Anxiety and apprehension have been prevailing themes in the upheavals brought about by this pandemic. Indeed, how do our juniors feel as they graduate in this very unique academic year and enter the wards as newly minted house officers? To find out, we invited three Duke-NUS Medical School graduates to share their concerns. And to address those concerns, we felt there would be no better group of doctors than our seniors – those who battled with SARS 17 years ago. We were interested to hear what the seniors, with the wisdom of experience and hindsight, would have to say to this new cohort. Thus, we have paired one senior with each junior for this special series, and will be featuring their insights in the coming months.
Clement Sim
An Unprecedented Education
In Singapore, the activation of the Disease Outbreak Response System Condition (DORSCON) level to Orange meant the universal ban of all medical students from any clinical posting. This was a sensible decision with the intention to protect medical students from the high-risk situation and to minimise the possibility of transmission from the hospital to the community. However, as a medical student, it was initially difficult to appreciate these intentions; to us, our education was more important. Our graduation was more important.
With the announcement of DORSCON Orange on 7 February 2020, my family medicine posting at Bright Vision Community Hospital was halved. I was upset at the loss of a valuable opportunity to finally learn about the importance of community hospitals in the transition of our patients' care back into the community. In addition, I was starting to become concerned about the prospects of my final examinations as well as student internship, both of which were required for the completion of my medical degree. It was a period of uncertainty I had to live with.
With the implementation of safe distancing measures, many aspects of the final examination were affected. Firstly, group study sessions had to be done online, making physical examination and procedural practices difficult. Next, the actual examination itself saw the unprecedented need to segregate not just the students, but the patients and the faculty as well. Finally, once we were done with our examinations, we were not able to congregate as a class to celebrate. While safe distancing measures are essential, it has definitely made my final few months in medical school difficult.
Once our final examinations were done, the only thing left was our Student-In-Practice (SIP) postings which were also required for our timely graduation. Fortunately, the faculty at Duke-NUS Medical School was quick to come up with an alternative to our usual curriculum while waiting for clearance from the Ministry of Health to allow us back into the clinical setting. They designed four weeks of content that involved both online Zoom lectures as well as appropriate face-to-face sessions. These online lectures focused on various skills needed during our time as a house officer and important lessons by allied healthcare professionals. In addition, simulation exercises were organised for small groups for sessions such as critical conditions and airway management. Overall, these four weeks proved to be both beneficial and productive amid these uncertain times.
When we were informed that we were going to begin our SIP postings on 4 May 2020, I finally felt relieved. Relieved that I was done with the numerous online lectures, relieved that I could finally head back to do clinical work, and relieved that I could graduate on time. Due to safe distancing measures, students were posted to hospitals nearest to them; even within the various institutions, SIPs were divided into smaller groups to prevent cross-contact. At the point of this writing, I have successfully completed my SIP in surgery and one week of my medical SIP. From my point of view, getting students back into the clinical setting during such times will allow us to appreciate the various measures taken within the hospital, as well as inculcate safe practices which are cornerstone to the profession.
While I am grateful to be back in the clinical setting, I am worried about the curriculum of my juniors. I have heard their concerns about being out-of-touch with their clinical skills as well as the delays in their curriculum in general. To this end, I continued to encourage them to make the most of their time to revise on their clinical knowledge, spend time with their families and look after themselves, both physically and mentally.
These uncertain times have required the implementation of unprecedented measures. It has definitely taken a toll on everyone, not just the medical professionals. Fortunately, it is encouraging to see the various initiatives to help the community as well as those who volunteer to help within the hospitals. This is not a fight we can win as individuals but one we can win together. While some may worry about graduating as a doctor to enter the workforce during such times, I am genuinely excited about finally being able to contribute and doing what I can to help.
Agnes Tay
The Evolution of Preparedness
February 2020: "Paediatric clinics count as specialist clinics, so we're not allowed to order Ministry of Health (MOH) personal protective equipment (PPE) from Zuellig. "Tried calling Zuellig, can never get through!" "Zuellig will supply two boxes of N95 masks but they only have the 8210, no stock of the smaller 8110 that we use…" The flurry of texts and conversations brought a sense of deja vu, giving me flashbacks to a similar hunt for N95 masks during SARS…
March 2003: Alone in a solo practice that wasn't even two years old, I struggled to hunt for information ranging from PPE vendors willing to supply PPE in small volumes, to medical updates. Even worse, I recall vividly the crushing sense of isolation and helplessness that engulfed me when I saw on the news that a dear friend M, a solo GP, had seen a SARS patient who was then linked to a cluster. Although we had been good friends in junior college and medical school, SARS happened in the era before WhatsApp and Facebook, so it was a scramble just to find a current contact for her. It was a relief to find her well after her self-quarantine, but sadly SARS went on to claim the lives of several healthcare workers in Singapore.
Fear of infection aside, one of my growing fears during SARS was that of insolvency. Not only was there little revenue because patients were scarce, but there were loans to be serviced and bills for bulk purchase of PPE to be paid. On the long drive to work each morning, I tried to encourage myself with these lines from my favourite hymn, "Because He lives, I can face tomorrow. Because He lives, all fear is gone, because I know He holds the future..."
A few years after SARS, there was the H1N1 pandemic. That time, MOH was a lot better organised and my solo practice received a generous stream of free PPE! It turned out to be a bit of a false alarm, which lulled me into a sense of complacency – I thought I would never have to struggle with N95 masks again.
Yet, here we are, in May 2020, three months after moving into Disease Outbreak Response System Condition Orange, and still in the throes of circuit breaker. In many ways, COVID-19 is a tougher battle than SARS, much longer drawn out and with many puzzling facets. Still, there is much to be thankful for. After some initial hiccups, we are now blessed with a steady supply of PPE – items made more precious when we read about the shortages faced by healthcare workers elsewhere...
Today, thanks to much improved electronic communication, healthcare workers in Singapore no longer face a pandemic in isolation. Indeed, we sometimes contend with information overload instead. I am very thankful for my MBBS 1984 class WhatsApp group, with its amazing mix of journal updates, MOH chats, jokes, brain teasers and debates. (Thanks, CK, for feeding us the latest journal articles complete with explanations and commentaries; and George, for faithfully relaying MOH chats and circulars!) Similarly, our private paediatrician chat group serves up a blend of journal articles, webinar reminders and humour. Thanks to COVID-19, I learnt to use Telegram and now have a much better appreciation of the many battles faced by GP colleagues, to whom I take my hat off!
In most medical practices outside of dormitories and hospitals, patient attendance during the circuit breaker has plummeted drastically. While personally thankful that I am now a salaried employee in a small group practice, I am well aware of mounting financial pressures in these practices, including ours. Yet, though the economic lookout is grim, the sight of our closet filled with PPE gives me courage for the long road ahead to recovery.
Pandemic or not, internship through the ages has traditionally been a year of sleep deprivation and missed meals, a roller coaster of highs and lows, but most of all, it is a time of learning. As the battle against COVID – 19 continues, internship will surely be a year of precious lessons in the science and art of medicine. I urge our young graduating doctors to embrace fearlessly the challenge of caring for patients, colleagues and self. This is the challenge our profession has faced through the ages, and one in which we stand in greater solidarity than ever before, as we seek to serve together with sincerity and humility.