethics, law, leadership and patient safety throughout the five years, to prepare them for their future roles as medical professionals. Vice-Dean for Clinical Affairs and Lead for Professionalism Associate Professor Pang Weng Sun said, “We bring students back to the classroom during the clinical years to enable them to develop their professional identities and fully understand their professional and societal responsibilities as future doctors, as well as to understand and deal with encounters that challenge this.”

By involving clinical and other healthcare professionals in the curriculum from Day One, students and their tutors are also more familiar with each other, relationships which can absorb some of the impact of the transition. Ms Lim said, “It has been a great opportunity to be involved in nurturing these young people.”

Within the cohort, the students are also supporting each other. At the end of the posting, students swap advice for the next posting among themselves. “That is very useful. We get the most out of the postings with the support of our friends,” said Yirong.

Students go through patient case files to practise their clinical needs assessment skills

Besides the academic purpose of the clinical years, Dr Siew wants to make sure that students enjoy their postings and see the softer side of medicine. “I want them to see the human side of medicine, something which is not found in books. They need to have something to hold on to when the going gets tough, to keep them inspired and motivated,” said Dr Siew.