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After more than 20 months of battling the COVID-19 pandemic and adapting to the changes in rules and restrictions, many medical educators, doctors and students may be feeling the toll of it all. The interviewers speak with Prof Chong Yap Seng, Dean of the Yong Loo Lin School of Medicine, National University of Singapore (NUS Medicine) to learn more about mental health in medical school during the pandemic.
Mental health challenges in pandemic times
How has planning of the medical curriculum changed since the pandemic?
The first thing we had to learn was to cope with the safe management measures, such as physical distancing and temperature taking, and delivering teaching remotely. That wasn't a problem for most of the didactic teaching, but where clinical teaching was involved, that was an issue. Especially in the early days of the circuit breaker, we faced issues because everyone was trying to figure out what the disease was about. I think both the Ministry of Health and Ministry of Education were generally cautious, so clinical teaching was interrupted for quite a long time. It was only towards the end of 2020 that we started to get back to some form of face-to-face contact again. Even when we did allow our students to return to the wards, we again had to adapt to safe management measures. We could not have our students roam freely so they were kept within one unit, one ward and one hospital. The groups were not allowed to intermingle and ward duties were restricted to half a day as compared to a full day. These were just some of the logistical aspects of our planning. We had to adapt significantly to carry on some form of clinical teaching while adhering to the rules and restrictions.
I think remote teaching appeared difficult at first because most of us did not know how to use Zoom or Microsoft Teams before February 2020, but since then we have all become experts. Most of us quickly got used to the idea of delivering teaching online albeit with some initial denial and bargaining. Later, the main problem proved to be the difficulty in getting responses and feedback from students during these online sessions. The benefit of remote teaching, however, is that we might actually get a higher rate of attendance than normal and if people kept their video cameras on, you can somewhat ensure that there is some attention retained. However, many often keep their videos off and we cannot be sure if our students are paying attention or doing something else.
Then, there is the aspect of the assessments. Our school is one of the few medical schools that carried on with the final examinations. Once again, the safe management measures were difficult to implement for sessions that were held on campus. We also had to learn to conduct online proctoring for written examinations that did not require physical contact. The good thing that came out of all this was that we realised that remote teaching was much easier than we thought it to be, especially once we had gotten used to the regime, and there is indeed potential in it. Hence, we are now exploring how we can leverage remote teaching to reach a wider audience and make it more convenient for educators, students, and staff.
One last thing I would like to add – the electives. As there are restrictions on travelling in COVID-19 times, sending our students on overseas electives is impossible, so we had to create new local pathways for students to explore the humanities, data analytics and so on. Again, most of this was delivered online.
No doubt both faculty and students have been challenged by COVID-19. What are some of the mental health challenges among preclinical versus clinical year students highlighted to the faculty?
For preclinical students, one challenge is the sense of isolation. It is particularly bad for the freshmen – when they matriculated into medical school, they did not get to see their classmates at all. Even up till now, after two years, I believe they have yet to meet the whole class. I think that is rather unfortunate because part of the experience of undergraduate education in university is getting to know new people. Plus, another very big thing among this generation is FOMO (fear of missing out), right? I think many do feel that they have missed out and this is not just a few months, but coming up to two years. So, FOMO and isolation are the main issues for preclinical year students.
For the clinical medical students, I think it is a different kind of FOMO – they might feel that they are not learning the content and skill sets they should be learning. The FOMO stems more from the fear that they may not be as well trained or prepared for postgraduate work.
Some other issues common to all students would be the family circumstances during the pandemic. One, there are many students whose parents were unfortunately affected economically. Two, some might find that home-based learning is difficult in a smaller and more crowded environment at home, as compared to school.
How have these mental health challenges raised been different from non-pandemic times?
