Digital competencies for Singapore’s national medical school curriculum: a qualitative study

ABSTRACT

Studies have shown that national-level initiatives to equip medical students with relevant digital competencies carry many benefits. Yet, few countries have outlined such competencies for clinical practice in the core medical school curriculum. This paper identifies current training gaps at the national level in digital competencies needed by students in the formal curricula of all three medical schools in Singapore from the perspectives of clinical educators and institutional leaders. It bears implications for countries that intend to implement standardized learning objectives for training in these digital competencies. Findings were drawn from in-depth interviews with 19 clinical educators and leaders of local medical schools. Participants were recruited using purposive sampling. Data were interpreted using qualitative thematic analysis. Thirteen of the participants were clinical educators while 6 were deans or vice deans of education from one of the three medical schools in Singapore. While the schools have introduced some relevant courses, they are not standardized nationally. Moreover, the school’s niche areas have not been leveraged upon for training in digital competencies. Participants across all schools acknowledged that more formal training is needed in digital health, data management, and applying the principles of digital technologies. Participants also noted that the healthcare needs of the population, patient safety, and safe procedures in the utilization of digital healthcare technologies should be prioritized when determining the competencies needed by students. Additionally, participants highlighted the need for stronger collaboration among medical schools, and for a stronger link between current curriculum and clinical practice. The findings highlighted the need for better collaboration among medical schools in the sharing of educational resources and expertise. Furthermore, stronger collaborations with professional bodies and the healthcare system should be established to ensure that the goals and outcomes of medical education and the healthcare system are aligned.

KEYWORDS:

• Technology
• medical education
• curriculum
• clinical competence
• Singapore

Introduction

The advent of digital technologies such as Artificial Intelligence (AI), Internet of Things (IoT) and Machine Learning (ML) have influenced healthcare delivery worldwide. In view of these digital transformations in healthcare, medical schools need to train their students in relevant digital competencies for them to succeed in clinical practice [1–5]. Such competencies would include skills in handling big data, understanding how they are being personalized in healthcare delivery through AI applications, utilizing AI and other digital technologies in a safe and ethical manner in clinical practice, knowing the limitations, pitfalls and benefits of these technologies for patient care, and communicating effectively with patients while using digital tools such as the electronic health records (EHRs), to name a few [2,6,7].

Studies have shown that national-level initiatives to equip medical students with relevant digital competencies would facilitate collaborations and exchange of knowledge across institutions [8,9], establish legal frameworks that promote training of medical students [1,10], enable systematic curriculum development, assessment, training and advocacy, as well as increase awareness of integrating digital concepts into the medical school curriculum [8,9], among other benefits. Yet, few countries have outlined national learning objectives and outcomes pertaining to digital technologies in the core curriculum. Although some developed countries have initiated such objectives, they are largely focused on specific digital technologies such as medical informatics [8,9,11], and digital health [12].

This paper contributes to the existing literature in two ways using Singapore as a case study. First, rather than assuming that certain digital competencies are relevant to medical students, it identifies the digital competencies that are deemed important for students through the perspectives of clinical educators and leaders of medical schools. It focuses on their opinions given their significant role in curriculum delivery and development, as well as high-level curriculum decision-making. Uncovering their views would enable an analysis of how the training of medical students in healthcare digitalization and the needs of the healthcare system can be more aligned. Second, by evaluating the curricula of medical schools with different focus areas and years of establishment, this paper fills the dearth in existing research by listing some considerations for countries with varying medical school curricula that plan to implement standardized learning objectives for the training of digital competencies among medical students.

Medical education in Singapore

With its current land size of about 710 square kilometres and a population of approximately 5.6 million people [13], Singapore is the smallest country in Southeast Asia. Nonetheless, its education system is highly recognized globally. For instance, its oldest medical school, the Yong Loo Lin School of Medicine (YLL) at National University of Singapore (NUS), is consistently ranked among the top 30 schools of the Quacquarelli Symonds (QS) World University Rankings, coming in 21^st in 2022 [14].

Medical education in Singapore is served by three medical schools. YLL, founded in 1905, and Lee Kong Chian School of Medicine (LKCMedicine) at Nanyang Technological University (NTU), established in 2013. Both offer a five-year undergraduate program in which students learn the foundation of basic medical sciences in the first two years (pre-clinical), followed by clinical clerkships from their third to fifth year of study. While YLL was formed to address the pressing healthcare needs of the local population during the colonial era, LKCMedicine was set up to address the surge in healthcare demands brought about by an ageing population [15]. To enhance Singapore’s capability in translational medicine, the Duke-NUS Medical School (Duke-NUS) was established in 2005 as a partnership between NUS and Duke University in the United States (US). Duke-NUS is a graduate medical school that offers a four-year MD Program, with the first year focusing on the basic sciences and the second year on clinical postings. Students spend their third year of study on developing research skills and their final year on clinical clerkships [16]. All medical schools in Singapore are publicly funded and the students’ tuition fees are subsidized by the government.

