Singapore is a small island between the Malaysian peninsula and Indonesian archipelago with a population of 4.8 million people. The ethnic composition is a microcosm of Asia, with three main races/cultures: Chinese (74.7%), Malay (13.6%), and Indian (8.9%).

Psychiatry specialty training is entering a new stage in Singapore. Psychiatry training is conducted at a national level with weekly training sessions for all trainees in a centralized location by psychiatrists in the public sector (who are responsible for and conduct essentially all the psychiatry training in Singapore). In 2008 the training program transitioned from a rigid system of time-based (3 years of basic and advanced specialty training each) and phasic progression (determined by the passing of a Master of Medicine examination before progression to the advanced phase) to a competency-based and seamless progression of training (requiring only 5 years). Although the core syllabi of both phasic and seamless training are similar, the rigor of the training will increase with the implementation of standardized assessments, new modules on basic sciences and research, and a new examination format with objective structured clinical examinations (OSCEs) in addition to multiple choice and essay questions. This new training system is also in line with the recommendations under the National Mental Health Policy and blueprint to rectify the shortfall of mental health professionals and encourage research (1).

With the emphasis on competency-based training, it is timely to take stock of the perceived adequacy of current training while there is a mixture of the last batches of trainees under the old phasic training system and the first batch under the seamless training. We decided to conduct a survey of all psychiatry trainees and all psychiatrists in the public sector on the perceived importance of various aspects of psychiatric training and the current adequacy of such training.

Ethical approval for the survey was obtained from the institutional ethics review board. A list of all psychiatry trainees and psychiatrists in the public sector was obtained from the specialist training committee and Ministry of Health specialist register. In total there were 46 trainees and 64 psychiatrists. About one-quarter of the trainees were under the new training program. One-half would be considered basic trainees and the other half advanced trainees. We (PT, EK) developed an anonymous survey covering 11 aspects of training and mailed it to all potential respondents. The 11 aspects were chosen based on the core syllabi of both the phasic and seamless training. Respondents were asked to separately rate the importance and adequacy of the psychiatric training on a Likert scale from 1 to 5, with 5 being very important or very adequately done. A comment section was provided for other aspects of training that they believed were important. The end result was an average score of each aspect as rated by the respondents.

The survey was conducted from February to March 2008. All analyses were done using SPSS version 14 (Chicago, 2005). Comparisons between subgroups were done using independent t test analysis. Two-tailed tests of significance were used, and significance was set at p<0.05.

A response rate of 49.1% (54 of 110) was obtained. Twenty-six respondents (48.1%) were trainees and 23 (42.6%) were psychiatrists. Five respondents did not indicate their training status, and their data were excluded from analysis. The current adequacy of training was less than the perceived importance of training for all 11 aspects of training (Table 1). In general, psychiatrists rated most aspects of training as being more important than trainees, with the exception of basic neuroscience, cultural aspects, and research. Similarly psychiatrists rated the adequacy of training better for all aspects of training except for research.

The greatest differences in opinion between psychiatrists and trainees for aspects of perceived importance lay in three areas: psychosocial treatment knowledge, psychotherapy treatment knowledge, and ethics, with psychiatrists rating the importance higher than trainees. For current adequacy of training, the aspects of greatest difference were psychotherapy treatment knowledge and clinical interview skills, with psychiatrists rating the adequacy higher than trainees. However, these differences did not reach significance, with the exception of psychiatrists rating psychotherapy treatment knowledge adequacy higher than trainees (p<0.05).

There was a consensus on the four most important aspects of training, with a clear majority of total respondents giving them the highest possible rating of 5 and with psychiatrists giving a higher importance rating than trainees for all four aspects (clinical interview skills: 91.7% versus 77.8%; clinical treatment skills: 95.8% versus 74.1%; disorder and diagnosis knowledge: 83.3% versus 70.4%; pharmacological treatment knowledge: 83.3% versus 74.1%). However, there was no clear consensus on the importance or adequacy of other aspects of training.

