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					  Residency Guidebook

     Yong Loo Lin School of Medicine




A PRODUCTION BY THE 63RD MEDSOC ACADEMIC
              DIRECTORATE
                               TABLE OF CONTENTS
    I.        Overview
              INTRODUCTION
              STRUCTURE OF CURRENT SYSTEM – THE NEW VS THE OLD
              HALLMARKS OF RESIDENCY
              SPONSORING INSTITUTIONS
              APPLICATION PROCESS AT A GLANCE
              RESIDENCY PROGRAMMES
              TRANSITIONAL YEAR CURRICULUM

    II.       The Match
              INTRODUCTION
              WHY DO WE HAVE THE MATCH?
              WHAT IS THE MATCH?
              WHO IS ELIGIBLE TO APPLY FOR RESIDENCY MATCHING?
              THE ALGORITHM
              DETAILED EXAMPLE
              HOW DO I REGISTER FOR THE MATCH
              SINGAPORE-SPECIFIC TWEAKINGS
              THE US SYSTEM

    III.       Thoughts by Residents

    IV.        Frequently Asked Questions
              RESIDENCY STRUCTURE
              APPLICATION AND ADMISSION
              PROGRAMME
              CAREER PROGRESSION
              OTHER ISSUES

    V.        Acknowledgements




1
               RESIDENCY GUIDEBOOK
                                          INTRODUCTION
The Residency Programme was introduced in 2010 as a new post-graduate medical training and
education system in Singapore. The advent of this programme had been marked by intense debate and
discussion, leaving innumerable frantic or clueless as to what exactly to make out of it.

This handbook thus seeks to expound on the core truths of the programme to ameliorate doubts and
reduce information asymmetry with regards to Residency. It also aims to shed light on the
programme’s goals and reveal the answers to some common queries on the Residency system. The
application procedure will only be described briefly here as all other information can be readily found
on the MOHH website (http://www.physician.mohh.com.sg/residency/faq.html). Also, details of the
various specialties and sub-specialties will be highlighted in a later production.

Put together by a team of equally curious and eager medical students under the Academic Directorate,
this booklet stemmed from the determination to help clueless or worried classmates on Career
Guidance. It is sincerely hoped that this booklet will go a long way in quashing your initial doubts and
providing a reliable source of information on the Residency programme. All sources of information are
from official sources and all facts written in this guidebook are indeed accurate at the moment of
publication, and facts are bound to change with time and will be updated accordingly in the guidebook. If
you would like to point out any clarifications or express your opinions, do drop an email to
acadmedsoc@gmail.com and we’ll address them as soon as we can.  Enjoy!




                                                                                                            2
              THE NEW VS. THE OLD           (EDITED FROM HTTP:// SINGAPOREMD.BLOGSPOT .COM/2009/09/RESIDEN CY.HTML)




              Singapore will start to switch to a US-style residency program for the graduating medical students
              of 2010. This is an almost complete revamp of our current training system for junior doctors, which
              is based largely on the UK system. Just a quick recap of the existing system, which can be somewhat
              confusing:

              The Old

         1.   Medical students become house officers upon graduation. For one year, they will rotate through 2
              or 3 rotations in medicine, surgery, orthopaedics, paediatrics, or obstetrics & gynaecology to
              acquire practical skills in doctoring to function in the public hospital setting.
         2.   Upon completion of housemanship, one becomes a medical officer (MO), who will typically have 6-
              monthly rotations through postings of one’s choice. MOs can elect to take up basic specialty training
              (BST, i.e. surgery, medicine, family medicine, paediatrics etc.) which is usually a 3-year process,
              completion of which is contingent on passing yet another exam as well as jumping through
              whatever hoops set up by the all-powerful BST committees. Of course, MOs could also just float
              through the system for a few years before going out to set up their GP clinics or to join other GP
              groups.
         3.   Those who complete their BST could then opt to join a relevant clinical subspecialty as a registrar
              (this can be tougher than it sounds for specialties that are over-subscribed – the wait for a training
              slot can be up to a year or longer), and the advanced specialty training (AST) is usually 3 years in
              length (again, it is longer for certain subspecialties such as cardiothoracic or neurosurgery).
         4.   After finishing the AST, doctors become certified specialists and attain the rank of associate
              consultant in the local hospitals.

              As you can see, it takes a minimum of 7 years (usually longer) before a medical school graduate
              becomes a clinical specialist under the current system. There are variations, of course – some
              specialties have a “through-train” training track that shortens the process considerably.

              The New

              Under the new residency system, it will take an average of 3- 5 years to complete training in most
              specialties. Medical students can opt to join a hospital residency program upon graduation, if they
              are certain as to their future career (i.e. specialist) tract. They become 1 st-year residents, equivalent
              to the current internship or housemanship, but with greater educational opportunities and clinical
              involvement. From the 2nd to 5th years, the residents will continue to train in the specialty and
              subspecialty of their choice, and will theoretically become fully-trained specialists after the 5th year
              of residency – employed in the hospitals as specialists1.

              There are some advantages to the residency program – medical education becomes more important
              for the hospitals, and hopefully residents will get a more structured training program. It could be
              considered a good thing to shorten the time to being a specialist by 2 years, but the current batch of
              house officers and even 1st/2nd year medical officers may be a bit disadvantaged with the rollout of
              the new system. It will be interesting to see how things will unfold from next year.




    1On exit of Residency, one may not immediately become an associate consultant. Promotion is based on merit
    as well as availability of spaces. For more information, refer to the FAQ section below, question “5. After I
    graduate from a residency, will I be an associate consultant?” under Programme.