Although all three schools place an emphasis on developing innovative clinicians through involvement in research [16], their varying curricula approaches and niche focus areas make the standardization of digital competencies a potential challenge. To illustrate, LKCMedicine, with its model of team-based learning, emphasizes equipping students with skills in communication, team work and leadership [17]. In contrast, the curriculum of Duke-NUS, which is modelled after that at Duke University and adapted to local needs and learning environment, has a distinctive focus on research [18]. While YLL also aims to cultivate the spirit of inquiry and innovation in students, training in research skills does not necessarily form part of the compulsory curriculum [16].

There are clear gaps in the training of medical students in relevant digital competencies worldwide, including Singapore. For example, according to a global survey of young healthcare professionals under 40 from 15 countries including Singapore, close to 50% of the Singaporean doctors surveyed perceived that their medical education did not sufficiently equip them with the skills needed to optimize the data-related aspects of their role in healthcare delivery [19]. Additionally, digital competencies did not feature in the list of recommendations provided by the National Medical Undergraduate Curriculum Committee (Ministry of Health, MOH 2014). In-depth training in particular technologies often take the form of electives rather than part of the core curriculum [20]. Although there have been initiatives to train medical students in digital technologies, such as exposing them to Virtual Reality in the core curriculum of YLL, there is limited application of digital skills to clinical practice [20]. Furthermore, while the schools have introduced some training on digitalization of healthcare, they are not standardized nationally (Table 1). This paper thus explores several considerations that are needed to implement a national curriculum that focuses on training medical students in Singapore with relevant digital competencies for the digital age.

Table 1. Students’ exposure to digital technologies in medical school as reported by participants.

Medical School	Amount of Exposure to Digital Technologies in Formal Curriculum
NUS’s YLL	Brief exposure in Year 3 to informatics as part of clinical or population-based health research Brief exposure to Virtual Reality in core curriculum (varies between 1 and 2 hours per session for several sessions) Brief exposure to 3D technology in anatomy in the last few clinical postings
NTU’s LKCMedicine	Exposed to a core module on digital health covering its uses, limitations and ethical concerns
Duke-NUS	Taught broad concepts related to innovation and transformational change

Materials and methods

Sample and setting

The consolidated criteria for reporting qualitative research (COREQ) was followed in the reporting of this study (Table 2) [21]. Data was collected from October 2020 to April 2021 through semi-structured individual interviews with clinical educators, deans and vice deans of education of local medical schools. For maximum variation, purposive sampling was used to recruit clinical educators from Singapore’s three public healthcare organizations and medical leaders from the three medical schools. The inclusion criteria for participation included having at least five years of experience in clinical education or institutional leadership. Additionally, clinical educators included those who are engaged in teaching and who generally spend more than 20% of the working week in education-related matters such as bedside teaching, curriculum planning, education administration and research.

Table 2. COREQ checklist.

