MASTER'S MESSAGE (JAN-FEB 2014)

10 March 2014

Dear Fellow Academicians

I hope you have a good start in 2014.

Today you would have received Call for Nomination for Elected Members to serve on the Academy Council (2014-2016).  Over the years, the Academy’s role has gradually been increasing, especially in areas of professional opinions and advocacy where our inputs and contributions are called upon to improve healthcare in Singapore.  I would like to encourage you to volunteer or nominate suitable academicians to serve the Academy and our specialist community.

In this message, I would like to seek your opinions and views on an important subject: Has Family Medicine become a specialty of medicine or is Family Medicine always a specialty of medicine?

On several occasions, I was asked by past and present Presidents of Hong Kong Academy of Medicine (HKAM) why our specially trained Family Medicine Physicians are not Fellows of our Academy.  Family Medicine is a specialty in Hong Kong, and the Hong Kong College of Family Physicians (HKCFP), with 408 Fellows on its registry, is one of the 15 specialty colleges of HKAM.   As a matter of fact, the President of HKAM, Dr Donald Li KT, is a Family Physician and Past President of HKCFP.  My simple explanation was our Family Medicine Physicians have its own independent college, the College of Family Physicians, Singapore (CFPS) which was established in 1971 (initially as the College of General Practitioners Singapore and later renamed as CFPS in 1993), 33 years before our Academy formed its own Colleges in 2004.

I learnt from our senior academicians that in late 1960s, General Practitioners (GPs) were invited to form a Chapter under the Academy.   At that time, GPs felt that they were different from specialists owing to the nature of their practice and also no additional training was required of them to practice “family” medicine.   As such, they elected to form their own College while doctors practising “specialty” medicine joined the Academy to be qualified as “Specialists”.  This “divide” between “family medicine” and “specialty medicine” continued through 1990s with the Specialists Accreditation Board (SAB) formed in 1998 and Family Physicians Accreditation Board (FPAB) established in 2011.  Despite this artificial divide, our Academy and CFPS have always enjoyed good professional relationship over the last 4 decades.

The advancement of Family Medicine the last 20-30 years have prompted many of us within the Academy to re-think whether Family Medicine has become or all along is a specialty of medicine.  With aging population, the role of Family Physicians has become even more important.  We need many more well trained doctors to provide better holistic, less fragmented and more integrated care at the community level.  If the provisions of such care by our Family Physicians are rock solid, the burden and strain on more specialized or acute hospital care would be markedly reduced, allowing specialists to provide more focused care and get our patients back to the community care earlier and faster.

The path to become Family Physicians has changed tremendously from the time I graduated many years ago.  My classmates and many others who left after serving their bond became General Practitioners (GPs) – the “Family” Physicians of that era.  But now GPs and Family Physicians are different.  Those doctors who wish to practice Family Medicine must undergo structured and comprehensive training.  In addition, to be registered as Family Physicians, the doctors have to obtain a relevant postgraduate academic qualification (e.g. Master of Medicine – Family Medicine) and have relevant number of years of post-housemanship experience.  To be Fellows of FCPS, further training and assessment are needed (vide infra).

Perhaps, it is timely for us to relook at Family Medicine with an open mind.  I have listed a few points below which I welcome your views:-

One of the challenges to consider Family Medicine as a specialty is how we define “specialties” and “specialists”.  Traditionally in Singapore and in many other parts of the world, specialists are doctors who have undergone structured training and assessment, and become competent in a “specialized, focused and/or narrower” area of medicine.  Since the field of Family Medicine is “very wide and general”, it might not be easy to change the mind set of our local medical community to accept Family Medicine as a specialty.  Actually, to concurrently learn and keep up-to-date in internal medicine (with 14 sub-specialties), general and specialized surgeries (e.g. Orthopedic and ENT surgeries), paediatric medicine, obstetrics & gynaecology, emergency medicine and other clinical medicine are much harder than concentrating and excelling in a specialty and/or sub-specialty.

Many of us might not be aware that Family Medicine has already been recognised as an important “specialty” of Medicine in Singapore as early as 1970s.  When we were medical students many years ago, we were posted to GP clinics to learn the arts and science of Family Medicine.  In 1987, Family Medicine was recognised as a distinct academic discipline in medicine and the Department of Social Medicine and Public Health was renamed as Department of Community, Occupational and Family Medicine (COFM) in NUS’ Faculty of Medicine.  From a two-week posting in 1990s, Family Medicine now requires an 8-week posting in 5 different rotations.  In 2009, a Division of Family Medicine was formed within the Department of Medicine of the Yong Loo Lin School of Medicine. 