3
               STRUCTURE OF CURRENT RESIDENCY SYSTEM (AS OF 2012)

                                                       Available choices


                       Residency
                                                                 Transitional Year              Housemanship
                      Programme



      Direct entry-                                                                                 Medical
                                                          Generic TY         Categorical TY
      Residency R1                      HO/TY-                                                      Officer
      starting from                    Entry after
      PGY1 or after                   PGY1/TY/HO
         TY/HO



                             1. Anesthesiology
                             2. Diagnostic Radiology
 1. Emergency Med            3. Obs & Gyn
 2. Internal Med             4. Orthopaedic Surg
 3. General Surgery          5. Otorhinolaryngology
 4. Pediatric Med            6. Ophthalmology
 5. Preventive Med           7. Pathology
 6. Psychiatry               8. Family Med
                             9. Cardiothoracic Surg
                             10. Hand Surg                             PGY1: Post-graduate year 1
                             11. Neurosurg                             TY: Transitional year
                             12. Plastic Surg                          HO: Housemanship
                             13. Urology


FIGURE 1




                                                                                                               4
                                            HALLMARKS OF THE RESIDENCY SYSTEM
    The Residency Program is a US-styled postgraduate medical education where medical graduates
    undergo training in a supervised and organized way to ensure they become competent and excellent
    specialists.

    Although the old Graduate Medical Education (GME) system has served the Singapore healthcare sector
    well, the need to constantly innovate and adopt the best practices in education in order to meet
    with evolving healthcare demands and ensure that future generations of clinicians are well-
    trained has been strongly advocated by the Ministry of Health (MOH), Singapore. After discussions
    with the Specialists Accreditation Board (SAB), MOH thus recommended the introduction of the
    Residency Program. This was in response to a high percentage of doctors leaving for private practice
    without undergoing any formalized training program.

    The Residency Program will be a structured training framework and education curriculum, based on
    established standards from the American Council for Graduate Medical Education (ACGME). The
    program is a rigorous system designed on a formative model for quality training. The learning process
    will       be         enhanced        through         the       6          core         competencies.

    Under the old system, medical officers will rotate from one posting to another and be responsible for
    their own training outcome. With the Residency Program, training will be more structured and
    Sponsoring Institutions will take ownership of the training outcome of the residents.

    A key feature is in its evaluation methods - an ongoing system to assess residents' skills, ensuring
    a continual review of the learning progresses. This differs from the current system, which utilizes a
    summative method where assessments accumulate in intermediate and final exams.

    Accreditation Council for Graduate Medical Education (ACGME) evaluates and accredits medical residency programs
    in the United States. The mission of the ACGME is to improve health care by assessing and advancing the quality of
    resident's                         education                        through                         accreditation.

    MOH has invited ACGME to assist us in the drive to improve the graduate medical education in Singapore.
    The collaboration between ACGME and MOH is known as ACGME-International (ACGME-I), and it is the
    first of its kind. ACGME-I will develop a set of standards for Singapore in the areas of curriculum
    development, assessment and teaching methods, data collection systems, professional development and
    training for program directors and program coordinators.

    Depending on the Residency Program you are enrolled in, the program can range from 3 to 5 years. You
    may check out the number of training years for the specific department and Sponsoring Institution
    stated in the table a few pages after.
           (INFORMATION EDITED F ROM HTTP:/ / WW W . SI N GHEAL T H. C OM. SG/ EDUC ATI ON AN DTRAI N I NG / RESI DENC Y/ F AQS/ PAG ES/HOME. ASPX )




    Quicks facts about the Residency Programme:
       3 different Sponsoring Institutions (SIs for short)

        Which are the Sponsoring Institutions?
        Currently, there are 3 approved Sponsoring Institutions (SIs), namely:
                1. National Healthcare Group (NHG): Tan Tock Seng Hospital , Institute of Mental Health,
                Alexandra Hospital / Khoo Teck Puat Hospital
                2. National University Health System (NUHS): National University Hospital, Jurong
                General Hospital


5
            3. SingHealth (SHS): Singapore General Hospital, KK Women's and Children’s Hospital,
            Changi General Hospital

   Has 35 specialties, 4 sub-specialties and Family Medicine
   Retains the advantages of the HOPEX/MOPEX (Housemanship and Medical Officer Posting Exercise)
    system while adapting to the current needs:
        o Duration of training for each specialty retained
             Allows longer exposure and training in each specialty
        o Broader-based post-graduate education
             Wider breadth of knowledge in relevant specialty covered such that new specialists have the
             confidence to advise patients without the need to refer them to other specialists
        o Supplemented by a dedicated teaching faculty – Senior physicians have protected time to
             mentor and guide their students
   Application choices
        o Each candidate can only choose 2 specialties per SI, thus a total of 6 choices to be listed
        o Advised to apply for all 3 SIs as shown in Figure 2 to increase chances of matching to SIs
        o Candidates interested in the Clinician Scientist track can apply for one additional
             specialty per SI, thus a total of 9 choices
   Regular formative assessments
        o Ensure trainees attain core competencies at each stage of training
        o Assess both theory and practical skills attained by residents
   Transitional year
        o Designed to fulfill the needs of graduands who desire a well-balanced, broad-based year in
             different disciplines within the structured framework of a Sponsoring Institution before
             specialization
   Clinician Scientist Track
        o Programmes with clinician scientist tracks will have at least a year of research built into the
             curricula of advanced residency years
        o As aforementioned, applicants can choose up to 3 programmes if any of their choices are
             clinician scientist tracks, instead of just 2




                                                                                                            6
                                               SPONSORING INSTITUTIONS


                                          Sponsoring Institutions (SIs)



                    National Healthcare                                          Singapore Health
                     Group - Alexandra            National University
                                                    Health System                    Services
                      Hospital Pte Ltd




                          Khoo Teck Puat
                          Hospital (KTPH)                  National                   Changi General
                                                       University Health              Hospital (CGH)
                                                        System (NUHS)

                          Tan Tock Seng
                          Hospital (TTSH)                                            KK Women's and
                                                                                    Children's Hospital
                                                        Jurong General                     (KK)
                                                         Hospital (JGH)
                         Institute of Mental
                            Health (IMH)
                                                                                    Singapore General
                                                                                      Hospital (SGH)


    FIGURE 2

                                       APPLICATION PROCESS AT A GLANCE

               •Open House/Career Symposium to explore and choose SIs
               •Encouraged to choose all 3 SIs regardless of actual preference
      July