Topic	Item No.	Guide Questions/Description
Interviewer/facilitator	1	Humairah Zainal (HZ)
Credentials	2	HZ [Ph.D., Sociology], Xin Xiaohui (XXH) [M.Soc.Sci, Sociology], Julian Thumboo (JT) [MBBS, MMed (Internal Medicine), FAMS (Rheumatology), FRCP] and Fong Kok Yong (FKY) [MBBS, MMed (Internal Medicine), FAMS (Internal Medicine, Rheumatology), FRCP]
Occupation	3	HZ- Research Fellow, XXH- Senior Research Manager, JT- Senior Consultant, Rheumatology and Immunology, FKY- Senior Consultant, Rheumatology and Immunology
Gender	4	HZ- female, XXH- female, JT- male, FKY- male
Experience and training	5	HZ- Trained in qualitative research and methodology, educational background in Sociology. XXH- educational background in Sociology. JT- educational background in Medicine. FKY- educational background in Medicine
Relationship established	6	No
Participant knowledge of the interviewer	7	Participants were informed about the study by the Principal Investigator (P.I.), FKY, through email before being contacted by the researcher, HZ, with details about the study.
Interviewer characteristics	8	No other characteristics were reported by the interviewer.
Methodological orientation and Theory	9	Coding frameworks and themes were developed iteratively using Braun and Clarke’s (2006) six-step process.
Sampling	10	Purposive sampling and snowballing.
Method of approach	11	Via email and department heads.
Sample size	12	Nineteen participants.
Non-participation	13	Not applicable.
Setting of data collection	14	Eighteen over Zoom (due to the physical and social restrictions brought about by the COVID-19 pandemic), one in-person (upon participants’ request)
Presence of non- participants	15	None
Description of sample	16	More than 5 years of experience in organizational leadership or clinical education: 19
Interview guide	17	Refer to Table 3
Repeat interviews	18	None
Audio/visual recording	19	Zoom and audio recording
Field notes	20	Yes, made after interview to jot down fieldwork impressions
Duration	21	30–40 minutes
Data saturation	22	Yes
Transcripts returned	23	No
Number of data coders	24	Two
Description of the coding tree	25	Yes. Available upon request.
Derivation of themes	26	Inductive, derived from the data
Software	27	NVivo 12
Participant checking	28	No
Quotations presented	29	Yes
Data and findings consistent	30	Yes
Clarity of major themes	31	Yes. These include the types of digital competencies perceived as important for medical students in Singapore, as well as current barriers to the implementation of a national medical school curriculum that incorporates training of digital competencies for clinical practice.
Clarity of minor themes	32	Yes. These include current gaps in the core curriculum of each medical school in the training of digital competencies for clinical practice.

Source: Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care. 2007. Volume 19, Number 6: pp. 349–357

Table 3. Interview questions.

No.	Questions
1.	In general, what are the clinical skills that a medical doctor should have?
2a.	Which of these skills are still relevant in the digital age?
2b.	Are there any skills that have been replaced by digital technology, be it partially or completely?
3a.	What new skills, clinical or otherwise, should a doctor have today and in the future in order to practise medicine?
3b.	In your opinion, are our locally trained doctors well-equipped with these skills?
4a.	What clinical skills are currently being covered in the local medical schools?
4b.	Which of these skills should be emphasized more in the medical school curriculum?
5.	What other improvements can be made to our local medical school curriculum to better prepare the students for clinical practice in light of rapid advances of technology (for example, the advent of AI, big data, imaging, smartphone applications, and digital equipment such as handheld ultrasound)?
6.	How can local medical schools improve their collaborations with professional bodies and healthcare institutions to prepare medical students for clinical practice in this era of new technology?
7.	What can the healthcare system do to support medical students and young doctors in this era of new technology?
8.	Do you have any other comments on the digital transformations of medicine or healthcare before we end this interview?

We then adopted an iterative sampling approach where we recruited and interviewed three educators from each healthcare organization before conducting data analysis and more interviews to identify variants that were lacking in the current sample. This process continued until data saturation was reached. All 19 participants we invited via email accepted our invitation for an interview. Thirteen of them were clinical educators while 6 were deans and vice deans of education of one of the three medical schools. Eight of them were from Duke-NUS, 6 from YLL and 5 from LKCMedicine. Waiver for ethical approval was granted by SingHealth Centralised Institutional Review Board (Reference Number: 2020/2880).

Data collection

Acceptance of email invitations from all participants served as consent for participation. All interviews were conducted in English. Eighteen were conducted over Zoom whereas one was done in-person. Each interview lasted approximately 30 to 40 minutes. The interview questions sought participants’ views on the skills that doctors would need in the digital age, particularly for clinical practice, the current clinical skills taught in local medical schools, suggestions for curriculum improvement to better prepare students for clinical practice in the digital age, and stakeholders’ roles to better support postgraduate trainees when utilizing digital technologies in clinical care (Table 3).

The interviews were transcribed verbatim by a transcriber and the transcripts reviewed by HZ to ensure transcription accuracy. In reviewing issues of reflexivity in qualitative research [22], the threat of potential researcher biases due to the established professional relationship between the P.I. FKY, and research participants, was overcome by having HZ, who had no prior relationship with any of the participants, as the interviewer. To protect participants’ anonymity, we assigned code identifiers beginning with ‘EL’ to the participants, which refer to either educators or leaders of medical schools, and named the three medical schools ‘X’, ‘Y’ and Z’ in the reporting of findings.

Data analysis

HZ read the transcripts independently and adopted an inductive thematic analysis approach when evaluating the data to draw common and shared meanings among participants [23]. Coding frameworks and themes were developed iteratively using Braun and Clarke’s (2006) six-step process [24]. We also compared the findings with all available up-to-date global literature on countries that have developed national competency-based learning objectives for the training of specific digital competencies for medical education [1,8–10], and with other similar studies of clinical educators and healthcare leaders’ perspectives on healthcare digitalization[20,25]. Any coding discrepancies were resolved through consensus between HZ and FKY and through seeking the opinions of our co-authors.