One thing I did not mention earlier, which was present especially in the early days, is the fear of whether one would get exposed to the virus itself. There is a whole spectrum of emotions parents feel: some of them were very afraid of their children getting exposed to the virus while others were more relaxed. The main difference lies in the uncertainty about the disease. As we learnt that COVID-19 symptoms are not as serious among the younger age group, there were other issues raised too. If one gets the infection, he/she will be quarantined and hospitalised. The management and measures have changed so much throughout the pandemic and there is this persistent uncertainty – which is probably one of the key features of COVID-19 times. I remember when I was living through SARS back in 2003, it was a very different experience. SARS was deadly and there was quite a high fatality rate compared to COVID-19. The outbreak started in early March and ended in May, so before we knew it, it was gone. I could tell that back in the middle of the SARS infection, we were all quite terrified, but the interesting thing was that none of the healthcare staff backed out and just continued to figure out how to get things done.
The main difference this time is that it is a prolonged period of change. The whole world, not just Singapore, has been affected for such an extended period. Even today, things just have too many twists and turns. Look at Singapore – we did very well then we started getting more cases, progressed back and forth, and now we don't know where this is going. In September, I was showing the faculty graphs and telling them that COVID-19 has gone out to the community and that I don’t think we can bring it back to where it was, which is alright because it was all part of the plan. All in all, uncertainty is certainly a key feature of this pandemic, along with its prolonged nature.
What are the mental health support systems in place and how has the school been adapting to supporting students amid the COVID-19 situation?
I think the first thing was getting information to the students. With so much uncertainty, we tried to pass on whatever information we had as clearly and as quickly as possible, with rules that were relevant to our students.
One of the initial challenges was temperature-taking twice a day. A lot of people did not quite believe in it, so getting people to comply was an issue. Some students had violated the safe-distancing measures, knowingly or unknowingly. Of course, the university had to step in and be quite strict about it.. The faculty would give students a verbal warning rather than something that would stay in the records. In this aspect, we had to do a lot of education in helping our students understand the regulations and ensure that they would treat them seriously.
For the students who were in quarantine or under stay home notices, our teams quickly reached out to them to make sure that they were doing well. Regarding financial support, the Dean’s Office did our best to support every student who needed financial aid and there were no more restrictions than we normally had.
Certainly, the University Health Service provides counselling services as well, which we proactively asked our students to reach out to if we thought they needed help. Additionally, the faculty is always open to listen to our students through our Student Affairs Office. They are our first line of defence and the team is always available for any kind of concerns, be it logistics, financial, or any other worries. We do also have our house system in place, though granted this pandemic situation has increased the difficulty to access and make good use of the house systems. However, there are always house mentors and seniors forming the more informal line that one can approach if they preferred smaller group interactions.
Aside, the faculty did our best to make things more convenient for our students. For example, when vaccinations started this year, we arranged vaccination sessions at our university hospital so students wouldn’t have to go to various places to get it done, at least for the initial phase.
Apart from medical students, educators alike have been challenged by the pandemic to adapt quickly to new teaching platforms and methods. Could you elaborate on some of the changes they managed?
As I said, in the early days, we went through the process of denial and bargaining, but ultimately the faculty got the hang of things quickly. I remember the first thing we had to handle was mask-wearing, back in March 2020 when Singaporeans were not yet wearing masks. Mask-wearing was only introduced later in April that year. I vividly remember driving down Orchard Road with Prof Dale Fisher, on our way to meet the Prime Minister at the Istana, and Dale said, “Fantastic, nobody's wearing a mask.” He was very proud that our communications were effective as at that point, Singapore was doing very well. We had closed our borders, infection rates were quite low and nobody had to wear a mask. Of course, just a few days later, the dormitory cases broke out and everything changed.
When we met the Prime Minister later that day, the first thing he asked was how we would conduct our admission interviews. We had decided to conduct our interviews via Zoom early on, but we were also concerned that the internet connection might be poor for some students and that might disrupt the interview. Thus, we considered asking our prospective students to come on-site to do the Zoom interviews – each in a different room to ensure that there was a good internet connection. He was not quite convinced of our logic and we agreed to pivot our plans once it became clear that it was not a good idea to bring the students over onto campus.
Next was the examination season in May. Most students will know that we had to revise all examination methods in shortly over one month, from using real patients to having standardised patients for examinations. The ability to pivot so quickly was truly amazing. Within a six-week time frame, our examination team had managed all those changes. I must take my hat off to them for they have put in the hours and great effort to get everything done nicely. I do think the board of examiners was satisfied with the quality of the examinations.
