By now, we're all familiar with the COVID-19 pandemic and its effects on the world, society and our healthcare system. The disruption it has wreaked has been unprecedented in this century. As doctors, our whole way of life, both personally and professionally, has been upended in a short space of time, ever since Singapore's first imported case of COVID-19 infection in late January 2020.
As a clinician-educator, I've seen the same disruption happen to our medical education systems – from medical schools to residencies – affecting thousands of students and residents. It has been a hectic and trying time for students, schools, residents, programmes and faculty in the first 100 days of the pandemic as we struggled to adapt. Yet in many ways, this struggle has helped many of us clarify and reaffirm our professional identities as doctors and educators.
So many things have happened that it would be impossible to describe them all, but I will try and describe some of what happened and frame it using three themes – adaptability, learning and solidarity.
Adaptability
This was what got us through the first 100 days. There were rapid and far-reaching changes in so many areas as our understanding of the disease changed and as Government and international policies shifted as we learnt more about the virus. The need for safe distancing measures meant medical students could no longer learn and see patients in healthcare institutions. Faculty swiftly moved towards e-learning, online quizzes, video conference tutorials via Zoom and using simulation for procedural skills training. Final MBBS examinations had to be adapted at short notice, using simulated patients and reorganising the objective structured clinical examinations for student, faculty, staff and patient safety. Technology proved to be a major boon, and "technology-enhanced/enabled learning" became a new buzzword that the faculty quickly learned.
For residents, some previously planned rotations were paused to avoid cross-institution movements, leading to much reorganisation of rosters and rotations. Some examinations were even cancelled – for example, the Membership of the Royal College of Physicians Practical Assessment of Clinical Examination Skills examination – leading to worried residents wondering if they could progress in their training without these examinations. Residents were also posted out to community care facilities. Residents and programmes, however, adapted quickly to make contingency plans for rotations and examinations, communicating frequently and proactively to residents to allay concerns.
On a system level, the medical schools and the Ministry of Health (MOH) adapted swiftly as well. MOH crafted policies on conduct of training and examinations soon after the Disease Outbreak Response System Condition level was raised to Orange. By doing this collaboratively with medical schools and the clusters, it provided much needed clarity for the effective implementation of these adaptive changes. I was heartened by the consultative approach MOH took with the schools and the residencies. Tough decisions had to be made, and there was sometimes robust debate, but once the decision was made, everyone pulled in the same direction.
For example, the final year students had to start work slightly earlier after passing their examinations to ensure they were prepared for the new demands and clinical environment of the COVID-19 pandemic. This generated some unease among the students – while some took to social media to bemoan their shortened holidays, others were concerned about infection risks. The schools and MOH, recognising these sentiments, proactively communicated with the students via dedicated Zoom sessions to allay their concerns and explain the rationale behind this policy. The students' concerns were assuaged, and at this time of writing, they appear to be coping well as new house officers.
Learning
While on the surface our students and residents seem to "lose out" in learning opportunities, in truth the pandemic offers rich learning in other less-visible aspects of the medical curriculum. While the obvious new learning opportunity is the skill of donning/doffing of personal protective equipment, our students and residents are also learning about infectious diseases, epidemiology and public health in real time as the pandemic unspools around them.
Importantly, as our medical officers and residents go out to the community care facilities to manage the populations there, or when they take on new roles doing triage and screening of potential COVID-19 patients, they have an invaluable opportunity to acquire new knowledge and skills. These include resource management and logistics, decision-making in uncertainty, systems thinking, understanding social determinants of health, the importance of communications, and the role of culture in medicine. Importantly, this helps to train adaptability, innovativeness and resilience, as our young doctors wrestle with and solve emergent problems on the ground in real time.
I'm also gratified that many senior doctors – both from the private and public sector – have volunteered their help in these areas. I feel this provides wonderful role-modelling for all to learn from. The way our senior doctors have quietly sacrificed their time (some in private practice have even closed their practices) to steadfastly provide care in these facilities is a shining example of professionalism despite adversity, and I hope our junior doctors can learn from these exemplars.
Solidarity
This brings me to the final theme of solidarity. The hashtag #SGUnited has been trending on social media, and has been a rallying point for many Singaporeans. This pandemic has also brought doctors in Singapore together in the realisation that we have common goals, and that while we do sometimes disagree, it is time to put aside differences and fight a common enemy. In the realm of education, it is immensely satisfying to see schools, residencies, healthcare institutions and MOH coming together to get things done (often with tight timelines and over weekends) to ensure adequacy of training while not compromising student or patient safety.
As educators, we talk about professional identity formation, where a doctor (or medical student) grows in "stages over time, during which the characteristics, values and norms of the medical profession are internalised, resulting in an individual thinking, acting, and feeling like a physician", to quote from Richard and Sylvia Cruess. This is an important concept, where being a doctor is not merely about acquiring knowledge and skills, but about internalising the values of the profession and behaving professionally at all times.
So many of my colleagues I've spoken to have expressed how they've rediscovered their values and identity as a doctor amid this crisis. In the dormitories, junior doctors find new purpose in caring for our migrant workers, inspired by senior doctors working alongside them. In hospitals and clinics, senior doctors now have a little more time to reflect and refocus on their clinical duties and the "core business" of being a doctor. Whether senior or junior, several colleagues have told me how this reflection and rediscovery of purpose has reminded them of why they wanted to do medicine in the first place, and that the reforging of their professional identity through the fires of the COVID-19 crisis has made them even more determined to remain true to their mission of helping others.
Conclusions
It has been in many ways a tumultuous first 100 days of the COVID-19 pandemic, as seen through the lens of a clinician-educator. We've had to adjust and adapt rapidly to help our students and residents, with a tremendous amount of groundwork done by multiple parties, but in return we have been rewarded with extraordinary opportunities to learn new skills.
I'm proud to say that as a profession we have been equal to the task, with the medical education system displaying adaptability and resilience despite being buffeted by forces both local and global. These struggles have not daunted us but instead given us invaluable opportunities to reflect on our professional identity, reaffirm our unity and rediscover our sense of purpose.