Perspective
Pandemics and Their Impact on Medical Training:
Lessons From Singapore
Zhen Chang Liang, MBBS, MRCS, DipSpMed, PhD, MBA,
Shirley Beng Suat Ooi, MBBS, FRCSEd (A&E), MHPE, FAMS,
and Wilson Wang, MBBS, FRCS, DPhil
Abstract
The ongoing coronavirus disease 2019
(COVID-19) crisis has hit Singapore hard.
As of February 25, 2020, Singapore had
the fourth highest number of confirmed
COVID-19 infections outside of China,
only trailing behind South Korea, Italy,
and Japan. This has had reverberating
effects on Singapore’s health care
system, and has, consequently, also
affected medical education all the
way from the undergraduate to the
postgraduate level. While efforts are
underway to contain disease spread and
T he turn of this decade has seen
China, and increasingly the world, being
inundated by the emergence of the
coronavirus disease 2019 (COVID-19)
crisis. The first cases of COVID-19
infection were reported in late December
2019 as a cluster outbreak in Wuhan,
China, in patients linked to a seafood
wholesale wet market.1 Since then, it
has spread to involve countries across
multiple continents—all in the space of
2 months. Infectious disease pandemics
respect no boundaries and have rippling
effects, which reverberate throughout
global health care systems. COVID-19
is not the first, and will certainly not
be the last, global health emergency
that we will encounter in our careers
as health care professionals. In the past
Please see the end of this article for information
about the authors.
Correspondence should be addressed to Zhen Chang
Liang, Department of Orthopaedic Surgery, NUHS
Tower Block, Level 11, 1E Kent Ridge Rd., Singapore
119228; email: zhen_chang_liang@nuhs.edu.sg.
The authors have informed the journal that they
agree that both Shirley Beng Suat Ooi and Wilson
Wang completed the intellectual and other work
typical of the senior author.
Acad Med. XXXX;XX:00–00.
First published online
doi: 10.1097/ACM.0000000000003441
Copyright © 2020 by the Association of American
Medical Colleges
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Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
transmission, the authors believe that
this is an opportune time to examine
and reflect on the impact that medical
crises like COVID-19 can have on
medical training and education and to
evaluate “business continuity plans” to
ensure quality medical education even
in the face of constant disruptions from
pandemic outbreaks. Medical training
is as important a mandate as patient
care and service. The authors believe
that even in trying times like this, rich
and precious lessons can be sought and
2 decades alone, we have witnessed
a deluge of emerging infections, for
example, the Severe Acute Respiratory
Syndrome (SARS; 2003), the H1N1
swine flu (2009), and more recently the
Ebola outbreaks (2016). These outbreaks
will only become more commonplace
given increasing urbanization rates, the
widespread accessibility of air travel,
and worsening climate change.2 Hospital
resources will be stretched in efforts to
manage and contain these outbreaks.
This may result in medical training
taking a back seat, as critical resources
are channeled toward frontline efforts to
combat outbreaks. Medical education is
just as important a mandate as patient
care and service. Given this and the
increasing occurrence of viral outbreaks,
contingencies should be in place, ready
to be activated to minimize disruptions
to medical training. We believe that
this is a timely opportunity for medical
educators to examine and reflect on the
impact that medical crises can have on
medical training and education and to
evaluate their “business continuity plans”
to ensure quality medical education even
in the face of constant disruptions from
pandemic outbreaks.
How Have We Been Affected?
Singapore has been hard-hit by the
COVID-19 outbreak. As of February
taught, which will immensely benefit
medical students and residents—the
health care leaders of tomorrow. In this
Perspective, the authors discuss the
various ways in which the COVID-19
crisis has affected medical instruction in
Singapore and explore pertinent practical
and creative solutions for the continuity
of medical training in these trying times,
drawing on their previous experience
with the Severe Acute Respiratory
Syndrome outbreak in 2003 as well as
the current ongoing COVID-19 crisis.
25, 2020, Singapore had the fourth
highest number of confirmed COVID-19
infections outside of China, only trailing
behind South Korea, Italy, and Japan.3
With the escalation of Singapore’s alert
status in response to early community
spread of COVID-19, there have been
reverberating effects on Singapore’s
health care system. Consequently,
medical instruction all the way from
undergraduate to postgraduate training
has been invariably affected. Clinical
rotations for undergraduates have been
suspended immediately; interhospital
residency rotations and combined
teaching sessions have also been ceased
until further notice. Nonurgent elective
surgeries and clinic consultations
have been postponed or canceled to
prevent hospital overcrowding, protect
vulnerable patient populations, and free
up hospital beds. In this, procedural
specialties are perhaps the most adversely
affected. For residents in surgical
and other specialties heavily skewed
toward elective and nonemergency
work, this will inevitably affect their
hands-on surgical experience and case
logs, significantly disrupting residency
training. Considerations of whether the
fulfillment of entrustable professional
activity targets in clinical training can be
met in this situation of reduced clinical
exposure present both educational and
professional conundrums. The situation
1
 Perspective
is compounded by the tremendous
amount of uncertainty surrounding
such viral outbreaks. No one is the wiser
as to when an outbreak will abate. To
suspend training indefinitely would be
unnecessary and impractical. Medical
educators will need to innovate and
think out of the box to maintain quality
medical education amid this current
COVID-19 pandemic.