               •Central applications for interview through MOH
               •Portfolio creation and submission at MOHH website
    Aug-Sep    •Choice of programme (2 choices) and sponsoring institution (3 choices)

               •Multi-Mini-Interviews by National Interview panels
               •Interviewers consist of Programme Directors from the respective SIs, Residency Advisory Committee (RAC) member
    Oct-Nov     and a Clinician Scientist Mentor (if applicable)

               •Ranking by candidates and SI's preferences
               •The Match (details below):
    Dec-Feb     Independently matches candidates and SI's preferences for each other

               •Release of Match results: 1 doctor to 1 specific programme of 1 SI
               •Applicants who do not obtain a successful match for residency will enter HOPEX/MOPEX with the applicants who
    Mar-Apr     chose HOPEX/MOPEX




    FIGURE 3



7
                                       RESIDENCY PROGRAMMES


Programme                Programmes          Training   NHG - AHPL   NUHS   SHS
Group                                        Length
                                              (yrs)

Direct Entry       Emergency Medicine           5                          
                                                                           
Programmes         Internal Medicine         3 + 2/3
                                                                           
                   General Surgery              5
                                                                            
                   Paediatric Medicine         3+3

                   Preventive Medicine          5                     

                   Psychiatry                   5           
                                                                           
HO / TY            Anaesthesiology              5
Programmes                                                                 
                   Diagnostic Radiology         5
(Entry after PGY
                   Obstetrics &                 6                           
1)
                   Gynaecology
                                                                           
                   Orthopaedic Surgery          6
                                                                           
                   Otorhinolaryngology          5
                                                                           
                   Ophthalmology                5
                                                                           
                   Pathology                    5
                                                                           
                   Family Medicine              3
                                                                            
                   Cardiothoracic Surgery       6
                                                                           
                   Hand Surgery                 6
                                                                            
                   Neurosurgery                 6
                                                                           
                   Plastic Surgery              6
                                                                           
                   Urology                      6
TABLE 1




                                                                                  8
                       TRANSITIONAL YEAR CURRICULUM FOR EACH PROGRAMME


    Programme Group                       Programmes                                   No. of Months in Each

    Direct Entry               Emergency Medicine                       4IM + 4EM + 4GS + 2PM
    Programmes                 Internal Medicine                        4GS + 1N + 1RP + 1G + 1C + 2GM + 1R + 1E + 1O

                               General Surgery                          4GM + 8S

                               Paediatric Medicine                      2GM + 2X + 4S (incl. 1PS) + 2GP + 1PaedsO+ 1PaedsR

                               Preventive Medicine                      4GM + 4GS + 3/6 X

                               Psychiatry                               3GM + 3N + 3IP

    HO / TY Programmes         Anaesthesiology                          4IM + 4GS +2PM + 2EM + 2A
    (Entry after PGY 1)        Diagnostic Radiology                     9FYAPC + 3(Chest, VIR, MSK)

                               Obstetrics & Gynaecology                 4OP + 3LW + 3W + 2X

                               Orthopaedic Surgery                      4A + 4GS + 4EM

                               Otorhinolaryngology                      6GS/CC + 6ENT

                               Ophthalmology                            Weekly EM + GOP + CTO

                               Pathology                                CPT

                               Family Medicine                          X

                               Cardiothoracic Surgery                   6GS + 2U + 2NS + 2VS

                               Hand Surgery                             6GS + 2U + 2NS + 2VS

                               Neurosurgery                             6GS + 2N + 3NS + 2X

                               Plastic Surgery                          6GS + 2PL + 2A + 1OR + 1X

                               Urology                                  8GS + 2NS + 2VS
    TABLE 2


    GS      General Surgery                      GM   General Medicine                CC    Critical Care
    N       Neurology                            R    Renal                           ENT   General Otolaryngology
    RP      Respiratory                          E    Endocrine                       U     Urology
    G       Gastrology                           O    Oncology                        NS    Neurosurgery
    C       Cardiology                           S    Surgery                         VS    Vascular Surgery
    EM      Emergency Medicine                   PM   Pediatric Medicine              PL    Plastic Surgery
    IM      Internal Medicine                    A    Anesthesiology                  OR    Orthopedic
    X       Elective/Misc                        PS   Pediatric Surgery               GOP   General Ophthalmology
    GP      General Pediatrics                   IP   Inpatient Psychiatry            CTO   Cataract Teaching OT
    FYAPC   Foundational Year Anatomy &          LW   Labor Ward                      DR    Diabetic Retinopathy Screening Clinic
            Physics Course
    OP      Outpatient                           W    24 Hours Clinic                 CPT   Core Pathology Training




9
                                       THE MATCH
                W HA T O N E A R T H I S I T A N D W H Y A R E W E C O P Y I N G T HE A N G M O H S



WHY DO WE HAVE THE MATCH?
Under the old HO/MO system, it would take a minimum of 7 years for a medical school graduate to
become a clinical specialist.

Under the new system, a specialist doctor can complete his training at least one year earlier,
depending on the discipline. This is especially important in view of the pressures presented by
Singapore’s aging and expanding population.

Not only is the duration of training shortened, the training programmes are also more structured,
ensuring more holistic training for the graduates. The Residency Programme strives to allow every
student to experience a value-added post-graduate education by emphasizing on systems-based
practice and practice-based learning (see chapters ? interviews with current residents to see
whether this is true or not ;))

WHAT IS THE MATCH?
The new residency programme for post-graduate medical education was introduced in May 2010.
Alongside the new system is a posting exercise based on the US medical system’s own, elegantly
fine-tuned to suit Singapore’s needs, in which medical students are sorted to their preferred
specialty and Sponsoring Institution (SIs). This exercise is known as the Match, developed by MOH
Holdings as an easily accessible, efficient online system, Residency Matching Exercise (RMEx).

The Match is a computer-run system that aims to match medical students with residency
programmes and residency programmes with medical students in such a way as to ensure greatest
utility for all; that is, medical students get posted to their most desired programmes while the
programmes are allocated students that they most desire. Ideally, it is a win-win situation for
medical students and SIs both. It uses an algorithm based on that used in the US for matching the
thousands of medical students they have to the hundreds of available residency programmes.

