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Environmental concerns and diet in Singapore.

Many factors affect how people perceive the world and their environment, and how such perceptions affect lifestyle decisions, yet the relationship between personal perceptions about environmental hazards and diet is rarely examined. In this study, environmental concerns on a local and global scale were examined, along with dietary patterns, to determine if there were associations and age-related differences. The hypothesis that concerns about water pollution might be reflected in choices about seafood consumption was examined. Many aspects of dietary choices varied significantly by age, including (1) younger people ate more "fast food" than others, (2) subjects aged 22-32 yr ate more meals in restaurants than older or younger people, (3) older individuals drank more tea than younger subjects, while younger people drank more soda than older people, and (4) there were few significant differences in total fish and shellfish meals, although young people ate more meals of other types of meat. Individuals who rated their health the best reported significantly fewer seafood meals than others. People who listed pollution as the major environmental problem did not consume seafood less often than others. While pollution was listed as the most important environmental problem globally, people distinguished between air and water pollution only for Singapore. Although Singapore, with its rapidly expanding economy, has reason to be concerned about both water and air pollution, only 14% of those listing pollution as the main Singapore environmental problem mentioned "water pollution." Singapore has been able to take measures to reduce water pollution from internal sources. Respondents considered air pollution a greater problem, perhaps reflecting recent haze disasters from deliberately set forest fires in Indonesia, which are beyond the direct control of Singapore or Singaporeans.

Adolescent↗

Refractive errors in Singapore and Xiamen, China--a comparative study in school children aged 6 to 7 years.

PURPOSE: To compare and contrast the prevalence of myopia and other refractive errors in Xiamen city, Xiamen countryside (Southern China), and Singapore. METHODS: One hundred thirty-two schoolchildren aged 6 to 7 years from Xiamen city, 104 from Xiamen countryside, and 146 from Singapore city were recruited to join the study. Cycloplegic autorefraction, keratometry, and biometry measurements were performed on all children. RESULTS: The prevalence of myopia was 12.3% in Singapore city, 9.1% in Xiamen city, and 3.9% in Xiamen countryside. The prevalence of astigmatism was higher in Singapore compared with Xiamen. The rates of hyperopia and anisometropia were similar in all three locations. CONCLUSIONS: The myopia rate in Singapore city was higher than in Xiamen city; the lowest rates were found in Xiamen countryside. As the Chinese population from all three sites is of similar genetic stock (predominantly from Southern China), it is postulated that the differences in myopia rates in these three localities may be related to environmental factors.

Anisometropia↗

Quantitative characterizations of speech rhythm: syllable-timing in Singapore English.

British English and Singapore English are said to differ in rhythmic patterning. British English is commonly described as stress-timed, but Singapore English is claimed to be syllable-timed. In the present paper, we explore the acoustic nature of the suggested cross-varietal difference. In directly comparable samples from British English and Singapore English, two types of acoustic measurements were taken; we calculated a variability index reflecting changes in vowel length over utterances, and measurements reflecting vowel quality. Our findings provide acoustic data which support the hypothesized cross-varietal difference in rhythmic patterning; we show (1) that successive vowel durations are more nearly equal in Singapore English than in British English, and (2) that reduced vowels pattern more peripherally in the F1/F2 formant space in Singapore English than in British English. We complete the paper with a comparison of our vowel variability index with a set of acoustic measures for rhythm proposed by Ramus, Nespor, and Mehler (1999), which focus on variability in vocalic and intervocalic intervals. We conclude that our variability index is more successful in capturing rhythmic differences than Ramus et al. (1999)'s measures, and that an application of our index to Ramus et al.'s intervocalic measure may provide a further diagnostic of rhythmic class.

Adult↗

Racial variation of cord plasma lipoprotein(a) levels in relation to coronary risk level: a study in three ethnic groups in Singapore.