Results

Overall, the participants acknowledged that there are several clinical competencies that are currently lacking in the medical school curriculum, especially those that require digital skills. Specifically, they highlighted three skills that they felt should be incorporated, if not emphasized more in the local medical school curricula. These are skills in digital health, in data management, and in applying the principles of digital technologies, which are elaborated in the sub-section below. Based on our generation of codes and sub-themes as shown in Table 4, the theme on ‘digital health’ was derived from the elements that constitute this field of healthcare, which include health information systems, video consultations, wearables and healthcare-related applications [1,3]. Furthermore, codes that reflected the importance of handling data in an ethical manner also contributed to the theme on ‘data management’ (Table 4). Additionally, the theme on ‘applying broad principles of digital technologies’ was formulated based on codes that emphasized skills in applying general concepts, theories and principles of digital technologies as opposed to niche sub-specialty information (Table 4).

Table 4. Codes, sub-themes and themes identified from coding process.

Codes	Sub-Themes
Theme: Skills in digital health
Communication on digital platforms Communication skills Virtual consultation Human touch Zoom, video call Electronic health records Health information systems Decision support systems	Skills in telemedicine/telehealth/teleconsultation Skills in maintaining doctor-patient relations while using digital platforms Skills in EHRs
Process Fitbit information Smartphone applications Wearables	Skills in using smartphone applications Skills in using digital healthcare devices
Theme: Skills in data management
Data security Data privacy Data analytics capacity Data literacy skills IT security issues Ethics Regulations Analyzing big data Handling large amounts of data	Skills in managing data in an ethical manner
Sifting information online	Skills in synthesizing information
Theme: Skills in applying broad principles of digital technologies
Boundaries, limitations, restrictions Patient confidentiality Patient privacy Personal Data Protection Act (PDPA) Social media, Facebook, Instagram, Twitter Safe	Knowing limitations, contexts and etiquettes of using digital technologies Knowing the pitfalls, pros and cons of digital technologies
Fundamental concepts and principles (as opposed to niche, sub-specialty information) General exposure	Knowing broad concepts and principles rather than details
Theme: Lack of collaboration among medical schools
Competition Not standardized Goals and priorities not alignedDifferentiated learning outcomes and objectives	Need for greater collaboration among medical schools
Theme: Disconnect between medical school curriculum and clinical practice
Learnt on-the-job, Workplace Limited training: Poorly equipped, inadequate, lacking in curriculum, just scratching the surface, heavy curriculum, packed curriculum, disconnect	Lack of exposure to digital technologies used in clinical settings Disconnect between medical school training and postgraduate experience
Communication with patients Clinical settings Artificial environment	Lack of training in communication skills while using EHRs

In addition, participants also noted several gaps in the medical school and healthcare systems that they thought act as barriers to the implementation of a national medical school curriculum that would incorporate the training of digital competencies for clinical practice. In particular, perceptions of competition, differentiated learning objectives and outcomes, as well as unstandardized goals and priorities among the local medical schools, signify a lack of collaboration among the schools (Table 4). Moreover, limited training brought about by a densely-packed curriculum, as well as existing gaps in the training of communication skills and other clinical skills, reflect the disconnect between medical school training and clinical practice.

An interesting finding that emerged is that despite the focus of each school on specific niche areas (communication skills for LKCMedicine, research skills for Duke-NUS and innovation drive for YLL), these strengths were not necessarily leveraged upon by the schools to equip their students with relevant clinical competencies needed for the digital age. For example, although communication with patients is known to be the forte of LKCMedicine’s education, there is limited training in how students can practice communication skills while using digital tools such as EHRs, as shared by one of the participants. Similarly, students from Duke-NUS do not get much exposure to digital technologies during their research year unless they work on projects that are related to such technologies, the topics of which are mostly determined by their mentors. While students at YLL have the opportunity to participate in the NUS Medical Grand Challenge, a one-year student-led medical innovation program that teams them up with students from two other faculties in driving innovations to drive unmet healthcare needs, this does not form part of the core curriculum.

Skills in digital health

Participants from all three medical schools shared that students need more training in digital health, as illustrated by EL10, EL3 and EL16 below. This includes skills in communicating with patients while using digital tools and platforms such as EHRs and video consultations. The participants also noted that the challenges faced by some physicians while using Zoom during the COVID-19 pandemic reiterated the need to equip medical trainees with relevant skills in teleconsultation.