Of course, without proper knowledge of how the Match works, it is easy for students to end up
unmatched, which means that the student would automatically enter the House Officer Posting
Exercise (HOPEX), which is probably not, as the name suggests, the beacon of hope to most medical
students these days. However, failure to be matched doesn’t truly have the negative connotations
most people attribute to it.

WHO IS ELIGIBLE TO APPLY FOR RESIDENCY MATCHING?
In M5, Residency applicants will first sit for 2 rounds of interviews:

       Multiple Mini-interview



                                                                                                      10
           Department Interview

     Multiple Mini-interview

           The Multiple mini-interview is a common, national interview by all 3 SIs for each specialty a
            student is interested in. This interview is designed to find out whether an applicant is
            prepared to start residency. This is done by putting an applicant in various scenarios. For
            Clinician Scientist applicants, an additional interview session may be arranged.

     Department Interview

     The SIs may decide to do separate interviews (usually during their open house sessions) to help
     them rank all the medical students who apply to their residency programmes.

     Only if a student has sat and passed an interview are they eligible to apply for RMEx; otherwise,
     M5s will need to re-sit for interviews the following year. In the meantime, they join HOPEX.




                                                      Successful Match            Residency/TY

                                  eNRMP
                   Pass           + HOPEX
                                                                                      Specialise
      Interviews                                      Unsuccessful match
                                 Reapply
                                 next year
                   Fail
                                                                                    Give up.
                                  HOPEX/                                           Go private
                                  MOPEX                                                OR
                                                                             Work as a non-specialist
                                                                              doctor in the hospital
                                                                                   (resident
                                                                               physician/service
                                                                                   registrar)




11
THE ALGORITHM
The RMEx matching algorithm based on the
same principles as its US counterpart. The                DID YOU KNOW?
matching process will match candidates' and
programmes’ preferences for each other.                   The Match algorithm is an extension of the
                                                          stable marriage problem in mathematics and
The basic goal in the simple case of the                  computer science 
hospitals/residents problem is to match
                                                          But let’s not get too confused with these
applicants to residency programmes so that the            technicalities!
final result is "stable". “Stability" in this case
means that there is no applicant A and
programme P such that both of the following are
true:

       A is unmatched or would prefer to go to P over the programme he is currently matched with

       P has a free slot or would prefer A over one of the candidates currently filling one of its slots.

The Rank Order Lists

Based on the specialty interviews,Each SI will rank interviewees based on the SIs’ order of
preference for offering the student a position. In arriving at their order of preference, SIs will assess
a student based on his online portfolio as well as his performance during the national and SI-
specific interviews. The SI may or may not rank all interviewees who applied for training positions.
This produces an institution’s “rank order list” or ROL.

Students will also rank the programmes of their choice on the RMEx website. This produces a
student’s ROL.

The Confusing Algorithm

The computer will process students’ ROLs in a completely random order. For each student, based
on their and the SI’s ROL, the computer will make a tentative match. Matches
are "tentative" because an applicant who is matched to a program at one point in the matching
process may be removed from the program at some later point, to make room for an applicant more
preferred by the program (i.e., highly ranked by the SI).

This continues until all students have been matched, at which all matches become permanent.
Applicants are first matched to his first choice programme, then to his second choice programme if
he fails the first match, and so on, until a match is made or all applicant’s choice have been
exhausted (at which point, applicant
remains unmatched).
                                                       LONG STORY SHORT!

                                                      The algorithm aims to match the
                                                      Departments’ top choices to the Students’ top
                                                      choices as far as possible!

                                                                                                             12
     The algorithm in diagram


                                                1st applicant’s ROL                                         Programme’s ROL




                                                         Computer tries to place applicant into 1 st choice programme
         1st round of matching




                                            Applicant ranked +                         Applicant not ranked/
                                            available spaces                           spaces filled by more preferred applicants



                                                                              Applicant matched with next choice programme

                                         Tentative match
                                                                            Process continues until tentative                 Unmatched
                                                                            match obtained



                                                2nd applicant’s ROL                                         Programme’s ROL




                                                         Computer tries to place applicant into 1 st choice programme
                 2nd round of matching




                                            Applicant is more highly                      Applicant not ranked/
                                            ranked than tentatively                       spaces filled by more preferred applicants
                                            matched applicant in full
                                            programme


                                                                                Process continues until tentative               Unmatched
                                                                                match obtained
                                          Least preferred applicant
                                          in programme removed
                                          and tentative match made
                                          for 2nd applicant




                                          Least preferred applicant goes through another round of matching until tentative
                                          match made/all choices exhausted



            Subsequent rounds
            Process carried out for all applicants until each applicant has been tentatively matched to the most
13          preferred choice possible/all choices have been exhausted


        FIGURE 5
SO LET’S SEE WHAT HAPPENS…
Illustrate with a few examples of students with choices are matched with the system; NRMP
website has good example

http://www.nrmp.org/res_match/about_res/algorithms.html

How do I register for the Match

Go to MOHH website 

http://www.physician.mohh.com.sg/residency/

Singapore-specific tweaking

       Clinician Track (aka the usual way)
                                                             DID YOU KNOW?
A candidate can only choose 2 specialties. Candidates
are advised to apply for all SIs because applying to         Candidates are advised not to apply for a
fewer SIs will reduce their chances of matching with         clinician scientist track and clinician track for
the SIs.                                                     the same specialty. Contrary to belief, this
                                                             will not increase the success rate by 2! In fact,
2 specialties X 3 SIs = 6 choices                            it may even lower your success rate because
                                                             the interviewers will be the same with the
       Clinician Scientist Track                            exception of a clinician scientist in the
                                                             clinician scientist track interview.
2 specialties X 3 SIs = 6 choicesCandidates
interested in the clinician scientist track can apply for
one additional specialty.

