Genesis: A medical school by Singaporeans for Singaporeans

The School is a special institution, made possible by one of Singapore’s first community-led philanthropic initiatives. Launched as the Straits Settlements and Federated Malay States Government Medical School in 1905, the School was the first institute of higher learning set up in Singapore. It came into being because of the vision of a group of local community and business leaders, who saw the need for a medical school to train local, native doctors to care for the community.

Led by businessman Mr Tan Jiak Kim, the group petitioned the British colonial government, which promised its support for staff salaries and maintenance if the sum of $71,000 could be raised by them. The group exceeded the target and raised $87,000 comfortably.

When the Straits and Federated Malay States Government Medical School opened its doors on 3 July 1905 for what was to be the historical beginning of medical education in Singapore, 16 young persons presented themselves for the full five-year course that would lead, on successful completion, to their qualification as medical practitioners and in the words of one of the recommendations of the Kynnersley Commission of 1902 on the system of English Education in Singapore, “supply the demand for Assistant Surgeons and General Practitioners among the native population and the poorer inhabitants”.¹

Left: Medical school at Sepoy Lines, Outram. Right: College of Medicine Building.

The young medical school’s first seven pioneering graduates were S.R. Krishnan, Ino Gnanapragasam, Chen Su Lan, M.W. Chill, E.W. de Cruz, J.S. Lee and W.S. Carnage.² As remembered 60 years later by the late Dr Chen Su Lan, one of the seven successful candidates who passed the final examination in Medicine, Surgery and Midwifery in the shortest prescribed time in 1910, “The Medical School was born without a flourish of trumpets.”³

In 1913, the School changed its name to King Edward VII Medical School, in recognition of an endowment by the King Edward VII Memorial Foundation and was later renamed to King Edward VII College of Medicine in 1921. The School then merged in 1949 with Raffles College, an institution for higher education in the arts and sciences, to form the University of Malaya—which morphed into the University of Singapore after separation from Malaysia in 1965. The University was renamed the National University of Singapore after it merged with Nanyang University in 1980. A name that has persisted into the new Millennium.

Over the course of 117 years, the NUS medical school—still fondly referred to by the moniker, NUS Medicine, by alumni—has educated and trained more than 12,000 men and women to become some of the best doctors, medical teachers and scientists in the world. And since 2005, we have also produced some of the most highly regarded nurses in the profession.

The work that NUS Medicine does has shaped the health and healthcare of Singapore. Its graduates have gone on to be leaders and decision-makers in many areas, improving the lives and welfare of millions. What the School does, matters. And it matters in ways big and small, in good times and especially in bad ones.

Nearly three years since a coronavirus ambushed an unsuspecting world, we are still not fully out of the COVID-19 woods. Like the rest of the world, the NUS Yong Loo Lin School of Medicine has had to adjust to the significant changes brought about by the pandemic. We have adapted, moved on, and thrived, revelling in the freedom to try new approaches, and leverage on technology, egged on by the restrictions on physical proximity. After some hitches in 2020, we resumed clinical training without compromising either the safety or the learning experience of our students.

Our academics have outdone themselves in research efforts while also contributing to national and international efforts on COVID-19. Taking advantage of new flexible work arrangements, our people have had the opportunity to rediscover and develop themselves with various online learning initiatives. Overall, the School has done well and improved our international standing despite the turbulence and headwinds of 2021, placed at 21^st place globally in the Quacquarelli Symonds 2021/2022 ranking of medical schools around the world, while the Times Higher Education ranking listed NUS Medicine at 17^th for 2022. This drive to live up to the values of the School, to serve with unstinting grace against the odds, traces its DNA to those who laid the foundations for the School. Some died doing just that, even before they could graduate.

Remembering the pioneers

On the grounds of the Singapore General Hospital stands a modest memorial to a group of medical and dental students who lost their lives to enemy fire in February 1942 during World War II. The events that led to their deaths is recounted in an absorbing article by a classmate, Dr Abdul Wahab.⁴ In any retelling of the history of the NUS medical school, the names of the 11 students who died should be remembered:

While the ultimate sacrifice of these students in service to their fellow men has thankfully not been repeated since that fateful day in 1942, the spirit of service that energised them lives on in NUS Medicine alumni, as well as staff and students of the School today.

First cohort of students in 1910 pioneer group standing behind teachers.