In summary, a lot of quick thinking and hard work was involved. Regarding teaching, as I said, the faculty got used to it pretty fast. The only thing they could not get used to is the lack of feedback when they teach.
From personal experiences
What are your thoughts regarding some of the challenges medical students face now?
Medical school is tough because the workload is heavy and there is pressure on yourself because you want to do well. There will inevitably be times when you feel down. I remember once when the institution mandated seeking mental help for all of us, a large majority of us went. It was indeed a relief to be able to talk to somebody. I think stress is something that many Singaporean students would be familiar with – facing various examinations such as the GCE O and A Levels. It has always been stressful as students want to do well.
One thing I want our students to bring home is that sure, you wanted to do well for your O and A Level examinations because you wanted to get into medical school. But now that you are in medical school, this is a different thing altogether because it is no longer about being top of your class. The whole class is meant to graduate and there is no intention to fail anybody. Students might find themselves failing if they have medical conditions, including both physical and mental health issues, disciplinary issues, or major academic problems. The percentage of students who fail every year is about 2% or 3%, but there is a re-examination where they usually pass and graduate.
Essentially, the competition is with yourself, not with your classmates. I want to emphasise to students that it is important to work together and help each other. You are not going to lose out by helping somebody get better marks. Grades do not help you get accepted into a residency programme and we do not look at your grades when you apply.
That's the other thing – residency. Once our students hit their third year, they are suddenly focused on applying to residency programmes and getting that offer. That sounds very typical of us Singaporeans, driven by our kiasu characteristic and the strong desire to be offered whatever we choose. I do think that is one of the unnecessary pressures that our students put on themselves. You will need to find your place in residency and you might not which programme is best for you while in medical school, so do not hurry to pick something and aim for it. Once you get enough life experience, you will realise that no matter how bad things are, they will pass and often, you will be left wondering why you were so worried about it in the first place. The number one thing to remember is that generally, things will work out for the better. Number two is not to worry about something so far ahead of time, and just manage the issues as they come. As long as you're not slacking off and doing the work, you will be fine.
Do you have any coping strategies that have worked for you to recommend to medical students facing mental health challenges during this period?
It is always good to talk to someone about it. The idea is to not deal with it completely by yourself. Consider talking to people; it will be great to talk to your family members and certainly your friends too. I guess what is being discussed now is not worrying about the stigma if you do decide to seek help. People should feel that it is alright to seek help from counsellors and though it might be difficult, it will help when you are facing issues.
Looking back someday, you will realise that a lot of things you worried or were upset about are very minor and that they generally passed, no matter how bad things seemed at that point. From my experience – my extra years on top of yours – things generally resolve by themselves. As I have said, do not worry about things you cannot control and instead, deal with what you can. Importantly, do not close up. For instance, someone who is in debt would normally stop opening their mails to avoid looking at their bills, burying his/her head in the sand, but it is essential to continue to deal with things one step at a time and seek help. Most people are willing to help you if you reach out as it is in our human nature to help those around us so people usually would not decline.
How do you think preclinical and clinical year medics can take care of their mental health during their time in school, especially with the ongoing pandemic?
Personally, the best thing is to form strong relationships with their classmates and to have that peer support. Count on your family where possible, and it is important to be able to open up and talk. As you know, the house system is there for a purpose, to give students a sense of belonging, especially in the first two years when students spend most of their time on campus. So, do make use of it and always know that the house mentors are there to listen to you. Don’t try to compete with your classmates too much because really, the competition is with yourself and not others.
Prof Chong, how has your work been during COVID-19?