The other thing I know that students are trained for in the US but not here is communicating with patients while using the electronic health records, which is why you get complains from patients that the doctor is just looking at the computer screen all the time instead of looking at them. We do communications in the clinic room but the computer is never on, so that creates a very artificial environment. (EL10, educator in School X)

We need to train students to communicate not just face-to-face but also on digital platforms like Zoom, what the advantages and disadvantages are, the use of phone apps and how to empower patients to input data into the phone. (EL3, educator in School Y)

With telemedicine, students have to understand its limitations and the conditions where telemedicine can be used. They need to make an assessment of whether the patient can make his own assessment … they cannot just assume the patient understands. (EL16, educator in School Z)

The above excerpts show that the advent of digital tools such as EHRs means that basic communication skills have become even more important than before so as not to compromise the doctor-patient relations. Apart from training students in ways to interact with patients while digital technologies are being used, it is also vital to equip them with the skills to engage and empower patients in the latter’s healthcare experiences, be it during their consultation with the doctor or when using smartphone applications for health-related purposes. Furthermore, the intentional incorporation of telemedicine competencies in the medical school curriculum is especially crucial in countries like Singapore where the primary care setting is the only setting where students receive exposure to telemedicine. Their brief exposure to this setting in the curriculum, which is during their rotations in Family Medicine [26], as well as the lack of telemedicine utilization in primary care clinics, further limit their experience with digital health.

Skills in data management

Another gap highlighted by some participants, such as those quoted below, is the lack of training in data management, such as in data analysis, data protection and security.

Big data is a useful skill especially for public health. In Singapore, we don’t really have an understanding of data [because] nobody has actually collected the information … big data can help us understand the disease process, behavioural characteristics like how the public use healthcare services, and also for operational things, like exploring why certain pockets of the population are underrepresented in screening for breast cancer; is it due to financial issue? Access issue (access to public sector clinics)?… Maybe we can have case studies for students on how big data is used (EL16, educator in School Z).

What needs to be emphasized more is skills in mining data with a consideration for moral and ethical implications of data. (EL15, leader in School Z)

All these talks about patient confidentialities and PDPA. Schools need to be very deliberate in teaching students and making sure that they know the seriousness in the boundaries they have to adhere to. (EL4, educator in School Y)

Based on the above excerpts, it can be inferred that the skills identified as crucial for students by the participants need to be contextualized within the healthcare needs of the population and the legal framework for clinical practice. The former would include a consideration for the socio-economic and cultural factors that influence healthcare behaviour and outcomes, whereas the latter entails a deliberation of the legal consequences physicians may face if they are not equipped with the knowledge and skills to handle data ethically. In a world where data privacy can be easily breached if not managed carefully, imparting relevant digital skills to students in the core curriculum becomes all the more important.

Skills in applying the principles of digital technologies

The participants also perceived that skills in applying the principles of digital technologies such as AI are important for medical students. Specifically, they opined that students need to be taught broad principles and concepts of these technologies so that they can practise safely and identify accurately the context in which these technologies can be used.

It’s important to understand the limitations, restrictions or appropriate application of certain techniques and technologies because anything applied in the wrong context can always send you the wrong rabbit hole. So, it’s about training clinicians with research literacy and a critical ability to understand how to advance the contemporary practice of medicine. (EL15, leader in School Z)

Students have to understand the usefulness and limitations of AI in medicine, know when to use technology and when to go back to clinical skills where relevant. Technology may tell us about a patient’s diabetic control but it may not tell us the psychosocial issues behind it. (EL9, leader in School Z)

These excerpts imply that the rationale for training medical students in these competencies also lie in the need to prioritize patient safety and needs rather than for the sake of utilizing digital technologies in healthcare. They also suggest the need to balance the impartation of digital skills with basic clinical assessment skills such as physical examination so that the former will not lead to the erosion of the latter, a point that has been discussed by Zainal et. al. 2022 [20].

Overall, the findings show that although the three medical schools have different focus areas, representatives from all schools identified the same rationale behind the prioritization of competencies that should be taught to medical students: the healthcare needs of the population, patient safety, and safe procedures in the utilization of digital healthcare technologies. In terms of barriers to implementation, the participants’ views are captured in the following excerpts.