In the comment response section, most replies touched on the need for more emphasis and training on psychotherapy and for mentors and more motivated trainees who take charge of their own training. The numbers for each reply were too small for analysis.

This is the first study of the Singaporean psychiatric community’s views regarding psychiatric training. The strengths of this survey lay in a small and close-knit psychiatric community with a standardized national psychiatry training program in a small country. This allows for a robust assessment of a national training program that is generalizable to the entire country. The large gap between perceived importance and adequacy in training confirms a long-held suspicion that there is a perceived broad inadequacy of psychiatry specialist training in Singapore. There was a generally more sanguine view of psychiatrists toward the adequacy of training when compared with trainees. This is in keeping with previous research (2) in the West and suggests that trainees in both the East and West may be overly critical about their own training (3). One explanation for this finding could be the frequent 6-month rotation of trainees through different postings. This does not encourage longitudinal assessment, management, and follow-up of patients and necessitates more of a “firefighting” approach toward clinical problem solving. Under the new program, close and continuous contact with a cohort of patients is more likely and will help close the gap between perceived adequacy of training and training importance (4).

It is interesting that psychiatrists rated the adequacy of psychotherapy training higher than the trainees. One possibility is that it may be challenging for psychiatrists to truly assess the summative competencies of trainees. Most psychotherapy done by trainees is unobserved, and supervision is usually done by the trainee recounting his or her session to the psychiatrist. Even if sessions were observed, there is no universally accepted standard of psychotherapy competence to apply, and psychiatrists commonly differ in their opinions (5). Difficulty with training assessment may have led to an overestimation of the training adequacy of psychotherapy and perhaps other aspects of training.

The perceived inadequacies in clinical aspects of training are to be addressed in the new program, but little formal attention is paid to the nonclinical aspects of training (e.g., ethics, team leadership, and collegial skills). The Singapore Medical Association organizes ethics courses that are a mandatory part of medical specialist training. However, the courses are not specific to psychiatric ethics and may be conducted toward the end of training, where the impact on training may be low. There is no formalized training on how to lead a psychiatric team, and these skills are picked up on the job. It may be useful to include leadership modules and to bring forward the ethics module in the new program to address this gap.

Although the differences in opinion between psychiatrists and trainees for various aspects are not significant (except for adequacy of psychotherapy training), it is intriguing to speculate on the possible reasons why basic neuroscience, cultural aspects, and research bucked the trend of psychiatrists rating importance higher than trainees. Singapore has three main races/cultures (Chinese, Malay, and Indian), and there is increasing evidence that race/culture is related to the prevalence of minor psychiatric morbidity (6), rates of dementia (7), and even help-seeking status (8). Yet there is little formal teaching of cultural aspects in the curriculum. Similarly for basic neuroscience and research, a paradigm shift toward more biological psychiatry (9) and a new local emphasis on research to further medical knowledge (10) may be changing the training priorities of new trainees.

The limitations of this survey include the low response rate and corresponding lack of statistical power. However, an almost even number of trainees and psychiatrists responded, and the trends for differences between the two groups were generally consistent, suggesting a real difference of opinion between trainees and psychiatrists. Another limitation is that the survey is not validated, and certain aspects of training may not have been included. This is not likely, because respondents were given a free-text option and no additional training aspects were suggested other than the 11 prespecified categories. The last limitation was the inability to differentiate among trainees in the different phases of training and location of training because of the need to maintain anonymity in a small psychiatric community.

The survey has confirmed the perceived inadequacy of psychiatry training in Singapore. The results have also provided a consensus on the core aspects of training (clinical interview skills, clinical treatment skills, disorder and diagnosis knowledge, and pharmacological treatment knowledge) and help focus future training. The assessment of training adequacy, especially psychotherapy, should be standardized for better validity. Nonclinical aspects of training (e.g., ethics, leadership) should be included in the new training program.

At the time of submission, the authors reported no competing interests.