3 specialties X 3 SIs = 9 choices



WHAT HAPPENS IN THE US
The NMRP is actually a non-profit, private organization formed in 1952. It was cosponsored by five
medical associations in the US to improve on the then extremely messy way of allocating students
to residency programmes. In the US, The Match is commonly views as a rite of passage for American
medical students, who eagerly await Match Day as the day heralding the rest of their lives. This is
not unlike the god-like status attributed to that first week of March when A level results are
released, or for medical students, the day that brown envelope arrives in the mail

Why did the NRMP come about?

By the late 1940s, the traditional matching process was growing increasingly chaotic. There were
almost twice as many residency positions as there were U.S. medical graduates. More competitive
programs had the luxury of receiving and reviewing large batches of applications before doling out
their residency spots late in the students’ fourth year. Less competitive programs tried to get a head


                                                                                                         14
     start by asking students to commit to the program early in the fourth year or even during the third
     year. (there are 4 years of postgraduate medical school in the US) As a result, students were forced
     to gamble by deciding whether to accept an early offer from a less competitive program and forfeit
     a later shot at better programs or to pass up the early offer and risk not being accepted in a better
     program. Residency directors faced a similar dilemma. If they filled all their positions too early, they
     would not be able to offer a position to a more desirable candidate who applied later; however, if
     they held out for better applicants, they risked not filling their programs. As a solution to these
     dilemmas, the first Match was held in 1952. It was a huge success, with over 98% of the residency
     programs and 97% of the students participating. The Match eliminated guessing games for the most
     part by allowing applicants and programs to rank each other on the basis of desirability. The
     algorithm used to match applicants with programs has remained largely unchanged over the years.




15
THOUGHTS BY RESIDENTS
    INTERVIEWS (SOON TO COME!)




                                 16
               FREQUENTLY ASKED QUESTIONS
     RESIDENCY STRUCTURE

         1.   What is the Graduate Medical Education Committee (GMEC)?
         2.   What is a Sponsoring Institution? How many Sponsoring Institutions are there in Singapore?
         3.   What are the roles and responsibilities of the Designated Institutional Official?
         4.   What is the role of Associate Designated Institutional Official?
         5.   What are the responsibilities of the Program Director?
         6.   What are the responsibilities of the Associate Program Director?
         7.   What is the main role of the Program Coordinator?
         8.   What are the roles of the core faculty members?

     APPLICATION AND ADMISSION
         1.  Why residency?
         2.  What are the judging criteria of the matching process?
         3.  Who can apply for the residency programme?
         4.  Can MOHH increase the number of Transition Year residents?
         5.  Which are the Residency Programmes with too many applicants and which are the ones with
             vacancies? Do Group 2 specialty (ENT, O&G, etc) residents have to worry about the scarcity of TYs?
         6. Should I apply for the Clinician-Scientist track if I don’t think I can make it for the standard residency?
         7. Who will make up the National Interview panels?
         8. What happen if I am unsuccessful in obtaining entry into, or do not wish to apply for a Residency
             Programme?
         9. It is perceivably easier to get a residency slot in M5 compared to being a HO/MO (competing with
             everyone else, including international graduates). Could more be done to assure students that they
             will not be at a disadvantage if they do not apply in M5 but only do so in their post-graduate years?
         10. If there are such a small number of Residency places available, would a Doctor be at a disadvantage if
             he/ she delays making a decision?

     PROGRAMME
         1. What is a Transitional Year?
         2. What are the differences between Transitional Year and Housemanship?
         3. When does Residency begin? How long will my Residency Programme last?
         4. How will assessments be carried out? At the end of training, how will I exit as a specialist?
         5. After I graduate from a residency, will I be an associate consultant?
         6. How will switch between clusters and/or specialties be managed in the unlikely event that a resident
            needs to make a swop for unforeseen reason(s) and who will be involved?
        7. MOs have to start from Year 1 in the residency program when they apply this year. Can they be
            allowed to skip/accelerate parts of the training?
        8. What would happen to males who have to re-enlist to serve the remainder of their National Service?
            What are the allowances for National Service?
        9. What happen if I go on long leave during the residency year, (e.g. maternity leave), does it mean that I
            will have to repeat the whole year?
        10. I heard instances when my seniors exceed the 80 hours work week. Why?
     CAREER PROGRESSION
         1.   ACGME (I) is not recognized in the USA. For this reason, many will eventually still have to take Royal
              College Exams. Is ACGME recognized outside of Singapore?
         2.   What are the opportunities for graduates intending to pursue a research scientist or a clinician-
              scientist career tracks?


17
    3.Will residents completing their basic residency programs be able to immediately pursue an overseas
      fellowship program? Will such fellowship programs be considered as relevant training for
      subsequent appointment as an associate consultant and registration by the Specialist Accreditation
      Board?
   4. Is it possible to give HO/MO the same teaching and dedication as residents? If not, what can be done
      to ensure fairness in career progression for non-residents?
OTHER ISSUES
    1.   Is there are any preferential quota set aside for the Duke students?
    2.   How much are residents paid?




                                                                                                             18
     ANSWERS

     RESIDENCY STRUCTURE


                        MOH             Sponsoring                    GMEC
                                        institution


                                                               ADIO           DIO



                                                                       APD             PD



                                                                                      Core
                                                                                     faculty



                                                                                     Faculty



                                                                                    Residents

     FIGURE 6


        1. What is the Graduate Medical Education Committee (GMEC)?

            The GMEC exists to provide oversight and governance to all graduate medical education training
             programs under the Sponsoring Institution (SI). It monitors and provides advice on residency
             education and ensures substantial compliance withrequirements of the ACGME-I. The GMEC is
             chaired by the DIO and comprises members including Senior Management, Program Directors (PDs),
             peer-nominated residents, administrators and other members of the faculty.
            The committee is responsible to establish and implement policies and procedures regarding the
             quality of education and the work environment, and to ensure proper distribution of institutional
             resources across the resident programs.

