Benny Loo, Chairperson, SMA DIT Committee
From the SMA Medical Officer's Committee (1994) to the current SMA Doctors in Training (DIT) Committee, we have always striven to be the voice for young doctors in Singapore. 2019 marks the fifth year of this generation of the SMA DIT Committee in the residency era and we have achieved multiple milestones in this short period of time. We started out as a small group of resident representatives from the sponsoring institutions, to mentoring and supporting medical student projects across all local medical schools and, recently, voicing our young doctors' concerns on a national scale. I am very excited to have our current DITs share their achievements within their respective institutions and collaborations with the SMA DIT Committee over the past year. We kick off with Dr Lucy Jennifer Davies (SingHealth) highlighting some key roles that the SMA DIT Committee played in the past, and our current investment in house officers by helping them transit smoothly from students to doctors. Dr Chin Run Ting (National University Health System) shares the story behind the national survey on the current on-call systems of traditional full night calls and night floats, which the SMA DIT Committee supported with the aim to reduce burnout and improve patient care. Lastly, Dr Andrea Ang (National Healthcare Group [NHG]) concludes with the message that it is vital that SMA DIT Committee continues to engage young doctors on the ground and collaborate on a national level. I am very grateful to have many friends who have supported the SMA DIT Committee throughout these years and I look forward to future acquaintances.
Lucy Jennifer Davies
Reflecting on this academic year (AY) 2018/2019 when I was co-chairing the SingHealth Residents' Committee, I think about how quickly this year has passed. Last year, I found out for the first time about the SMA DIT Committee – a small group of key doctors from all three institutions keen to make life better for junior doctors, meeting in a little room deep in the SMA office on a Friday evening.
That night, Dr Benny Loo, who currently chairs the SMA DIT Committee, shared on some of the things the Committee has done in the past, which includes (but is not limited to) seeking higher pay for junior doctors. This is something that has come up again in recent times, with a recent repositioning in clinical allowance being allotted for job responsibilities instead of qualifications. This would mean more money, at least for some people.
Dr Loo, during his time as a SingHealth resident, was also responsible for starting up the SingHealth Residency Games which has been running strong over the past years. This year, we have exciting plans to convert it into a Residency Annual Dinner instead, to encourage more participation – perhaps not everyone plays games, but surely everyone needs to eat!
The SingHealth Residents' Committee Education Subcommittee also worked together with the SMA this year on updating the SMA House Officer's (HO) handbook, an initiative that I myself have benefitted from, having carried that handbook around during my first couple of months of HO-ship several years ago. Great thanks go to Dr Margaret Chong who headed the Education Subcommittee and her team comprising Dr Sarah Tan, Dr Jerry Nagaputra and Dr Lee Man Xin, who also organised and ran this year's Student Internship Programme Bootcamp – an event which helps our student interns become better HOs.
My own little contribution to SingHealth Residency this year was the introduction of a book donation drive which would not have been possible without the help of Prof Tay Sook Muay. Not only did she link us up with the welfare director of the 70th NUS Yong Loo Lin Medical Society, Ms Julia Cheong, but she also personally carried and drove several hundred books over from the Singapore General Hospital to the medical school; she is an amazing woman!
There is more to work on in the future, with the recent survey on on-call systems conducted by the SMA DIT Committee showing that more than 70% of some 630 responses from junior doctors across institutions are in favour the night float system, which is not widely used for various reasons, for doctors' and patients' safety.
Though it has been an exciting year, I am glad to soon be handing the baton over to the next co-chairs of the SingHealth Residents' Committee, who will continue to represent SingHealth in the SMA DIT Committee.
Chin Run Ting
"PGY1s should have sufficient rest for their physical well-being and to minimise errors due to fatigue." – Singapore Medical Council (SMC) October 2017 circular on Guidelines on postgraduate year 1 (PGY1) training and postings for the accreditation of PGY1 training posts.
Of note, the circular also mentioned that service commitments at the PGY1 level cannot be the priority since the priority for them is to first be trained and guided to develop skills and competencies, before they can deliver safe and effective patient care.
On the other hand, the same circular also provided guidelines for on-call duties, including the following requirements:
- Minimum of average four calls per month (ie, 16 calls in a four-month posting) with an optimum of five calls per month for every PGY1 doctor.
- PGY1 doctors who have completed a 24-hour duty period may spend up to six additional hours for handing over and other activities.
While we recognise that the SMC call requirement strives to provide training opportunities and on-call exposure, this may not always be the case on the ground. Doing more calls on paper neither equates to having better training/learning (quality) nor seeing more cases on call (quantity). Moreover, this may have inevitably resulted in a compromise of not just physician welfare, but also patient safety. Fatigue has been demonstrated to impair vigilance and accuracy of response, and decreased performance of motor and cognitive functions in a fatigued clinician may result in impaired judgement, late and inadequate responses to clinical changes, poor communication and inadequate record-keeping.
In fact, the consistent violation of working hours with traditional 24-hour calls had been the impetus for the implementation of the night float3 systems in most hospitals in the first place. A dedicated on-call team improves patient care and has led to reduced physician burnout, translating to improved patient safety. In response to the new PGY1 call guidelines, which resulted in the need to revert to the traditional 24-hour call system, the SMA DIT Committee conducted a nationwide survey in March 2019. It gathered respondents' opinions from across hospitals and various medical and surgical subspecialties regarding the SMC call requirements, including a comparison to the pre-existing night float system.
