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Singapore's healthcare system is under strain from the rising demands of an increasing and ageing population, resulting in delayed specialist care for patients presenting to the emergency department and requiring admission. Acute assessment units have been developed elsewhere but are not well established in local healthcare. Our institution extended our acute medical team to form an acute medical unit (AMU), in which focused internist-led teams are stationed on site to rapidly assess and re-triage patients. All patients (excluding those with very complex conditions) are admitted to the AMU and managed by internists who provide holistic, patient-centric care with better ownership, improved efficiency and less fragmentation. Patients can receive timely access to medical interventions and stable patients can benefit from early supported discharge, anchored by the nursing, allied health and transitional care teams. Given the ageing patient population with multiple comorbidities, this integrated model with exceptional outcomes is highly suitable for Singapore.
ABSTRACT
<p><b>INTRODUCTION</b>The implementation of competency-based internal medicine (IM) residency programme that focused on the assurance of a set of 6 Accreditation Council for Graduate Medical Education (ACGME) core competencies in Singapore marked a dramatic departure from the traditional process-based curriculum. The transition ignited debates within the local IM community about the relative merits of the traditional versus competency-based models of medical education, as well as the feasibility of locally implementing a training structure that originated from a very different healthcare landscape. At the same time, it provided a setting for a natural experiment on how a rapid integration of 2 different training models could be achieved.</p><p><b>MATERIALS AND METHODS</b>Our department reconciled the conflicts by systematically examining the existing training structure and critically evaluating the 2 educational models to develop a new training curriculum aligned with institutional mission values, national healthcare priorities and ACGME-International (ACGME-I) requirements.</p><p><b>RESULTS</b>Graduate outcomes were conceptualised as competencies that were grouped into 3 broad areas: personal attributes, interaction with practice environment, and integration. These became the blueprint to guide curricular design and achieve alignment between outcomes, learning activities and assessments. The result was a novel competency-based IM residency programme that retained the strengths of the traditional training model and integrated the competencies with institutional values and the unique local practice environment.</p><p><b>CONCLUSION</b>We had learned from this unique experience that when 2 very different models of medical education clashed, the outcome may not be mere conflict resolution but also effective consolidation and transformation.</p>
Subject(s)
Accreditation , Clinical Competence , Curriculum , Education, Medical, Graduate , Internal Medicine , Education , Internship and Residency , Models, Educational , Negotiating , SingaporeABSTRACT
BACKGROUND: Like their counterparts in many other nations, physicians in Singapore are tasked with providing care, conducting research, and teaching and providing leadership to junior doctors. In this paper, we describe our experience implementing the first chief residency program in Singapore. INITIATIVE: A pilot of a chief residency program was initiated in the Department of Medicine at National University Hospital in July 2008, with 1 chief resident (CR) and 2 associate CR positions. The pilot used the US model for CR training as the initial framework. CRs would assist in the orientation and integration of new residents, teach residents, promote camaraderie among residents, help resolve issues, function as a liaison to senior staff, and would be developed as potential health care leaders and physician role models. RESULTS: The CRs performed a host of administrative duties and initiated several improvements in the residency, including better practices for leave scheduling, call roster planning, and a night float system. CRs attended monthly meetings with division heads and participated in departmental strategic planning as well as professional development and leadership courses. The CR position was well regarded by the other residents, and this resulted in increased interest in identifying and addressing opportunities for improvement. The introduction of a chief residency also made the department a more attractive posting for residents and contributed to a significant increase in the number of applicants for residency rotations. CONCLUSIONS: A chief residency program can benefit residents' morale and a CR's development as a leader, and it can facilitate linkage between junior and senior hospital management that promotes active involvement in problem solving and clinical and education improvement. Support from hospital administrators and senior clinicians is essential, and mentoring and succession planning are important to ensure the program's continued success.
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<p><b>INTRODUCTION</b>Atherosclerotic coronary artery thrombosis is the most common cause of acute myocardial infarction.</p><p><b>CLINICAL PICTURE</b>A 30-year-old lady presented with acute peripartum massive anterior ST segment myocardial infarction and cardiogenic shock. This was due to acute Stanford type A aortic dissection with the intimal flap occluding the left coronary ostium. The initial diagnosis was not apparent. Echocardiography confirmed the diagnosis.</p><p><b>TREATMENT AND OUTCOME</b>She underwent emergency surgical repair (Bentall procedure). Pathology confirmed underlying idiopathic cystic medial degeneration.</p><p><b>CONCLUSION</b>A high index of clinical suspicion is required in acute myocardial infarction presenting without traditional cardiovascular risk factors.</p>