        2.   What is a Sponsoring Institution? How many Sponsoring Institutions are there in Singapore?

            The Sponsoring Institution (SI) is the organization (or entity) that assumes the ultimate financial and
             academic responsibility for a program of Graduate Medical Education. The SI has the primary
             purpose of providing educational programs and health care services
            Currently, there are 3 approved Sponsoring Institutions, namely:
                 1. National Healthcare Group (NHG)
                             Tan Tock Seng Hospital
                             Institute of Mental Health
                             Alexandra Hospital/ Khoo Teck Puat Hospital
                 2. National University Health System (NUHS)
                             National University Hospital
                             Jurong General Hospital
                 3. SingHealth (SHS)
                             Singapore General Hospital


19
                       KK Women’s and Children’s Hospital

   3. What are the roles and responsibilities of the Designated Institutional Official?

      The Designated Institutional Official (DIO) has an overview of the educational, fiscal and
       administrative health of the SI’s GME activities. The DIO leads an organized administrative system
       that oversees all ACGME-I accredited programs, maintain both ACGME-I Institutional accreditation
       and Residency Programs’ accreditation.
      With support from the GMEC, the DIO (who is also the chairperson of GMEC) establishes and
       implements policies and procedures regarding the quality of education and the work environment
       for the residents in all the programs.
      Nonetheless, the DIO’s ultimate goal is to institutionalize an educational experience that would
       enable residents to obtain the necessary knowledge, skills and attitude to practice as competent
       physicians.

   4. What is the role of Associate Designated Institutional Official?

      The Associate Designated Institutional Official (ADIO) is the designee of the DIO. In the DIO’s absence,
       the ADIO carries out the responsibilities and roles of the DIO. ADIOs are representations of the
       respective participating institutions at Changi General Hospital and KK Women’s & Children’s
       Hospital.

   5. What are the responsibilities of the Program Director?

      Each Residency Program will have a Program Director (PD) that is responsible for all aspects of the
       Residency Program. The PD has to administer and maintain an educational environment conductive
       to educating residents in each of the competency area.
      The PD will oversee the recruitment of residents and faculty, development of the curriculum with
       assistance from the faculty, and the assessment of the residents’ progress through the program. The
       PD will have to certify the competency of the graduates to practice independently.

   6. What are the responsibilities of the Associate Program Director?

      The Associate Program Director (APD) is a faculty who assists the Program Director in the
       administration and clinical aspect of the training program. There may be more than one APD for
       each program.

   7. What is the main role of the Program Coordinator?

      The Program Coordinator (PC) assists the PD in the daily administration of the Residency Program,
       especially to ensure that residents are informed and adhere to established educational and clinical
       practices, policies and procedures.

   8. What are the roles of the core faculty members?

      Core faculty members are clinicians who work closely with the PD and APD on the development of
       program, with matters ranging from curriculum to administrative planning and implementation.
       Together with a fleet of physician faculty, they will lead the team to teach, supervise and mentor the
       residents. For quality teaching, ACGME-I had stipulated a ratio of 1 core faculty to 6 residents for
       programs.


APPLICATION AND ADMISSION
   1. Why residency?


                                                                                                                  20
        Residency was created to introduce more structure into our current post-graduate training, which
         has a lot of inefficiency.
        One of the weaknesses in the previous system is that one is allocated to a supervisor and the quality
         of the supervisor is dependent on luck. There is poor regulation and standardisation.
        Specifically, the residency programme improves the learning environment by ensuring that there are
         3 tiers
              a. 1:1 faculty (mentor):resident ratio
              b. 1:6 core faculty:resident ratio with core faculty having 20% protected time
              c. Programme directors with 50% of the time protected to ensure they can focus on running
                  the residency programme
        Other reasons:
              a. To make students decide what they want to specialise in earlier so that they can commit
                  earlier. This is good for the individual departments in hospitals, as they can have a group of
                  trainees who will stick (instead of bailing out to another department/institution when their
                  brief tenure is up)
              b. To attract and retain clinicians who mainly teach: the clinician educators. It is hoped that
                  with such professionals, post-grad training could have better quality.

     2. What are the judging criteria for the matching process?

        Evaluation of your application is based on a few factors, and they are definitely not limited to your
         academic performance:
              a. Interview performance and letters of references (LORs) submitted by their referees
              b. Academic scores
              c. SIP performance
              d. Previous clinical work experience.
        This framework varies from speciality to speciality, and from Sponsoring Institution to Sponsoring
         Institution.
        An exception is the Transition Year, for which there is no interview, and your evaluation is based
         only on your portfolio and academic scores.
        For academic results, it is a broad strata system with MOH intervention only at extremes, so there is
         no real quota based on grades.
        Research may help as it acts as a surrogate measure for a candidate’s interest in a particular specialty,
         however, a generic research project will not give one a significant edge over his peers

     3. Who can apply for the Residency Programme?

        Graduands of Singapore medical schools and those with primary medical qualifications registrable
         under the Medical Registration Act (First Schedule) are eligible.
        This includes current HOs and MOs, however they will still be expected to enter residency training at
         Residency Year 1 (R1)
        Graduands with non-registrable medical qualifications may be considered on a case to case basis
        Graudands from overseas need to secure an offer of employment as a doctor from MOHH or local
         healthcare institutions before they are eligible.

     4. Can MOHH increase the number of Transition Year residents?

        Yes. Eventually, TY will apply for all, but it is limited by shortage of teaching faculty now as it is just
         starting off. However, don’t bet on this, because residency is still very far from maturation!

     5. Which are the Residency Programmes with too many applicants and which are the ones with
        vacancies? Do Group 2 specialty (ENT, O&G, etc) residents have to worry about the scarcity of
        TYs?


21
     Opthalmology, ENT and Pediatrics are the ones with too many applicants.
     The residency programmes with vacancies include Pathology and Family Medicine Residency
      Programmes due to a large number of vacancies offered (~50)
     The “limited” TYs are the Generic TYs. Group 2 specialty residents are under the Categorical TYs, and
      once they are accepted, the TY is considered part of their programme. Hence they do not need to
      worry about the limited spaces in the generic TYs. This confusion will be resolved once the naming is
      changed.