No pandemia here

It is seen for example in the creative approaches that were adopted to circumvent the interruptions to daily life brought about by the pandemic: student-hopefuls applying for a place were assessed differently. Where previously 1,000 candidates would put pen to paper at the University for their Situational Judgement Test, applicants in 2021 did this from the comfort of their homes—an online assessment, recorded for integrity, was held instead. The Focused Skills Assessment component of our admissions exercise, however, remained on-site. These tests, comprising role play, task-based components, group work, and interview stations, are vital to ensure students not only have an aptitude for medical studies but also hold values aligned with those of the School.

Our teaching staff too did not let teaching and learning come to a halt. Despite constraints such as a limited group size of five for bedside teaching—including patient, students, tutors, and other healthcare workers—and embargos on high-risk areas, students still benefited from the School’s creative pedagogy. For example, the School’s digital transformation journey progressed with even more cyber tools rolled out for our tech-savvy students.

The Department of Obstetrics and Gynaecology (O&G) and the Department of Anatomy—both of which celebrate centennials this year—have embedded virtual reality into their curriculum, adding to the suite of technologies and online learning platforms that had been introduced earlier. At the O&G Department, a simulated labour ward expands students’ clinical exposure beyond what they would otherwise receive in a six-week posting. Students are taken through a range of cases in the second and third stages of labour, via professionally animated videos on all blueprint topics and annotated surgical videos with commentaries. Each step is guided and every rationale explained, for common obstetric and gynaecological surgeries. Interactive presentations aid students as they take on the role of house officers, brainstorming patient management plans under various scenarios. Likewise, students learn about anatomy and physiology through 3D virtual learning technologies that even allow them to try their hands at virtual dissections, while instruction using cadaveric specimens provides critical understanding of the three-dimensional relationship of different anatomical structures and their variations.

Students using Hololens.

Examinations however, continued to be observed along national guidelines. They were held on campus, away from healthcare institutions. For theory assessments, additional measures included a maximum of 50 persons to an exam room, visual identity verification software, and staggered reporting times. For clinical examinations, supplementary measures comprised pre-event testing, staggered reporting, and cohorting. The use of real patients was re-instituted at certain stations.

In a feature article in the Singapore Medical Association, new house officers Dr Isaac Ng, Dr Valencia Zhang, Dr Tseng Fan Shuen, and Dr Desiree Tay described their final MBBS examinations as “a surreal experience”. Struggling to deal with the uncertainties thrown up by the pandemic, they were yet well prepared, noting, “In NUS Medicine, we are privileged to have access to comprehensive e-learning resources (as well as) virtual scenario-based clinical teaching.” They also shared that though batch-mates had significant worries, “We were extremely appreciative of the School’s efforts to provide regular updates through multiple online platforms … In addition, our clinical tutors held regular virtual townhalls to provide an avenue for students to voice their concerns.” The cohort has since passed a milestone. While the Commencement Ceremony for the Classes of 2020 and 2021 was first held virtually in July, Commencement for the Class of 2022 reverted to the traditional ceremony held on campus in July this year.

Translating biomedical findings to clinical practice

While the NUS medical school’s founding mission was to educate and train doctors for the community, the pivotal role of biomedical research has always formed the other raison d’etre for our work. Research at NUS Medicine focuses on finding solutions to diseases that afflict the Singaporean population, and aims to ultimately enhance people’s overall health and well-being.

With this in mind, the School reorganised its research structure into Translational Research Programmes (TRPs) in 2019 to promote interdisciplinary collaboration and cross-pollination of ideas. Strategically selected to meet the current and future healthcare needs of our population, our 10 TRPs focus on health matters relevant to Singapore, other Asian communities in the region, and beyond. Each of our TRPs is directed by a lead scientist and a clinical lead who manage the core funding for the programme to attract expertise and develop research facilities. With an interdisciplinary focus, our TRPs enhance collaboration and synergy to maximise limited resources. Research is also given the space to evolve to meet changing needs. Let me share a few key examples of our work.

NUS Medicine researchers are also working on identifying the multifaceted aspects of ageing to provide a more comprehensive understanding of the biology of ageing, and to add healthy years of life by delaying ageing, prolonging disease-free life, and increasing quality by allowing people to be more active and engaged. Take Alzheimer’s, which is a neurodegenerative disease manifesting as progressive memory loss. Ageing increases an individual’s susceptibility for this disease. It is usually seen among people above the age of 65. However, in certain cases, the disease can affect people in their 30s or 40s.

