Student in Practice the prelude to housemanship| MEDICUS 2023 Issue 3

Students in practice: The prelude to life as house officers
By Dionne Seah, Writer

Dr Gabriel Chew (left) with his classmates // Credit: Gabriel Chew

“‘With great power comes great responsibility,’” Duke-NUS Dean Professor Thomas Coffman reminded the Doctor of Medicine (MD) Class of 2023 just moments before they came up on stage to receive their degree scrolls during the Graduation and Hooding Ceremony held on 3 June.

And the quote from the Spiderman movie certainly rang true for the new doctors, freshly returned from the Student-in-Practice programme or SIP. The capstone eight-week long module, now the final leg of the four-year MD curriculum, embeds students with surgical and medical teams to learn the ins and outs of working as junior doctors.

“It begins after the students have cleared all other graduation criteria, so they can be free of the stress of examinations and instead focus their efforts completely on working within a clinical team and being responsible for patients,” said Professor Scott Compton, Associate Dean for Medical Education at Duke-NUS.

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Under supervision, the students took histories of newly admitted patients, ordered investigations, communicated with healthcare team members and updated worried family members. They even shadowed house officers during their on-calls.

“The programme is the time for medical students to learn work-related skills that will prepare us for work as house officers, and so it is a major milestone for any Duke-NUS student,” shared Dr Gideon Yosua Purwono, one of the 74 MD students who graduated in June. “First, it means that you’ve cleared the last major examination of your school life and are thus qualified to graduate as a doctor. Second, it marks the start of the transition from medical student to house officer.”

Summing up the aims of this programme, Compton added: “This programme was conceived as a means for our students to demonstrate that they have the prerequisite knowledge, skills and professionalism necessary to begin their first year of post-graduate training.”

Taking a hands-on approach to caring for patients

The main objective of the programme, that starts two months before graduation, is to help students evolve from being just learners to doctors.

“We’re expected to be fully in charge of a patient when they’re first admitted and so we’re given more responsibilities in the documentation of these patients too,” said Dr Gabriel Chew, one of the two MD-PhD students who graduated this year. “This includes admission notes, inpatient progress notes, calling up family to follow-up about the patients’ progress and drafting discharge summaries and referral letters.”

The wards get so busy with countless of exchanges that take place between staff, patients and their loved ones throughout the day. “In their final lap, these supervised students will know what it’s like being on the wards as not just a doctor but also part of the patient care team. They learn to get really integrated into the system and learn more useful, practical skills that go beyond the science underpinning medicine,” added Associate Professor Loo Chian Min, Chair (designate) of the Medicine Academic Clinical Programme under the SingHealth Duke-NUS Academic Medicine Centre and Clinical Assistant Dean of Education.

Starting broad with medicine and surgery

For Dr Michelle Ko, her Student-in-Practice postings saw her spending four weeks on the medicine wards of Changi General Hospital and another four on the surgery wards of Singapore General Hospital. During her first posting, she cared for patients with various medical conditions, from acute lung infections to chronic conditions such as diabetes.

“In medicine, my team was more focused on building the foundations of our medical knowledge,” she explained. “We had to constantly revisit the patient as a whole to ensure that we’ve taken care of all aspects of their care—be it physical health, optimising social setups or ensuring that there is continuity of care even after the patient goes home. It was a good learning exercise for us to learn how to be a holistic doctor.”

Dr Michelle Ko (second right) and her classmates on graduation day. They are joined by fellow batch mate Ryotaro Enoki (first right) from the MD-PhD programme

Unlike the patients on the medical wards, patients who were admitted for surgery tended to spend fewer days on the ward and rarely required long-term follow-up for their surgical issues. For instance, after simple procedures like the removal of an appendix, most patients return home in a matter of days and no longer have to follow-up with the surgeons.

“In their final lap, these supervised students will know what it’s like being on the wards as not just a doctor but also part of the patient care team. They learn to get really integrated into the system and learn more useful, practical skills that go beyond the science underpinning medicine”
Assoc Prof Loo Chian Min

“However, the pace of life in surgery was a lot faster and we learnt how to be efficient in doing junior doctor tasks during that posting,” Ko said. On top of the regular documentation, the students learnt how to consent patients for surgery, perform pre-operative anaesthetic assessment and conduct post-operative review.

Purwono agrees: “The infamous Murphy’s law appears to happen more often in medicine than in surgery. In medicine, everything can happen to a patient at any time and often all at once. Teams sometimes find themselves between a rock and a hard place when one treatment option can exacerbate other concurrent medical problems.

“These conundrums are not easily resolved and are always done as a shared decision-making process, discussed with the various medical and allied health teams, the patient and their loved ones. While this results in a plethora of referrals and replies to trace, it ensures that the team leaves no stone unturned in deciding what is in the patient’s best interest.”

Dr Gideon Yosua Purwono (third on the left) and his classmates celebrating the end of their Student-in-Practice programme with a well-deserved lunch

Crossing the final hurdle as medical students

The Student-in-Practice programme wasn’t always conducted after final examinations. This change was affected four years ago.

“We felt that it was better to let the students finish their exams and then go for their SIP without having the burden of worrying about taking their papers,” said Professor Lim Soon Thye, Associate Dean of MD Programmes at Duke-NUS. “Then, they can completely focus on trying to learn the day-to-day function of being a house officer.”

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And the feedback has been positive, according to Lim: “Around graduation, we always do a graduate survey to ask our students questions like how prepared they’re feeling as house officers, ready to enter the workforce. And after the change, when we look at the readiness comfort levels of the students, they went up significantly—by more than two to three times—compared to how it was before.”

And the doctors from this year’s cohort agree. “Being able to put our newly minted medical knowledge and clinical examination skills to our daily work was optimal for our development as junior doctors,” said Ko, now a house officer at KK Women’s and Children’s Hospital. “Without the stress of studying for exams, we could go into our SIP fully prepared and committed to becoming better doctors.”

Gabriel Chew, now a house officer at the National University Hospital, shares Ko’s sentiments: “This is the best time to learn how to function as a doctor because you’re still given some space to be a little slower than you’re expected to be as an actual house officer. To my juniors: fully immerse yourself in the programme because it’s really the best time for you to learn what your day-to-day life will be like as a doctor and it will only serve you to become a better houseman in the future.”