Last year, my first boss in MOH HQ, Dr Wong Kum Leng, passed away. I consider myself his apprentice, even though I never asked him if he felt likewise. Maybe some things are best left unspoken.

I became a Medical Officer (Trainee) [MO(T)] , in Public Health about 28 years ago. My first posting as MO(T) was to work in the newly set-up Traditional Chinese Medicine (TCM) Department. In addition to being the Director of TCM, Dr Wong Kum Leng was also a Deputy Director of Medical Services (DDMS). Almost all aspects of health regulation came under him, as the statutory board Health Science Authority (HSA) had not been set up yet then.

So, in addition to helping to set up the regulatory framework for TCM, I also learnt a lot about other aspects of health regulation. But in addition to acquiring knowledge, I also learnt how to think (and argue) from him. He had an incisive mind and a sharp tongue and could get to the bottom of things really quickly. He was a tough taskmaster but I enjoyed the two years working for him, discussing work matters, shadowing him in meetings and taking a lot of minutes of meetings. It was over these discussions and arguments that I learnt how to think.

The power distance between us diminished over the years as I matured as a doctor. I had many other masters who taught me much as a MO(T) in Public Health.

Looking back on my Public Health training, I realised I had undergone many apprenticeships with masters but little supervised training in Public Health as a MO(T). This is because I only had one direct boss who was a Consultant or specialist in Public Health. The rest included a plastic surgeon (the aforesaid Dr Wong), an ophthalmologist, an orthopaedic surgeon, a respiratory physician, a doctor who wasn’t a specialist, and two lay administrators before I exited.

If we go by today’s residency standards, the above list of supervisors would not withstand scrutiny that I had undergone structured and supervised training by specialists in the discipline that I was training for.

Which brings us to the issue of apprenticeship and residency. Today’s residency focuses on providing structured and supervised training to our residents with the aim of producing specialists that are competent in a predetermined list of knowledge and skills. These knowledge and skills are carefully curated in a list of Entrustable Professional Activities (EPAs) which a resident must achieve (to a minimum of “Level 4” competency in many specialties) before exiting as a specialist. Learning does not stop when one becomes a specialist but continues after that (i.e. Level 5).

These EPAs are described in a detailed document that is dozens of pages long that is called Specialist Training Requirements (STR). Each specialty and subspecialty training will have their own STR document which is revised periodically. In the STR contains a lexicon of terms and acronyms which will be bewildering to the uninitiated (e.g. myself, as I had left the public sector for 15 years before becoming Master-Elect last year). These include terms and acronyms such as JCC, PEC, RAC, JAC, STC, CEX, P-MEX, CbD, DOPS, EbD, MSF, DIO, ADIO, PD just to name a few… I won’t go into details here.

In addition to the list of EPAs which are described in detail, there are sections on Core Competencies, Sub-competencies, Milestones and Core Curriculum which describe in detail what the residents are expected to acquire or achieve.

What about the concept of “Apprenticeship”? I did a check on several STR Word documents that I was given on whether the concept of apprenticeship was considered in the current residency system. It is very easy to do so now; just click on the “Edit” tab and then locate the “Find” tab of Microsoft Word and look for “apprentice” and “apprenticeship”.

None of the STR documents I checked had these two words. It is as if the concept of “apprenticeship” had been expunged from our current residency system. On the other hand, “training” appears a multitude of times in all the STRs I perused.

The history of medical education is one that was originally founded on apprenticeship and professional guilds. The AMS can be considered a guild. As the practice of medicine became more complex and institutionalized in hospitals, medical education also had to move with the times and to medical schools which later were incorporated into universities.

But even as medical schools became the norm for basic medical education, apprenticeship remains an important aspect of postgraduate medical education. This is because medicine is an art and a science; and there are many who still believe that the art of medicine is best learnt by apprenticeship.

It was perhaps with this in mind that the founding members of AMS decided to name the top post in AMS as “Master” and not “President” or “Chairman” etc. Because with the idea of “Master” comes the notion of “apprentice” and “apprenticeship”. Likewise, behind every trainee is a trainer or trainers. But if you are a “resident”, one is hard put to pin down what we should call the other party to accurately describe the relationship (if any) between these two parties.

For the avoidance of doubt, I am not saying that apprenticeship is superior to the current residency system of structured and supervised training and examination with a well-catalogued list of deliverables. But there are some strengths of apprenticeship that should and could be retained in our residency system.

Firstly, there is the concept of learning by modelling. We learn from role models and by modelling our professional behaviour after these masters. This is probably the main avenue for learning the art of medicine for many of us. Modelling is evident in a master-apprentice setup.

Secondly, there is mentoring between a master and an apprentice; the master mentors those placed under his charge, often long after the apprentice has completed his apprenticeship.

Thirdly, if your apprenticeship is part of a professional guild, there is the larger network of professional relationships that comes with being part of a guild, including the relationships that bind one generation of guild members to other generations of guild members. These relationships are built on shared values, shared ethical frameworks as well as professional expectations that are found in apprenticeships and guilds.

With more than 1500 residents in-flight in our Public Health Institutions (PHIs) at any one time, there is a need for structure and systems. The old days where anyone knew everyone in the specialty (even for a small specialty like mine) are over. One of the weaknesses of the apprenticeship model often quoted is that it is inconsistent, opportunistic and dependent on the one-to-one relationship, and therefore cannot be relied to produce larger numbers of specialists who meet the minimum standards required. There is some truth in this.

But we need not treat the two ideas as being mutually exclusive: One can be a resident and receive the benefits of residency training, while incorporating the strengths of an apprenticeship into the education and training experience.

I understand that there is already some emphasis on mentors and more recently on role modelling and coaching on the ground. These components should be formally recognised in the STR documents, if possible. (the word “mentoring” also cannot be found in the STRs I had checked with).

We should also note that residency is limited to providing training so as to achieve minimum competency to be a specialist in a particular specialty. Notably, mentorship in a master-apprentice relationship exists beyond residency in the context of lifelong learning as specialists progress in their careers.

We need to look no further than about two months ago, when a general surgeon who is also a Past Master of AMS celebrated his 80th birthday. More than a hundred doctors turned up for the occasion in a Teochew restaurant, many of whom are not even general surgeons. They were there to celebrate the man, and to show their gratitude to him, for not so much as imparting to them the knowledge and skills to perform what are today known as EPAs, but probably more for the values that they had learnt from him.

Many who were present have gone on to mentor another generation of doctors, imparting not just skills but values, teaching not only the science but the art of medicine as well.

We need to continue this virtuous cycle of the master-apprentice relationship to complement our existing residency system.

I welcome feedback and suggestions as to how the AMS can facilitate this.