This is the third set of the three. To read the first and second sets, please visit https://bit.ly/3eVu768 and https://bit.ly/3k07Dnl respectively.
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.
June Yu Zijun
Counting Our Blessings in a Pandemic
This is a trying and unique period for healthcare workers and medical students of all levels as Singapore battles against COVID-19 and as unrest unfurls in various parts of the world, from neighbouring countries in Asia to the US.
During this period, there were many changes to the curriculum. Our Student-In-Practice (SIP) was shortened from eight to six weeks and we were barred from doing a number of aerosol-generating procedures, including nasogastric tubes and manual bladder washouts, and nasopharyngeal swabs.
As Duke-NUS Medical School students, we were fortunate to even have an SIP which took much planning and coordination among the various organisations. We had two weeks of pre-SIP preparation, during which we learnt how to do documentation for discharges and morning ward rounds from house officers (HOs) and medical officers online. There was reduced manpower in the general wards as some were deployed to the front line for the battle against COVID-19. These all had various impacts on our training, both negative and positive.
At first glance, it appeared that time allocated for training was reduced. Furthermore, senior staff faced increased workload and stress, as the entire healthcare team adapted to both the new environment and more administrative matters, such as postponing of clinic appointments. However, the increased workload also gave SIP students and junior staff an opportunity to integrate better into the team as we helped out with various tasks, sometimes administrative but often involving what we needed to learn and prepare ourselves as HOs. I was fortunate to be placed in an environment where my team would select tasks with learning value, such as making referrals, clerking new admissions and conducting discharges, instead of only administrative matters. Getting almost immediate and direct feedback after completing these tasks greatly aided my learning, and the opportunities were abundant as the workload in this particular situation was not light.
However, what worried me was the lack of exposure and practice on COVID-19 related conditions such as respiratory chief complaints and aerosol-generating procedures. While we were barred as students, we would be working on these as HOs. We could not escape from them even as we were kindly placed in non-isolation and relatively safer wards in the many hospitals for our protection as junior doctors. We had many safety briefings and practical teachings on personal protective equipment, and that prepared us well for work life. Hopefully as junior doctors, we would have further opportunities to engage with these conditions and procedures with supervision and guidance, for both our safety and the safety of our patients. This is really just nitpicking as we are already a fortunate group with minimal disruptions to our final year curriculum and SIPs compared to the other schools. This is all thanks to the efforts of the school and the rapid adaptation of the healthcare and education systems to the everchanging situation and escalating levels of the Disease Outbreak Response Condition system.
Many bedside teachings were also converted to online meetings, with the advantage of convenience and easier reference to lecture materials. However, these could hardly replace bedside teachings with regard to learning clinical skills. Fortunately, each hospital and the Ministry of Health Holdings (MOHH) have adapted to the situation and offered various Zoom lessons. MOHH also required a more rigorous compulsory one-week orientation for new HOs, with more checkpoints and feedback opportunities from supervisors through various systems to ensure that we were well prepared before we progressed on to working independently. Examinations were modified for each school to involve less contact with real patients to minimise transmission. Although we were told the standards of passing were not relaxed, as fresh graduates, the usual feelings of anxiety and inadequacies were often still present. These checkpoints with increased supervision and guidance, and the understanding of senior doctors, would be essential in aiding a smooth and safe transition for us.
In summary, this is a unique and challenging period for new graduates to enter the workforce. We are plagued with worries in the background, from questioning our own personal capabilities to various events happening around the world, including COVID-19. We can push through these times and come out more resilient, with a better understanding of dealing with situations such as COVID-19, and this can only be possible through cooperation and teamwork with each other and help from senior staff!
Thank you to all healthcare staff, from doctors to allied health, to nurses and fellow colleagues, for bearing with us fresh graduates as we embark on this journey during such stressful and challenging times. Thank you for the extra effort and understanding in guiding us through our first postings!