In terms of training opportunities, 89% of respondents disagree that the night float system makes junior doctors less competent simply because it may translate into shorter working hours. Conversely, 6% feel that the full night call system makes junior doctors more competent because it translates into longer working hours in a row.
In terms of patient safety, 90% of respondents agree that the night float system contributes to patient safety, compared to 7% for a full call system. 87% feel that the night float system helps to reduce medical errors, and 79% feel that it is less disruptive to daily ward work as compared to a full night call. 72% of respondents feel unsafe to function as a doctor after a full night call (post call). Of note, 75% share that either they or their colleagues have made a mistake at work and/or have been in an accident after being on full night call.
Last but definitely not least, in terms of physician welfare, 84% of respondents believe that the night float system helps to reduce burnout for junior doctors. 71% feel that the night float system builds teamwork and camaraderie as the same team members are on float for the entire week.
The survey also revealed that 89% of respondents feel that the night float system should be kept in place. More interestingly, 82% of our colleagues would prefer a hospitalised relative to be cared for by a doctor on night float as opposed to full night call.
Voices from the ground
- "Most of us don't drive post call. If we don't feel safe to drive ourselves home, how can we be safe enough to care for patients?"
- "A full call system leads to burnout in my juniors, which leads to more medical errors which are very unsafe for patients."
- "It is not so much the duration of time spent at work that is important, but rather the quality of that time that is spent working."
- "The capacity to learn, make good judgement and tendency for medical errors are negatively affected by prolonged consecutive working hours."
- "How can one expect a physician 30 hours post call to ever find the time to read, study or learn? Sleep becomes a priority.
- "The stress and risk they are exposed to, and the disillusionment and burnout they face, are not worth the supposed experience. Neither system is perfect. But patient safety should come first, and we should also work on improving the quality of life and career longevity of our juniors."
In summary, while there is no perfect call system, our PGY1 call requirements should ideally allow for the flexibility for call systems to be individualised to each hospital's and department's needs, with not just the aim of optimising training opportunities and physician welfare, but more importantly improving patient care and safety.
Acknowledgements
We would like to thank our mentors from National University Hospital, A/Prof Shirley Ooi, Dr Raj Menon and Dr Adrian Kee, and our fellow colleagues Dr Koh Zong Jie and Dr Hazel Teng, for all their efforts in improving the night call system.
Note
a. While there are variations across institutions and departments, the generic definitions of a "night float" and "full night call" are as follows:
- Night float: Approximately 12-to-14-hour night shifts (eg, 8pm to 8 am on weekdays and 6 pm to 8 am on weekends). The duration of night float varies from three to six days depending on the institution.
- Full night call: Overnight call from 5 pm to 8 am after a day's work prior to the call and having to round post-call and leaving post-call after 11 am.
Andrea Ang
The NHG Resident Council is a subcommittee of the Graduate Medical Education Committee and was established to be the voice and to protect the interests of all NHG residents. It comprises the chief residents from all the various subspecialty programmes. We help to improve residents' welfare and working environment by addressing their concerns and feedback.
Over the past year, we have organised events such as Ice Cream Day and Trivia Night where residents had the opportunity to hang out and get to know each other better in a laid-back environment. For our annual community engagement day this August, we organised a carnival with games and food to engage migrant workers from the Westlite Dormitory. We want our residents to get to know this arguably neglected population better and understand their living conditions, background and health beliefs. This will help them to serve these patients better and provide more holistic care, allowing them to grow as more well-rounded doctors. Other than organising these major events, the NHG Resident Council continually strives to improve the residents' working conditions. This year, we collated feedback on call rooms and phone reception throughout the hospitals and are working with the relevant departments to improve this. To help streamline administrative work, the team has also been collating feedback from residents on the difficulties that they face in answering complaint letters.
The Internal Medicine (IM) Residency programme is the largest residency programme in NHG and we have four chief residents. The IM chief and assistant chief residents work hard to provide satisfactory rotation schedules, facilitate adequate teaching opportunities and improve the welfare of their residents. Postings are planned yearly so that residents are able to plan their examination schedules and holidays. Posting planners help to ensure that residents rotate through all subspecialties they are interested in so that they have adequate exposure. Our academic team also plans various postgraduate activities to help residents prepare for major examinations – weekly didactic "best-of-five" learning sessions for the American Board of Internal Medicine examinations, and preparatory courses for the Membership of the Royal Colleges of Physicians of the United Kingdom Practical Assessment of Clinical Examination Skills.
We also plan undergraduate activities so that our residents are able to "pay it forward" and at the same time get teaching exposure. Our welfare team works throughout the year to ensure residents' needs are attended to, be it in terms of maternity leave and personal struggles, or issues with manpower and rostering within the departments. We hold quarterly formal feedback sessions to ensure everyone is heard. To help our residents cope better while on call, we have published two handbooks, Called To See Patient and Called To See Patient – Medical Intensive Care Unit, which we continually update and revise. On top of that, we also organise two major parties a year – at Christmas and at graduation, where we hold our black tag ceremony for graduating residents.
The beauty of NHG is the homeliness of it all, where the chief residents are committed to improving the welfare of their colleagues. We hope to pay it forward so that our juniors will experience a better working environment.
Moving forward, we hope to engage the SMA DIT Committee to provide continuous feedback on our juniors on the ground, with the hopes of improving their working environment at a national or ministry level, especially in areas where the NHG Resident Council may be insufficiently equipped to deal with.