What We Can Do as Medical
Educators
Crises like this are opportunities
for medical educators to leverage
technology for both undergraduate
and postgraduate medical education.
While newer initiatives such as
webcasts are increasingly being
adopted, in-person didactic lectures
and tutorials still remain a significant
cornerstone of medical education.
Given the highly infectious nature of
COVID-19, and likewise most emerging
infections, face-to-face interactions
in large-group settings (such as
lectures) can potentially be hotbeds
for disease spread and transmission.
To circumvent this, technology, for
example, videoconferencing4 and
e-learning platforms,5 can be used to
deliver lectures or tutorials remotely
via handheld devices and laptops.
Faculty, residents, and medical students
can then log in at designated times for
discussions, which can be facilitated
in real time via teleconferencing
applications. In addition to lectures,
teleconferencing can also be used
to demonstrate medical procedures
and surgical techniques.4 Centralized
teaching will, thus, still be able to
continue even with the cessation of
in-person lectures and interhospital
movement. Lastly, residents and medical
students should be encouraged to
use online resources to facilitate their
individual learning. In particular, for
procedural specialty residencies, remote
instruction via instructional videos or
online webinars can be integrated into
training programs. Faculty can follow-
on with online discussions to further
help residents consolidate their learning.
Courses emphasizing skills in open
communication, medical ethics, and
even clinical research or statistics can
also be organized via online modalities
for medical students or residents to
enable them to develop into more
holistic medical professionals.
2 Academic Medicine, Vol. XX, No. X / XX XXXX
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Medical education cannot only be
about the imparting of domain-specific
knowledge and skills. A highly skilled
surgeon or knowledgeable physician
does not necessarily make a good
doctor. In addition to domain-specific
knowledge, holistic noncognitive
attributes such as teamwork, empathy,
courage, and compassion are important
qualities that should be inculcated in
every medical student and resident in
training. The involvement of medical
students and residents in crisis relief
work can help achieve this. In 2003,
during the height of the SARS outbreak
in Singapore, medical students were
called upon to help with temperature
screenings. With the COVID-19 crisis,
residents across medical and surgical
specialties have been rostered for shifts
on the frontline, where they have
assisted (and are still assisting) with
the screening of suspected cases in the
emergency department. Besides easing
the manpower crunch, this has helped
foster camaraderie amongst residents as a
medical community, galvanizing them to
combat this pandemic on a united front.
Through this, residents have been taught
important lessons in courage, empathy,
and teamwork. It has also provided the
opportunity for specialty residents to
revise their general medical skills, which
can sometimes be forgotten after years
of highly specialized training.6 This can
only bode well for their development as
holistic medical professionals.
In addition, pandemics provide an avenue
through which to inculcate and further
hone residents’ skill sets pertaining to
systems-based practice, organization,
and leadership. For example, our
emergency medicine residents have been
intimately involved in the designing
of practical workflows for managing
patients presenting with respiratory or
fever symptoms during the COVID-19
outbreak. Important lessons in the
rational management of limited resources
that are in high demand have also been
taught, with residents having been given
real-life lessons on the optimization
of limited resources, for example, the
allocation of limited isolation facilities
against the ever-increasing number
of febrile patients. These learning
opportunities can be hard to come by
in training. For medical students and
residents to fully benefit from these rich
and precious lessons, medical educators
should incorporate reflective practice
into their medical teaching to encourage
deeper introspection.7
Furthermore, pandemic crises are
extremely fluid; plans change by the day
(or even by the hour) and situations can
exacerbate acutely overnight. These can
be lessons in versatility, adaptation, and
leadership as residents learn to adapt
to ever-changing plans as the situation
evolves. These skill sets are important
attributes for the future, which medical
students and residents will need to master
as they develop into the health care
leaders of tomorrow.
Conclusions
Medical crises like the COVID-19
outbreak will undeniably affect medical
training. However, contingencies
should be undertaken to minimize
disruptions. Technology can be harnessed
to facilitate medical instruction and
courses emphasizing skills such as
open communication and medical
ethics. Beyond domain knowledge,
the involvement of medical students
and residents in pandemic efforts can
be beneficial for their development of
holistic noncognitive attributes such as
leadership and adaptability. As medical
educators, we can and must rise up to the
challenge of continuing to teach even in
times of crisis. The time is now.
Funding/Support: None reported.
Other disclosures: None reported.
Ethical approval: Reported as not applicable.
W. Wang is senior consultant and associate
professor, Department of Orthopaedic Surgery, Yong
Loo Lin School of Medicine, National University of
Singapore, Singapore; ORCID: http://orcid.org/0000-
0003-3803-9392.
Z.C. Liang is a resident, Department of Orthopaedic
Surgery, Yong Loo Lin School of Medicine, National
University of Singapore, Singapore; ORCID: http://
orcid.org/0000-0001-7046-8918.
S.B.S. Ooi is senior consultant, Emergency Medicine
Department, National University Hospital, National
University Health System, associate professor,
Department of Surgery, Yong Loo Lin School of
Medicine, National University of Singapore, and
designated institutional official, National University
Health System Residency Programme, Singapore;
ORCID: http://orcid.org/0000-0002-8661-7225.
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