The main reason for this disease is the aggregation of malignant proteins like beta-amyloid in the brain. This detrimentally affects neurons and destroys memory. The hippocampus, a brain region crucial for the conversion of short-term memory into long-term memory, is one of the first affected regions during the early stages of the disease. When Alzheimer’s disease strikes, a person experiences a loss of neurons and the consolidation of memories is significantly impaired. Focusing on the hippocampus, our researchers discovered an aberrant function of micro-RNAs that impedes the conversion of short-term memory to long-term memory. Work is ongoing.

Another translational research effort sees an interdisciplinary group of researchers from the School’s basic science and clinical departments looking to characterise and develop interventions to maximise human potential for health and productivity. The influence of the groundbreaking work of Growing Up in Singapore Towards healthy Outcomes (GUSTO) researchers is well known and focuses on giving Singaporeans the best start to life. Another one of these is in the management of heat stress in tropical climates like Singapore’s.

Heat stress increases the risk of heat injury and accidents, interferes with work productivity, and can compromise decision-making. Long-term exposure to heat stress can also induce diseases such as chronic kidney disease of non-traditional causes even in healthy working adults. Our investigators are working with government representatives on updating guidelines on managing heat stress.

Given the limited evidence on occupational heat exposure, and the impact of age, physical fitness, and gender on well-being, health, and work productivity, improved knowledge is essential for the development of effective prevention programmes at and beyond the workplace. The investigator’s Project HeatSafe takes a multidisciplinary approach to understanding the complex threat that heat exposure poses on well-being and work productivity in the tropics. They also aim to identify sustainable, preventive policies and actions that can reduce the impact of heat stress on indoor and outdoor workers in chronically heat-exposed Singapore, Vietnam, and Cambodia so as to safeguard and heatproof workers in a warming world. The project will also examine the impact of heat on pregnancy and fertility, and on learning ability in children in tropical environments.

Going beyond the confines of traditional medical education

Even as our research efforts seek solutions to current healthcare challenges, the NUS medical school is also reviewing and re-examining the way we teach and prepare our students for future careers as healthcare professionals. Getting ready for the 21^st century entails acquiring a broader set of skills beyond technical competency.

The NUS medical undergraduate curriculum is a five-year course with two years of preclinical teaching and three years of clinical training. We provide many opportunities for self-exploration with a four-week elective period at the end of the third year and a 12-week elective period at the end of the fourth year. During these electives, undertaken locally or overseas, students can choose to explore personal interests in various aspects of healthcare, science, society, and humanity.

This comes as NUS declares the need to rethink higher education to produce graduates who are lifelong learners, who constantly add value to their work. We need to go beyond the traditional confines of medical education, which has tended to focus on preparing students for ‘sick care’ rather than healthcare, on understanding disease and treating it. Our focus needs to pivot to promoting population health and well-being, think beyond patients who are sick to those who are relatively well, and how we can help to make them remain healthy. To this end, we aim to produce a new breed of doctors who understand human potential in Medicine.

We have therefore taken several steps to address these gaps in the education of medical students. These include recruiting experts in family medicine to improve training in this area, conducting research into longevity and human potential, and offering courses in health economics and health systems. The School has also introduced five pillars of knowledge that are common across not just the school of medicine, but also the schools of dentistry, public health and pharmacy in NUS. These pillars are: social and behavioural determinants of health, professional practice and communications, teamwork, as well as data and digital literacy.

White Coat Ceremony 2022.

Finally, students also have the opportunity to do an MBBS with a difference. They may choose to take a gap year between Year 4 and 5 and spend a year working on a postgraduate degree e.g. a Master of Science in Bioinformatics or by Research, or a Master in Public Health. This means that students could graduate with both a Bachelor’s Degree in Medicine & Surgery as well as a postgraduate degree.

Students with Prof Chong at MedNurse RAG Performance 2022.

Conclusion

As we step out of the pandemic-induced darkness into the light once more, one of the most critical lessons the past two and a half years have brought home to us is that progress is meaningful when it embraces and involves many, and the benefits and mutual security that scientific and societal advances bring are enjoyed by everyone. As the NUS Yong Loo Lin School of Medicine looks forward to her 120th anniversary in 2025, it is also better prepared to face the challenges that will come her way. The School’s response to each and every major historical event has added to the legacy that we have inherited and which our generation must build upon. I am confident that like the early generations of medical graduates, the men and women of the NUS medical school today will continue the work of caring for the health and well-being of Singaporeans and do so, faithfully and magnificently.

This article first appeared in Century of Transformation, published by the Alumni Medical Association (Singapore).
This article is republished with permission.