Lack of collaboration among medical schools

Some participants felt that the different focus areas of the medical schools and the friendly competition in medical education across the schools to produce competent medical graduates pose a barrier to the implementation of a nation-wide curriculum that equips students with relevant digital competencies, as exemplified by the views of EL1 and EL10 below:

Singapore is built and developed on competing with each other and to be the best. The three schools are competing when competition should be based on research rather than education because ultimately, we are producing doctors to take care of the same patients … so, rather than competing for funds, resources and faculty, we should be collaborating and sharing instead. (EL1, educator in School Y)

I see the entire spectrum of medical school to PGY1 (Postgraduate Year 1) to residency to hospital accreditation as one continuum. I know there are efforts to make it into one continuum but very often, it does not feel like that. It feels as if each school has particular outcomes. It is only now we are having a national standard for all three schools. (EL10, educator in School X)

The above excerpts suggest that it would be challenging to develop a national curriculum on digital competencies that requires collaboration and participation of experts from all medical schools. Nonetheless, the need to produce doctors that meet the needs of the population should be the ultimate priority.

Disconnect between medical school curriculum and clinical practice

Others opined that there is currently a disconnect between medical school training and contemporary clinical practice, as shared by the participants cited below.

There is still a gap between learning clinical skills as a student and experiencing those skills … The exposure of students to take history on Zoom with a patient has been a coping mechanism due to the constraints brought about by COVID-19 rather than something that is deliberately thought through. So, I think the time has come for schools to take time to review the excellent things that have been introduced during COVID, and weave them into the formal curriculum. So, it will be skills like using digital platforms to take history and communicate with patients, and the demonstration of professional behavior on digital platforms. (EL8, educator in School X).

It is good to start introducing new technologies in the curriculum since some of these are already happening in the wards. But if students are not exposed to this in clinical practice, they won’t experience this and will only focus on what’s tested for the exams … Unfortunately, the hospitals are a bit slow in adopting AI. They may have it in certain areas but not in general medicine yet. (EL7, educator in School X)

The disconnect between the clinical skills taught in medical school and those needed for clinical practice is a common issue faced by medical schools around the world [20]. In Singapore, this is exacerbated by the gradual uptake of digital technologies in the healthcare sector. Indeed, only certain specialties, particularly radiology and ophthalmology, have begun adopting digital technologies such as AI in diagnosis of illnesses. This poses a barrier to the teaching of broad concepts on digital technologies used in healthcare to all medical practitioners.

Discussion

The findings reveal three digital competencies that are currently lacking in all three medical schools in Singapore, namely, skills in digital health, data management and applying the principles of digital technologies to clinical practice. Although these competencies have also been identified in past research conducted in other developed countries, such as Australia, Canada, Germany and USA [8–10,12,26–28], our study highlights the importance of contextualizing them to the needs of the local society, prioritizing patient safety and needs, as well as understanding the risks that technology poses before determining the type of competencies that are important to medical students.

Additionally, even though other studies have also reported about the value and significance of collaboration among medical schools and the need to bridge the gaps between medical school training and clinical practice [1,9], several unique characteristics of Singapore’s medical education system set this study apart. These include the competitiveness of the education system, which pose a challenge for the schools to collaborate effectively with one another, and the lingering concerns of some clinical educators and teachers, as reported in Zainal et. al.’s (2022) study. Some of these concerns include erosion of basic clinical skills, neglect of a generalist approach to healthcare characterized by holistic management of patients, inter-professional collaboration, and commitment to breadth of practice within each specialty, rapid pace of technological advances, as well as de-personalization by technology [20]. Moreover, several systemic barriers remain, including the gradual uptake of digital technologies in the healthcare sector, the lack of formal training in digital healthcare technologies among clinical educators themselves and relatedly, lack of role models and leadership, as shared by some of the participants of this study.

By exploring the necessary digital competencies needed for clinical practice and the potential barriers to implementing a national curriculum that trains students in these competencies, this paper fills the dearth of literature on barriers to implement standardized learning objectives in Asian medical schools. Studies on national curriculum reform in Asia, such as in China, Japan and Taiwan, seldom discuss the incorporation of digital technologies in the formal curriculum despite their focus on clinical education [29–31]. In fact, few have discussed the impartation of digital competencies in the context of clinical skills, with the exception of Nasser and Chung’s 2020 study, which suggests how medical schools in China can leverage the technological strengths of their cities to promote the training of digital technologies such as AI, robotics and big data analysis in the schools [32]. Our research adds to this literature by showing the importance of first identifying the barriers that act as a hindrance to the implementation of a nation-wide curriculum before specific digital skills can be introduced in the curriculum.

Recommendations

Findings from the interviews have reiterated the importance of bridging gaps in the medical school curricula and of systematically collecting feedback from doctors who are involved in curriculum development and delivery. This section offers recommendations to address each of the barriers stated above so that the existing curriculum can be improved to meet changing healthcare needs.

