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Transition from Existing Systems to Competency-Based Medical Education (CBME) Anchored on Entrustable Professional Activities (EPAs): The Singapore Experience [Part 1]

By: Mabel Yap, Kantharaj Reddy and Cedric Poh

Singapore’s Graduate Medical Education System

Singapore’s Graduate Medical Education (GME) system was primarily influenced by the United Kingdom (UK) system, which was then characterised by time-based apprenticeship and summative assessments. Specialist training was broadly categorised into two stages – basic and advanced.1,2 In 2010, with the assistance of the Accreditation Council for Graduate Medical Education International (ACGME-I)3, we began the move towards competency-based medical education by introducing a structured system that included regular formative assessments throughout training, and the accreditation of training providers. Since then, 34 out of 46 medical disciplines recognised by the Specialists Accreditation Board and the Family Physicians Accreditation Board have set up programmes under the structured ‘residency’ framework while the remaining 12 continued with the traditional basic/advanced/seamless training framework.

Transition to Competency-Based Medicine Education (CBME) Anchored on EPAs: 2020s

Despite the benefits of the ACGME-I training system, the need for local contextualisation, especially for training and assessments standards, became increasingly apparent over the years. The Ministry of Health, Singapore (MOH) then decided to develop a Singapore framework for specialist training standards known as the Accreditation of Postgraduate Medical Education, Singapore (APMES).

Under APMES, key structures that worked well for Singapore, for example the accreditation of training providers, have been retained. Specialties have been additionally required to articulate the learning outcomes contextualised to Singapore’s needs, by defining their Entrustable Professional Activities (EPAs). The use of EPAs anchors Competency-Based Medical Education (CBME), de-emphasises time-based criteria for completion of training and promotes greater learner-centredness, and defines the competencies attained and activities entrusted to newly registered specialists to support Singapore’s changing healthcare landscape and needs.

The ACGME Core Competency Framework has also been retained to define mid-level learning outcomes. Learners have to be proficient in multiple competencies to be able to perform an EPA at the desired entrustment level. Due to their complementary natures, we integrated both EPAs and Milestones into our curriculum. Specialties have been required to develop their competencies, sub-competencies and Milestones using the ACGME Core Competencies Framework, and map them against the EPAs to yield a competencies-EPAs matrix. For trainees not entrusted at the requisite levels for the EPAs by a specified stage of training, the matrix allows programmes to examine areas of weaknesses from the underlying competencies for further remediation.

Having a robust training system to ensure healthcare professionals possess the necessary competencies and capabilities to perform key tasks in the healthcare sector has been Singapore’s key strategy in manpower planning over the years. The CBME model contrasts with the traditional apprenticeship system, where the consistency of learning and development may be threatened during times of service pressure. In addition, the cancellation of several summative examinations during the COVID-19 pandemic catalysed the shift towards Workplace-based Assessments (WBA) anchored on EPAs. Hence, the pandemic further highlighted the benefit of adopting the EPA framework with WBAs in place to regularly track the trainees’ progress in performing the EPAs and acquiring the relevant competencies.

Such a transition requires a structured framework for change management to help stakeholders realise their objectives more effectively. In the next blog post, we share about how we adopted the ADKAR model as a lens to frame our change management initiatives over the years.

Admin note: Come back next week for Part 2!

ABOUT THE AUTHORS:
ADJUNCT ASSOCIATE PROFESSOR MABEL YAP IS DIRECTOR OF PROFESSIONAL TRAINING AND ASSESSMENT STANDARDS AT THE MINISTRY OF HEALTH SINGAPORE AS WELL AS ADJUNCT ASSOCIATE PROFESSOR AT NATIONAL UNIVERSITY HOSPITAL SYSTEM AND DUKE-NUS MEDICAL SCHOOL.
MR KANTHARAJ REDDY IS ASSISTANT DIRECTOR OF PROFESSIONAL TRAINING AND ASSESSMENT STANDARDS AT THE MINISTRY OF HEALTH SINGAPORE.
MR CEDRIC POH IS MANAGER OF PROFESSIONAL TRAINING AND ASSESSMENT STANDARDS AT THE MINISTRY OF HEALTH SINGAPORE.
MINISTRY OF HEALTH SINGAPORE

References

1.Chew CH, YC Chee. Postgraduate medical education and specialist training in SingaporeAnn Acad Med Singap. 2005;34(6):182C-189C.

2. Shanmugaratnam K. Distinguished Academician Lecture: Evolution of postgraduate medical education in Singapore- role of professional associations. Ann Acad Med Singap. 2005;34(11):678-683.

3. Samarasekera DD, S Ooi, SP Yeo, SC Hooi. Medical education in Singapore. Med Teach. 2015;37(8):707-713.

The views and opinions expressed in this post are those of the author(s) and do not necessarily reflect the official policy or position of The Royal College of Physicians and Surgeons of Canada. For more details on our site disclaimers, please see our ‘About’ page

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