I recently had the opportunity to participate in a week’s observation with Associate Prof Thomas Loh, a head and neck surgeon with a special interest in nasopharyngeal carcinoma at the National University Hospital of Singapore (NUHS). What was striking from my experience was the difference in the healthcare system and the training system in Singapore compared to the UK.
In Singapore, healthcare is part privatised; patients pay a proportion of the fee for their consultation with the remainder subsidised by the Singapore government. Patients who prefer a more comfortable hospital stay may contribute more for a bed on a more comfortable ward (i.e. with air conditioning and fewer beds per bay). During my stay, I had the opportunity to interview an ENT trainee (Resident) Dr Ng and the NUHS’s ENT training programme director, Dr Ngo about ENT training in Singapore.
Wai Sum Cho with with Associate Prof Thomas Loh.
How do trainees enter ENT training after graduating from medical school?
Dr Ngo: There are currently three ENT programmes in Singapore, accredited by the Accreditation Council for Graduate Medical Education International LLC (ACGME-I). Graduate medical students can be pre-selected into the ENT residency programme where they initially enter a transitional year programme (similar to a house officer, foundation or internship year). They start ENT residency training at Post Graduate Year (PGY) 2, after completion of a transitional year programme. Undergraduate doctors who are PGY-2 and above, if selected into ENT residency, can enter the programme directly.
What is the selection process for ENT training?
Dr Ngo: Residency application occurs once per year. All applicants apply to Ministry of Health Holdings Pte Ltd (MOHH) via an online portal. The selection process is a two-step process. The first step is to assess suitability to enter residency and the next step is to match the applicant to a programme. To assess suitability, an interview is scheduled for all applicants using a multiple-mini interview format. The interview panel is made up of the three programme directors and a representative from the Resident Advisory Committee (ORL). The format is a series of mini-interviews each lasting 10 minutes to assess professionalism and communication competency skills relevant to residency training. The applicants are then shortlisted for the residency matching exercise, where applicants rank their preferred residency programmes and programme directors rank their preferred applicants respectively. The National University Health System (NUHS) ENT residency programme conducts a separate interview for the shortlisted applicants prior to the matching exercise.
How long is the training programme?
Dr Ngo: The shortest training period after graduating from medical school would be six years. The first year would be the transitional or internship year. The last five years make up the ENT programme proper.
What examinations are required?
Dr Ngo: All residents are required to pass an exam on basic surgical principles. The current exam is the Intercollegiate MRCS General Surgery or ENT. They then take a Masters of Medicine (Otolaryngology) exam conducted by the Postgraduate School of Medicine, National University of Singapore. The exam includes a dissertation on a topic, an OSCE exam and a viva exam. This is taken during the second year of ENT training. Residents are eligible to take the final exit exam in the final year of training. This exam consists of an MCQ paper and a viva voce conducted by the Academy of Medicine, Singapore. A pass confers accreditation in Singapore as a specialist in the field of otolaryngology.
Dr Ng: As we transition into the ACGME-I residency system, we retain much of the examinations from the former training system, which comprise UK Intercollegiate examinations and examinations administered by the National University of Singapore. For instance, I took the MRCS in my first year of residency, and the Master of Medicine (ENT), administrated by the National University of Singapore, in my second year of residency, these are summative examinations. In addition, there are yearly formative assessments via in-service examinations. ENT residents take the American Board of Otolaryngology In-service Examination (OTE). This is a gruelling examination comprising 300 MCQs answered in six hours. All first to fifth-year residents take the same paper. Each resident is benchmarked according to the year of training. Each candidate is informed of the percentile band achieved after the examination. It gives candidates and trainers an idea of where trainees stand relative to their peer group.
Tell me about the teaching programme for residents.
Dr Ngo: All residents have a compulsory two-hour national training session on Monday mornings. The training is mainly faculty led didactic lectures and resident led question and answer sessions. In the NUHS ENT residency programme, there is an educational session every day which includes case discussions, question and answers sessions, journal clubs, morbidity rounds, hospital wide rounds and sub-specialty board meetings. On average, each resident has at least 16 hours of teaching per month.
The National University Hospital of Singapore (NUHS).
What about training courses?
Dr Ngo: Surgical courses relevant to otolaryngology are conducted by our programme. They include soft tissue handling, temporal bone dissection, endoscopic sinus dissection, head and neck dissection and paediatric airway courses. There is a course requirement for all residents to complete, to progress in training. Each resident is given 12 days of training leave a year to participate in these courses.
Dr Ng: There are many courses available, including temporal bone, functional endoscopic sinus surgery, head and neck, basic sciences, allergy and other courses. Some include cadaveric dissection. They can cost from hundreds to thousands of Singapore dollars. Each trainee has a S$1500 a year Personal Training Fund from the Ministry of Health to subsidise these courses. In addition, the Ministry sponsors examinations and expenses for conferences. Simulation facilities vary between hospitals. We have a temporal bone drilling simulator and we are also processing a grant application to develop middle ear models.
How do residents get involved with research (PhD, MD)?
Dr Ngo: Residents in the NUHS ENT residency programme may get involved in research during their rotations or may choose to take an additional year for research. Our programme has a three month research rotation for all residents to participate in research when they are released from clinical duties. All residents are taught basic research methods and by the end of training are required to have produced a study suitable for publication. Residents keen to take a year for research can opt for the clinician scientist residency track. This extends residency training by one year, trainees pursuing this route gain a Masters of Clinical Investigation.
Dr Ng: The Clinician-Scientist (CS) residency track allows residents to pursue a higher degree at a local or international institution. The Ministry of Health Holdings sponsors the cost of the degree. The CS track is a longer programme and the resident can be away from clinical training for more than a year.
Singapore water fountain show.
Are applications for fellowships from overseas encouraged?
Dr Ngo: Currently, there are no formal ACGME-I accredited fellowships in otolaryngology in Singapore. Fellowships are offered by individual hospitals in Singapore. The current fellows primarily come from countries in the vicinity like Malaysia, Myanmar, Vietnam and Indonesia.
Where do those who complete their training work?
Dr Ngo: To date, all residents who complete training start work in restructured hospitals (government funded). This enables them to apply for government sponsored overseas fellowship programmes to obtain sub-specialty training in their area of interest. On completion of the two to three year employment bond associated with the sponsored fellowship training, some consultants may then choose to work in the private sector.
Acknowledgements: ENT Tzar – partial funding.
Interview conducted by Wai Sum Cho