Stronger collaborations among medical schools and professional bodies

To address the lack of national-level initiatives to drive digital training in medical schools, Singapore can consider implementing some of the initiatives that have been adopted by medical schools and professional bodies in other countries. These include establishing networks to facilitate the exchange of best practices among experts and stakeholders in relevant digital fields. In Europe, this is done through the formation of the European Deans’ Meeting, a conference attended by deans, educational directors, student representatives from medical schools across Europe, representatives of professional and student organisations, innovators and policymakers [33]. It aims to prepare current and future doctors for digital healthcare transformation and integrate digital competencies in the education and training of doctors [1]. In Canada, the institutionalization of medical informatics knowledge in undergraduate medical education is driven by a partnership between two medical organizations- the Association of Faculties of Medicine of Canada (AFMC), which represents Canada’s 17 faculties of medicine, and Canada Health Infoway, a non-profit organization funded by the federal government to make healthcare more digital [9]. With the objectives of enhancing the reputation of medical informatics within medical education and equipping Canada’s next generation of doctors with the skills to flourish in a digitally-enabled clinical environment, the two organizations initiated projects that identified gaps in e-Health training in the national medical curricula and developed Canada’s first eHealth competencies for undergraduate medical education, among other efforts [9]. This partnership proved to be successful, as it led to desirable outcomes such as the establishment of a key strategic relationship with the Medical Council of Canada, an influential stakeholder, and the organization of webinar workshops for medical faculties [9].

In a similar vein, Singapore could establish similar networks not just for clinical educators but for students who would like to gain deeper insights into digital healthcare technologies. Within these networks, there could be a system that identifies clinical educators who can be good role models to students and who are assigned to teach the same course/s to all schools. Collaborative partnership and mentorship can be formed with experts from both the clinical as well as non-clinical fields. Multidisciplinary training is reported to be useful especially in implementation science and clinical informatics, as it fosters innovative thinking among clinicians [34]. For doctors with little or no experience with digital technologies, they could undergo formal training via Continual Medical Education (CME) programs and learn from those outside of the medical community.

In addition to forming networks, it is also important to advocate for awareness and integration of digitalization into the curriculum. Advocacy can take on many forms. It includes presentations at conferences, dissemination of published articles, and engagement with relevant stakeholders including meetings with key faculty and deans of medicine, as has been done in Canada [9]. Such initiatives have led to many positive outcomes including the creation of online educational resources that can be used by medical educators [9]. The support of the school leadership, together with key stakeholders, cannot be emphasized enough, as illustrated by the implementation of clinical informatics competencies in the curriculum of Oregon Health and Science University in the U.S. after years of advocacy [35].

In a similar way, the effective incorporation of digital training in Singapore’s medical school curriculum would require the endorsement and support of such training at the governance levels, from organizational leaders to deans of medical schools, vice deans of education and clinical educators. The role of professional bodies such as Singapore Medical Association (SMA) would be pivotal in helping medical schools achieve standardized outcomes. This would include implementing a shared process where local medical schools and healthcare institutions can work collaboratively and ensure that their goals in equipping medical students with relevant training are aligned. Additionally, more support is needed to create a national curriculum package for the integration of digital health technologies in the curriculum.

Bridging gaps between medical school curriculum and clinical practice

To ensure that the medical school curricula are aligned with the technological advances in clinical settings, a dedicated training in digital competencies for clinical practice is needed. One way is to reduce the time spent on memorizing medical information and increase the time spent on training students in digital skills [34]. Research have shown that a longitudinal curriculum has the potential to expose students to a wider range of skills [28,35]. For example, a revamp of the undergraduate curriculum at Oregon Health and Science University has led to the incorporation of clinical informatics training that expose students to EHRs, telemedicine, personalized medicine and skills in clinical decision support and quality improvement [35]. Similarly, a project group initiated by Hannover Medical School in Germany found that integrating digital competencies longitudinally into the compulsory curriculum would equip students with data literacy skills, which include skills in handling medical data and applying data in patient care and preventive medicine [28].

To expose students to digital technologies used in clinical settings, schools should introduce courses that familiarize students with the basic principles of such technologies and their applications to clinical work. During clinical rotations, medical experts should consciously introduce students to relevant applications of digital technologies in practice. At the end of training, students’ knowledge and understanding of such applications can be assessed through formal modes of assessment such as examination.