Similarly formal postgraduate training in Family Medicine was initiated in 1988 when a Steering Committee on Family Medicine Training was formed by Ministry of Health Singapore (MOH), CFPS and Department of COFM.  The first Master of Medicine (Family Medicine) examination was held in 1993 by the School of Postgraduate Medical Studies (now Division of Graduate Medical Studies).  CFPS also conducted several postgraduate courses and examination.  For the last 20 years, Family Medicine training continued to be more structured, and in 2011, Family Medicine Residency Programme (ACGME-format) started in Singapore.  MOH and Singapore Medical Council (SMC) also recognised the importance of Family Medicine by establishing the FPAB in the same year.

In the last 2 to 3 decades, doctors who want to be specialists have to undergo structured training, in two stages (basic → advance training: BSTs → ASTs; now residents → senior residents) and over a period of time (as short as 5 years and as long as 7-8 years).  To be specialists in Internal Medicine, General Surgery, Emergency Medicine, Psychiatry and Preventive Medicine, the training is as short as 5 years.  If those who are good and lucky to commence their residency training in post-graduate year (PGY) 1, they could be specialists as early as PGY 6, five years after graduation.

As of now, to be considered trained in Family Medicine and registered with FPAB, doctors have to go through one year of transitional year (TY) training before entering into a 3-year Family Medicine Residency Programme.   For those who have completed these 4 years of training and obtained Master of Medicine (Family Medicine), they could enrol themselves into the Fellowship Programme conducted by CFPS since 2001.

This advance Family Medicine training programme is structured and comprehensive.  It includes not only clinical training modules, but also two other modules covering scholarly activities (learning research methodology and conduct research) and medical pedagogy.  Each of the three modules has its own formative and summative assessments which are as rigorous as many of our specialties’ assessment and exit examinations.

From the specialty training perspective, Family Medicine is a specialty, because the 4-year Family Medicine Residency Training is equivalent to BST/Junior Residency training (TY+ R1 to R3) while the two-year Fellowship Programme of CFPS is on par with AST/Senior Residency training (R4 and R5).

Despite having to undergo 6 years of basic and advanced structured training and assessment, our Family Medicine Physicians do not enjoy the same recognition as our Specialists going through similar duration of basic and advance training.  The table below shows the “shortest” path to become specialists in a number of specialties as compared to FM Physicians:

*CFPS Fellowship Programme could commence upon completion of FM residency training + passing relevant exam

(e.g. M Med - FM)

It is therefore not surprising to hear that many local medical students and junior doctors do not choose Family Medicine as their career of first choice.   I was told that about half of the applicants for the recent Family Medicine Residency Programme were international medical graduates and only one local male medical graduate applied.  If this trend continues, our overall healthcare could significantly be affected without more doctors choosing Family Medicine as their career.

I am certain that our Health Ministry will do their best to attract good medical students and junior doctors to be Family Physicians.  Academy can do our part in giving appropriate recognition to our Family Medicine Physicians by welcoming them to join our Academy, i.e. revisiting what our senior academicians have attempted to do four decades ago.

The Academy’s M&AA’s Article 7 (a) (i) stated that “Fellowship shall be open to qualified members of medical profession holding a primary qualification registrable with Singapore Medical Council who have successfully completed an advance specialty programme approved by the Academy for purposes of Fellowship admission…”

The Academy’s Constitution Committee and Council have examined the curriculum and assessment methods of the CFPS’s Fellowship Programme and approved it to be equivalent to an “Advance Specialty Programme”.  As such, the Council has proposed to form a “Chapter of Family Medicine Physicians” under the Academy with the following eligibility criteria for Fellowship application: Physicians who are FPAB-registered and have completed advance Family Medicine training.   As the advance training programme of CFPS only started in 2001, we could also consider inviting the pioneer group of Family Medicine Physicians, e.g. elected Fellows of FCPS based on credential, who have contributed significantly to the development of Family Medicine in Singapore to join the Academy’s Fellowship.

I welcome your views and opinions.  Please send them to master@ams.edu.sg.

Thank you.

Best wishes

Lim Shih Hui

Master 

Academy of Medicine, Singapore

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