Preparing medical students to lead change in healthcare

What’s one of the most important parts of a medical school?

According to Professor Scott Compton, associate dean and deputy head of the Office of Education at Duke-NUS Medical School, it’s developing competent clinicians who will lead changes in current healthcare systems — thus Duke-NUS’ approach of “Clinician First, Clinician Plus”.

For clinicians to be effective, there is no substitute for hands-on experience.

In most Doctor of Medicine (MD) and Bachelor of Medicine and Bachelor of Surgery (MBBS) courses offered throughout the world today, medical students spend the first two years of their education almost primarily focused on building up their scientific knowledge through lectures and textbooks.

But this approach of heavily front-loading the curriculum with textbook learning falls short when it comes to developing students’ – in particular, adult learners’ – problem-solving skills, he says.

Enter the Duke-NUS model, which implements the pre-clerkship curriculum through the school’s distinctive TeamLEAD approach – integrating the typical first two years of basic sciences into a single, intensive year. 

Critical thinking skills, vital leadership aptitudes and fundamental doctoring skills are also developed during this time through knowledge application activities, which prepares them for their clinical rotations in their second year.

“The Duke-NUS model recognises that in our current times, with our rapid rate of new knowledge development and ever-evolving healthcare challenges, the educational focus of physicians has to exceed merely building a static body of knowledge in students,” says Prof Compton.

Instead, the curriculum also has to include the development of students’ problem-solving capacities to be able to address new challenges, he continues.

Streamlining the first two years of basic sciences into one also allows for a Research and Scholarly development period to be integrated into the curriculum, during which students conduct an immersive, mentored scholarly activity – such as a clinical research project – in a problem area of their choosing in order to hone their problem-solving skills and to address authentic healthcare problems.

According to Prof Compton, students’ research involvement in particular is a key process in adult learning: letting students draw connections from previous experiences and promoting their participation as partners in the learning process.

The possibilities for what students may undertake are endless. For instance, fourth year Duke-NUS student Sivanesh Sivarajan conducted a statistical analysis of the outcomes associated with the treatment of stage 3 colon cancer, attempting to determine the optimal duration of chemotherapy for patients for the most effective treatment. 

On the flipside, third year student John Low drew upon his previous experiences in an infectious diseases lab to undertake the Herculean task of analysing Singapore’s hospitalised Covid-19 population and determining if there are changing patterns and trends as the pandemic evolves.

Venturing from working with cell culture and viruses to data analysis was a literal breath of fresh air to him. “I really wanted the experience of working with large data sets, and I was trying to see what other forms of research were out there,” Mr Low says.

“The research was a good gelling of two disciplines that I’m trying to work towards – emergency medicine and infectious diseases.”

While the framework of the Duke-NUS curriculum remains fundamentally consistent, the faculty continually refreshes and revises it to capitalise on its understanding of what works and what is needed.

For example, Duke-NUS has recently revised its students’ initial medical school experiences by challenging them to consider some of the more wicked challenges facing healthcare right off the bat, such as recognising and dealing with social dimensions of health issues, says Prof Compton.

In the first week of medical school, students now have the opportunity to hear from and ask questions of real patients, hearing their stories and understanding what it is like for them to live with chronic conditions in their communities. 

This also gives students an understanding of the resources available to the patients and the challenges that they face. 

The stage is thus set for later parts of the curriculum, during which students develop the skills and competencies to take into consideration the role of socioeconomic, environmental, cultural, and other population-level determinants of health in patient care.

Constant analysis and revision of the curriculum not only keeps it up-to-date with current trends in healthcare but also makes it responsive to crises and disruptions. 

For example, the Covid-19 pandemic made patient-facing time less accessible to Duke-NUS students, leaving second-year students unable to begin their clinical rotations.

The faculty took the decision to have those students go straight into their research year instead by delaying clinical rotations to their third year and allowing them to continue their education with minimal disruptions.

“At the time, there were two options on the table,” recalls Mr Sivarajan, who was one of the affected students. “We could have kept to the pre-existing schedule, but we would have lost a lot of clinical time. There was some doubt as to whether the restrictions would have been lifted in time to get enough patient-facing time to become confident doctors.

“But the faculty managed to execute the swap in a way that allowed us to acquire the clinical experience that we needed to graduate on time,” he continues. “That was the really impressive element.”

The magnitude of clinical training and patient exposure is such that, even while students are engaged in their research and scholarly activities, they continue to engage in a family medicine requirement, where students must spend at least 30 hours attached to a general practitioner, and another 30 hours in a polyclinic.

This allows students to not lose touch with their clinical skills and bedside manners, explains Mr Low. When he first started his family medicine posting, the physician instructed him to perform a respiratory exam, the procedure of which took him longer than expected to recall.

“I could see the gears running in my own head,” he says with a sheepish laugh. “The family medicine component made a lot of us realise that without practice, our clinical skills could deteriorate faster than we think they might.”

Such flexibility is further embodied by Duke-NUS’ “Clinician First, Clinician Plus” philosophy, which trains every Duke-NUS graduate to not be just a physician, but also one that tangibly improves and contributes towards the greater medical community. 

“As a junior doctor, you really rely on your seniors so much,” he says. “A lot of people are under the impression that medicine is a qualification, but really, it’s a tradecraft.

“It’s up to us to really carry on that knowledge.”

Mr Sivarajan, on the other hand, looks forward to embodying the clinician-innovator role by spearheading research into the field of geroscience – finding ways in which to improve length and quality of life, particularly in old age.

Application closes on Jan 31, 2023. Submit your application now at https://admissions.duke-nus.edu.sg/apply/