Like everyone else, I have learnt a lot in COVID-19 times. In general, I don’t think productivity has necessarily dropped but it might not have gone up either. For example, I am here at work in Singapore all the time now as opposed to a normal year where I would have been away for at least two months, including travelling time. Additionally, we often do not travel out for meetings anymore. People are now seldom late and so, we can start on time for online meetings. If you happen to be late, you would hate it as the meeting might have started and is already halfway through the first agenda item, even just by being a minute late. Punctuality has certainly improved and attendance is much better. I would be able to get 500 to 600 people at a Townhall meeting now as compared to previously, where we would be lucky to have 100 to 150 participants. In terms of work, it has been good but you sometimes will feel guilty, because you know people outside this profession haven’t had such a good time and might not have coped so well.
It is heartening to know that the work we do here is meaningful and we have been able to achieve what we have set out to do despite the circumstances. The only thing I feel bad about is that the preclinical year students have not been able to experience university life and that the clinical year students have not had the amount of clinical exposure they would like, which are things we have unfortunately not been able to overcome.
Importance of mental health among DITs
Prof Chong, could you share with us your view on mental health among doctors in training (DITs)?
I do hear that there is a lot of stress and burnout among DITs and I can understand. You might think medical school is bad but the housemanship experience is far more physically and mentally tiring. However, if you do go through that year, you definitely will come out much stronger. Just like in the army, you might be physically and mentally stressed out but if you go through it, you realise that you can go through anything else.
I remember being a house officer at 3 am, wondering if this was going to end, especially since I had not slept at all and still had 20 patients to see. Yes, people might not be that understanding if the work isn’t done, but the reality is that the night ends, the sun rises, things get done and the scolding is not so bad. And, if you live through that, you become very strong and resilient. So, know that other people have gone through the same thing and they have survived. You will be stressed during training so tell them about your experiences and get advice from them. Learn to take things one at a time.
I do not think that the stress is worse than it used to be. I am not saying that what we have gone through in the past was good, but it is healthier now that we have a better awareness of mental health. It is a real issue and is certainly not that people are getting softer. Mental health and stress at work are real challenges. Sometimes it is not just self-expectations or work that contributes to the stress, it could be the patients and situations you find yourself in.
I remember the first day of my housemanship I had such a tough day. It was 4 pm and I had a patient, in her 30s, who came in with terminal ovarian cancer. Her husband and her two young children, about three and five years old, had accompanied her to the hospital. Unfortunately, she died within an hour of admission and I recall the two young kids crying- I was also crying. I had to write up the death certificate for the first time and really, on my first day as a house officer, I did not know what I was doing. It was a stressful situation to be in. That is one reason why I did not go into any field related to cancer and I avoided oncology all my life. Well, I did do it as part of a posting but I was very clear from the get-go that I never was going to do it as my specialty training.
What are some of the barriers you faced in trying to promote mental well-being among medical students?
It is mainly the stigma around seeking help. Many have difficulty dealing with the thought that we need help. Also, denial on some parts and entertaining thoughts such as, “Why can’t you deal with it?” and “Why can’t you get yourself out of the situation?”, and ultimately, the refusal to acknowledge that it is a real condition. Perhaps the darker, and more unfortunate, part is that some people feel that if they admit to having a mental health issue, it will be held against them in school, during their career progression, and even affect the registration of their medical licence. These are some of the real barriers preventing people from seeking help and I would say that the services that can be provided are probably not as well developed as they could be.
Words of advice
Thank you very much, Prof Chong, for leading our medical faculty through such difficult COVID-19 times. Could you share some words of advice with medics facing mental health challenges in Singapore?
Take your work seriously but not yourself. Be easy on yourself and be ready to laugh at your mistakes. I find trying to find humour in situations is always good. Try not to blame yourself when you face difficulties or make mistakes because everyone errs. This too will pass. Just look back on your own past experiences and you will know bad things will pass eventually. The idea is not to sit around and let bad things happen to you and yet not do anything to help yourself. Do what you can and that is all you can do; believe that things will get better. There are very few things that will stick with you unless you do something very wrong- which might also happen- but all humans will make mistakes in life. Even criminals and people who have committed errors do turn their lives around. You may also read in the newspaper about cases such as a drug user becoming an entrepreneur and going on to help other drug offenders. From this, we know there are very few unforgivable things, so I think having that positive attitude and trying to find humour in life is probably one of the ways I cope.