Barriers to using digital technologies effectively in the clinical setting also need to be removed. To overcome the gradual uptake of such technologies in hospitals, it would be useful for hospitals to obtain the advice of medical innovators on ways to optimize digital technologies in diagnosis, treatment and overall patient care. A technology assessment committee could also be set up to develop clear policy guidelines that would enable medical students and healthcare professionals to utilizedigital technologies safely and effectively without compromising patient care. Furthermore, at present, the limited access to and training on the use of EHRs are not unique to Singapore. As Paranjape et. al. (2019) highlighted, current training on EHRs often consists of brief introductory courses on ways to utilize the hospital’s system without addressing how EHRs may interfere with patient-doctor relations and data quality. Apart from teaching students the clinical applications of EHRs, a concerted effort of multiple stakeholders is needed to increase their access to these tools. As have been proposed by medical societies in the U.S., schools should establish policies on the placement of students’ notes, which, while compliant with all regulations, balance the need for patient privacy, liability concerns and the need to increase students’ competence [36]. At the national level, a move towards interoperability of systems that allow users to share data would facilitate students’ adaptation to new systems in different healthcare settings and monitoring of authorship in the EHRs [36].

Strengths and limitations

This qualitative study informs us about the types of digital competencies that are deemed important for medical students from the perspectives of clinical educators and medical leaders in Singapore’s medical schools. The sample achieved diversity in institutions and specialties, which contributed to the richness of the data. The senior roles of the participants in teaching, curriculum planning, education faculty administration, education research and leadership also enhance the credibility of data, as they arguably possess sufficient knowledge of the latest medical school curricula. Compared to past research that mostly identified pedagogies and learning outcomes for specific digital technologies in specific settings such as medical education in the UK and Germany [11,37,38], our study reveals required competencies that may be shared by many developed countries that are facing common healthcare issues while simultaneously highlighting those that are unique to Singapore.

One limitation of the study is that participants may not have recalled all of the digital healthcare education that are taught at their school, which risks under-reporting of training in digital competencies. To avoid this pitfall, we mentioned examples of digital technologies that may be useful for clinical practice that we obtained from our literature review and research of the schools’ websites. We also encouraged participants to utilize the ‘share screen’ function in Zoom if they wished to share more information pertaining to their school’s curriculum, which some of them did.

Additionally, findings from this study may not be generalizable to other countries, as they are unique to Singapore’s healthcare system. Nonetheless, the impetus for the integration of digital competencies in the medical school curriculum are arguably similar since many developed countries are also facing the issue of ageing population and are experiencing rapid digital transformations of healthcare. Hence, the feedback gathered from this study would still be useful.

Furthermore, stating in the recruitment email that the interview will be about medical school curriculum in the digital age may have pushed some participants towards views that speak favorably about their curriculum. However, this was not necessarily the case as they were honest with the current gaps in the curriculum and acknowledged the areas that need improvement.

A potential line of future research would be to explore the views of other stakeholders such as patients to find out if the skills identified by the participants of this study are indeed those that they would expect of doctors. Exploring their concerns about specific digital technologies would also be helpful. Lastly, the qualitative feedback obtained from this study could be used to developed a questionnaire that verifies the gaps of medical school curricula in the digital age.

Conclusions

This study has identified current training gaps in the core curricula of all three medical schools in Singapore and the digital competencies needed by medical graduates at the national level from the perspectives of clinical educators and leaders of medical schools. While previous studies have reported similar competencies to be incorporated in the formal curricula, our findings highlighted the need for these competencies to be based on the healthcare needs of the population and healthcare system, the legal framework of clinical practice, and the safety of patients. In addition, while the three medical schools in Singapore can have different areas of focus and their own identity, establishing a stronger collaboration among all schools and with professional bodies would not only lead to a common curriculum and platform to share resources but also the impartation of common knowledge and skills to students, all of which will ultimately benefit the country. The implementation of a national curriculum that focuses on imparting digital skills to students should therefore, take a collective effort. Overall, the research bears important implications for countries with varying medical school curricula and focus areas that plan to implement standardized learning objectives for the training of digital competencies.

Authors’ contributions

The first author, HZ, collected and analyzed the data, and wrote the initial drafts. The corresponding author, FKY, as well as the second and third authors, XX and JT, reviewed and edited the manuscript. All the authors read and approved the submitted copy.

Acknowledgments

The authors would like to thank the respondents for their participation in the research. They are also grateful to the reviewers for their helpful comments.

Data availability statement

The data that support the findings of this study are available from the first author, HZ, upon reasonable request.

Disclosure statement

No potential conflict of interest was reported by the authors.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This work was supported by SingHealth Duke-NUS Medicine Academic Clinical Programme under Seah Cheng Siang Distinguished Professorship in Medicine.