  6. Should I apply for the Clinician-Scientist track if I don’t think I can make it for the standard
     residency?

     Clinician-Scientist track is intended for candidates who have a strong interest in research careers.
      This is not a back door – candidates are expected to be good enough to be on the equivalent clinical
      track.
     One year is added to the normal clinical residency duration. Clinician-scientist residents will be
      provided with close mentorship from a clinician-scientist mentor. They will be expected to complete
      at least a Masters in Clinical Investigation or equivalent, and publish as first author in a reputable
      journal.
     Student can apply for one additional specialty if they apply for the research tracks (usual limit is 2
      specialties)
     Students are advised not to apply for the same clinician and research specialty
     Many departments offer additional positions for those on the clinician-scientist track

  7. Who will make up the National Interview panels?

     The National panels for each specialty generally include the Programme Directors (PDs) from each
      Sis, representatives from the Residency Advisory Committee (RACs) and a Clinician Scientist mentor,
      if that interview is for your chosen clinician scientist program

  8. What happen if I am unsuccessful in obtaining entry into, or do not wish to apply for a
     Residency Programme?
   Unsuccessful applicants will either be offered a House Officer position (for medical graduands) or a
     service Medical Officer position.

  9. It is perceivably easier to get a residency slot in M5 compared to being a HO/MO (competing
     with everyone else, including international graduates). Could more be done to assure students
     that they will not be at a disadvantage if they do not apply in M5 but only do so in their post-
     graduate years?

     Entry to residency training will always be a competitive process, be it at M5 level or the HO/MO level
     However, expectations are higher for those who are applying at the MO/HO levels as they would have
      been exposed to more clinical experiences and presumably acquired more clinical skills.

  10. If there are such a small number of Residency places available, would a Doctor be at a
      disadvantage if he/ she delays making a decision?

     When many doctors delay their decision-making far too long such that when they become Medical
      Officers, they see their peers ahead of them and feel discouraged, they end up not specializing
     However, sometimes it may be wise to take a step back or apply for a TY, in order to make a wiser
      decision at the end of the day

PROGRAMME



                                                                                                               22
     1. What is a Transitional Year?

        The Transitional Year (TY) Programme is designed to fulfill the education needs of graduands who
         desire a well-balanced, broad-based year in multiple disciplines and within the structured
         framework of the residency system.
        There are 2 types of TY.
            o    Categorical TY is followed by a specific Residency Programme. This categorical TY serves to
                 broaden clinician (scientist)’s field of knowledge/ foundation before specializing.
            o    Generic TY is not followed by a specific Residency Programme. Therefore, residents must
                 still apply for a residency at the end of the TY.

     2. What are the differences between Transitional Year and Housemanship?

        Unlike Housemanship where Houseman gets to rotate through different Sis, TY trainees will be
         subjected to the same structured training and formative assessments that full-fledged resident
         trainees receive, within the same SI
        Trainees have greater control over postings in generic TY and are likely to get offers from their SIs to
         advance to a specific Residency Programme
        In similarity, both houseman and TY trainees would have didactic lectures for learning

     3. When will Residency begin? How long will my Residency Programme last?

        For local YLLSOM medical graduands, first year residency begins in May
        For graduands of other schools, the start date is variable to cater to different graduation timelines
         which will last a minimum of 12 months
        Thereafter, the regular residency cycle commences in July of every year
        Generally 5-7 years of residency and fellowship training is required before specialist accreditation

     4. How will assessments be carried out? At the end of training, how will I exit as a specialist?

        There will be regular competency-based assessments to measure both theory and practical skills
         attained by residents. This will enable residents to realize their strengths and also highlight areas of
         weakness.
        Accreditation to practice as a specialist in Singapore is wholly governed by the Specialists
         Accreditation Board (SAB) which will recognize local training programmes and existing intermediate
         and exit examinations. Exiting will depend on the criteria and assessment as specified by SAB

     5. After I graduate from a residency, will I be an associate consultant?

        No. Currently this is not the case. Assignment of job titles is not dependent on the amount of training
         and number of post-grad degrees you have in your basket, but on your 1) performance and 2)
         availability of empty positions.
        This is how the system has been working for a very long time, and is unlikely to change even with
         residency. Remember that residency is a traineeship, not a ship that carries you to consultancy.
        However, for less competitive specialties such as family medicine, it is correspondingly easier to
         become a consultant, since positions are usually available.

     6. How will switch between clusters and/or specialties be managed in the unlikely event that a
        resident needs to make a swop for unforeseen reason(s) and who will be involved?

        To switch residency, you must resign from your current one and reapply for residency. There will be
         a one year penalty imposed, in this time you may not reapply for residency in the year after you
         resign from your current residency.



23
  7. MOs have to start from Year 1 in the residency program when they apply this year. Can they be
     allowed to skip/accelerate parts of the training?

     Residents typically expected to start from R1. However, some candidates might have considerable
      relevant experience at point of entry (e.g. senior MOs, especially if they have already passed
      intermediate exams).
     For such residents, the residency system provides for early progression to R2 after 3-4 months of
      observation at R1. This will be done based on departmental assessment of a resident’s capabilities,
      and in accordance with RAC and SAB guidelines.

  8. What would happen to males who have to re-enlist to serve the remainder of their National
     Service? What are the allowances for National Service?

     They may undergo a period of Residency training prior to their enlistment
     Generally, re-enlistment occurs at the end of postgraduate year 2 (PGY2), which would be at the end
      of R1 or R2
     At the end of the National Service period, one may resume where training left off but a certain period
      of remediation may be required by some programmes before trainee joins a higher residency year
     NS takes priority as the SAF has medical needs that need to be met for its soldiers and training is 2 nd
      priority to NS as was the case with BST/AST
     There will continue to be a pay increment for ORD-ed MOs to compensate for lost increments during
      NS years.
     There is no pay differential for HOs who ORD-ed prior to entering medical school as HO pay is a
      training allowance and is fixed.

  9. What happen if I go on long leave during the residency year, (e.g. maternity leave), does it
     mean that I will have to repeat the whole year?