Lim Ing Haan
Medical Training During SARS
My memory of SARS seems to have been written in the depths of my consciousness. As I write, snapshots of it come back all too clearly – but with many of the fears and unhappiness erased, leaving mostly feelings of gratitude for the little things in life and leaving me in awe of the universe we take for granted.
The events leading to 2003 cannot be more disparate from what befell the world in 2020. Both are coronaviruses with explosive transmissions among humans after zoonotic spillover. However, the differing epigenetic features created two contrasting beasts in so many ways. SARS burst onto the scene in mid-March 2003 but by 31 May 2003, Singapore was removed from the World Health Organization's list of infected areas. COVID-19 is not to be tamed so easily. Rather, it continues to rage and dominate, menacing all aspects of man and humanity.
Six doctors and nurses were admitted on 17 March 2003 following the intubation of a single patient admitted for heart failure. She was not a suspect case but later turned out to be positive for SARS. We had just had personal protective equipment drills but there was no protocol in place other than face masks for intubation of non-suspect cases. Tan Tock Seng Hospital's (TTSH) cardiology department was thus thrust into the deep end. 2020 cannot be more divergent in terms of the anticipation and the preparedness. The battle remains the same. We learnt the hard way. This time, we have not ceded one of our own and I am sure we will win this war.
My life as a busy cardiology registrar was abruptly recast in the most unfamiliar roles. On that fateful day, I was admitted for SARS. Snippets from my memory scrapbook remind me of a minor maladjustment with the role reversal. Thinking back, I can absolutely empathise with patients when they refuse antibiotics or wrestle with room arrangements. The protagonist, now in the role of a patient, has to learn to cede control, accept denial of dignity, loss of entitlements and endure the inevitable puncturing of pride. This was my lesson in compassion and empathy, two crucial qualities that medical education ultimately strives to impart to young doctors.
I returned to work after three weeks of hospitalisation and two weeks of medical leave. I truly looked forward to joining my worthy and courageous colleagues. Every moment, in my heart, I honour two of our best, Dr Ong Hok Su and Dr Alexandre Chao, both snatched away from us in the prime of youth by SARS. Thoughts about my cardiology training were the last thing on my mind.
Against this tragic backdrop, senior doctors bravely stepped in wherever possible to reduce the clinical exposure of junior doctors. I do not believe that such demonstrations of selflessness now would be any different. The segregation of teams also meant that some of the more senior registrars and consultants were physically stretched, while at the same time, junior doctors had dilution of on-the-job training. My take on this is that situational learning comes in all forms to the receptive and fertile mind. So junior doctors should take heart and attempt to capitalise on all learning opportunities.
Up till May 2003, TTSH was the SARS hospital and all elective admissions were halted. Thus there were not many cardiology patients to see. As a third year cardiology registrar, soon to embark on my training in interventional cardiology, I was rotated to take care of the AIDS patients in the old Communicable Disease Centre on Moulmein Road. These were open wards in the middle of very big fields. The tempo was a far cry from the hectic days as a cardiology registrar but it was all I could manage at that time. I recall that training was disrupted across all disciplines for medical officers and junior registrars. In a way, there was a weird fairness to the whole traineeship exercise. For most, it was a pause and reset.
Fast forward to 2020, the Internet and technology has levelled the learning platform of what used to be apprenticeship learning. Online lectures, webinars and live case discussions are freely accessible. In fact, during the pandemic, PubMed and online libraries offered access to their contents free for all. There is a phenomenal amount of quality educational resources available.
The life of a junior doctor is not easy and the challenges change with the times, but the fundamental difficulties remain. My message to junior doctors is that our learning journey is lifelong. The COVID-19 pandemic is a disruptor. Disruption allows a new personal narrative to be set. You are free to embrace new opportunities with boldness, unlearn old mindsets, develop rigours in judgement and, most of all, develop the power of resilience. In this long drawn pandemic, we are not just cogs in a wheel but valuable team members. Let’s make the most of what we have now and fight on together.