     Depending on your period of absence, the specialty you are in and the point at which you left
      residency training, you may enter where you left off
     If the period of absence exceeds a certain number of days, you may be expected to make up for the
      missing days of training or repeat a posting

  10. I heard instances when my seniors exceed the 80 hours work week. Why?

     The 80 hours work week/ 6 calls a month is a cap
     Extended hours once a while should be understandable and residents can approach MOH about their
      situation if necessary



CAREER PROGRESSION
  1. ACGME (I) is not recognized in the USA. For this reason, many will eventually still have to take
     Royal College Exams. Is ACGME recognized outside of Singapore?

     No, it is not. In short, this is a one-of-its-kind thing from Singapore, and its main purpose is not to
      standardise training to send trainees overseas, but to help build and accredit Singapore’s Residency
      system.
     Accreditation Council for Graduate Medical Education (ACGME) evaluates and accredits medical
      residency programs in the United States.
     MOH has invited ACGME to assist us in the drive to improve the graduate medical education in
      Singapore. The collaboration between ACGME and MOH is known as ACGME-International (ACGME-



                                                                                                                 24
            I), and it is the first of its kind. ACGME-I will develop a set of standards for Singapore in the areas of
            curriculum development, assessment and teaching methods, data collection systems, professional
            development and training for program directors and program coordinators.

        2. What are the opportunities for graduates intending to pursue a research scientist or a
           clinician-scientist career tracks?

           Programmes with clinician scientist tracks will have at least a year of research built into the curricula
            of advanced residency years.
           The entry requirements of such programmes will be similar to their corresponding default Residency
            Programmes.
           Applicants however, can choose up to 3 programmes if any of their choices are clinician scientist
            tracks, and up to 2 programmes if otherwise.
           Clinician scientist residents will be provided with close mentoship from a clinician scientist mentor
            and will be expected to complete at least a Masters in Clinical Investigation or equivalent, and publish
            as first author in a reputable journal

        3. Will residents completing their basic residency programs be able to immediately pursue an
           overseas fellowship program? Will such fellowship programs be considered as relevant
           training for subsequent appointment as an associate consultant and registration by the
           Specialist Accreditation Board?

           MOHH is working with ACGME to roll out Internal Medicine specialties by 2013 so that residents
            completing IM training can progress to further training immediately after completion of their IM
            residency

        4. Is it possible to give HO/MO the same teaching and dedication as residents? If not, what can be
           done to ensure fairness in career progression for non-residents?

           MOH is currently working with the different Sis to substantially increase the number of TY positions
            available starting 2012. However, graduands may still become HOs if they wish.
           It is hoped that with working experience, whether as a houseman or as a TY resident, you may have
            sufficient insight to make a decision
           If you choose not to join residency training after housemanship or TY, the system still allows you to
            join residency at any given training year
           The goal is for the system to eventually be able to offer residency positions for all who are ready to
            start training, however, entry into a training programme is a competitive process and the hard truth
            is that not everyone may be accepted in their desired programme or SI, and they may need to re-
            consider alternative programmes or career paths


     OTHER ISSUES
        1. Is there are any preferential quota set aside for the Duke students?

           No, there isn’t. At least officially.

        2. Is there a difference in treatment between Duke and YLLSoM students?

           There will not be any difference in pay for Duke-NUS GMS or YLLSoM residents because both will be
            doing the same level of work. The first post-grad year remains a licensing year for both.
           Beyond residency, Duke-NUS GMS graduates may progress faster in their careers on the basis of their
            prior academic qualifications, but that will depend on the specific paths they take. For instance, some
            Duke-NUS GMS students already have PhDs, which could be an advantage in academic medicine.



25
       Ultimately, it’s still an issue of an individual’s competence and presentation, it has nothing to do with
        whether they are from the GMS or YLLSOM.

    3. How much are residents paid? Is it different from the HOs?

       Allowance for some specialties may differ:
       Additional training allowance is given for those pursuing less popular specialties such as Pathology.
       Conversely, popular specialties such as Ophthalmology require co-payment for training.


SOURCES:

       1st Residency Focus Group meeting with Prof Satku,
       2nd Residency Focus Group meeting with Prof Satku,
       3rd Residency Focus Group meeting with Prof Satku
       Singhealth Residency FAQ,
        http://www.singhealth.com.sg/EDUCATIONANDTRAINING/RESIDENCY/FAQS/Pages/Home.aspx
       MOHH Residency website FAQ, http://www.physician.mohh.com.sg/residency/faq.html
       Pulse Residency Article, ‘Hard & Heart truths about Post-Graduate Medical Eduation: The Residency
        Programme’

CONCLUSION
While Residency may have some imperfections with several things still vague or unclear to us in its
primordial stages, it does seek to enhance our graduate medical education and equip us with better skills to
meet the challenges of being future doctors.

As students who will quickly progress to the stage where choices are to be made with respect to our future
careers, we should try to continually gain exposure in the fields where our interests and passions lie but at
the same time, never stop having an open mind towards the different specialties available. Not all of us will be
matched to our first choices, but as long as we constantly remind ourselves that our central goal should be to
help our patients as best as we can, I believe all of us will eventually still attain the same kind of satisfaction
no matter which field we end up in.




                                                                                                                      26
                            ACKNOWLEDGEMENTS
     Personal review (from The Old VS. The New): Singapore M.D. Blog
     http://singaporemd.blogspot.com/

     SingHealth Residency FAQ Webpage
     http://www.singhealth.com.sg/EDUCATIONANDTRAINING/RESIDENCY/FAQS/Pages/Home.aspx

     Editorial team
     Chief Editors                              Liu Xuandao
                                                Valencia Foo
     Design                                     Jacqueline Quek
     Research and writing
          Applications                         Chua Min Jia, Margaret Teng
          The Match                            Valencia Foo, Rebecca Hoe, Liu Xuandao
          Programme                            Jacqueline Quek
          FAQ                                  Wang Daobo, Adita Sangam
     With advice from                           Manpower Standards and Development Division, MOH




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