Lipoprotein(a) [Lp(a)] is recognized as an independent risk factor for atherosclerosis. Studies have also shown that there are racial differences in the Lp(a) profile. The multiracial population of Singapore has demonstrated a differential prevalence of coronary artery disease, which is concordant with the plasma Lp(a) profile in the adult populations of Singapore. The level of Lp(a) is under strict genetic control, and its plasma concentration is determined significantly by inheritance. Expression of the racial profile of Lp(a) at birth was studied in the cord blood of 542 male and 468 female newborns from three ethnic groups of Singapore using the sandwich-ELISA. The Lp(a) levels were then related to the coronary risk levels of their respective adult populations. Lp(a) levels in Singapore newborns were found to be independent of the infant's birth weight and sex but were significantly influenced by race. Indian newborns had significantly higher plasma levels of Lp(a). Chinese newborns had the lowest Lp(a) levels at birth. The ranking of Lp(a) levels at birth was concordant with the relative coronary mortality rates for the respective adult populations of Singapore. Racial differences in plasma Lp(a) levels are present and expressed at birth.

Analysis of Variance↗

Experience of severe acute respiratory syndrome in singapore: importation of cases, and defense strategies at the airport.

BACKGROUND: The importation of SARS was responsible for the outbreaks in Singapore, Hong Kong, Vietnam and Canada at a time when this new disease had not been identified. We report the incidence and impact of cases of SARS imported to Singapore between 25 February and 31 May 2003, and describe national measures to prevent further importation. METHODS: Information on imported cases of SARS and measures taken at entry points to Singapore was retrieved from the Ministry of Health and the Civil Aviation Authority of Singapore. RESULTS: Of the 6 imported cases, which all occurred before screening measures were implemented at the airport, only the first resulted in extensive secondary transmission. Of 442973 air passengers screened after measures were implemented, 136 were sent to a designated hospital for further SARS screening; none was diagnosed as having SARS. CONCLUSIONS: The SARS outbreak in Singapore can be traced to the first imported case. The absence of transmission from the other imported cases was probably a result of relatively prompt identification and isolation of cases, together with a low potential for transmission. New imported SARS cases therefore need not lead to major outbreaks if systems are in place to identify and isolate them early. Screening at entry points is costly, has a low yield and is not sufficient in itself, but may be justified in light of the major economic, social and international impact which even a single imported SARS case may have.

Adolescent↗

Incidence and survival characteristics of retinoblastoma in Singapore from 1968-1995.

PURPOSE: To describe the incidence and survival of 69 Singapore residents with retinoblastoma in all Singapore hospitals from 1968-1995. METHODS: Data of all Singapore residents diagnosed with retinoblastoma from 1968-1995 were collected by the Singapore Cancer Registry based on notifications from physicians, pathology records, hospital discharge records, and death certificates. The medical records of 46 patients were traced, and information on laterality of tumor, spread of tumor, mode of treatment, and family history of retinoblastoma was obtained. Time trends and survival characteristics of the cohort were described. RESULTS: The incidence rate of retinoblastoma was 2.4 per 1 million for children <9 years and 11.1 per 1 million for children <5 years. The incidence of retinoblastoma has been almost uniform over time from 1968-1995, except for an apparent increase in 1988-1992. The 3-year survival rate for retinoblastoma was 83%. Survival rates were higher in children <2 years because children who present at a younger age may have tumors diagnosed at earlier stages of the disease. There was no difference in survival rates for sex, race, laterality, family history of retinoblastoma, treatment, or year of diagnosis. CONCLUSION: Retinoblastoma is the most common eye cancer in children that may cause blindness or death. The incidence rates of retinoblastoma in Singapore have remained fairly stable over 28 years, and the survival rate is higher in younger children. This study will be helpful in monitoring future disease patterns in Asian populations.

Child↗

Analysis of deaths during the severe acute respiratory syndrome (SARS) epidemic in Singapore: challenges in determining a SARS diagnosis.

CONTEXT: An outbreak of severe acute respiratory syndrome (SARS), an infectious disease attributed to a novel coronavirus, occurred in Singapore during the first quarter of 2003 and led to 204 patients with diagnosed illnesses and 26 deaths by May 2, 2003. Twenty-one percent of these patients required admission to the medical intensive care unit. During this period, the Center for Forensic Medicine, Health Sciences Authority, Singapore, performed a total of 14 postmortem examinations for probable and suspected SARS. Of these, a total of 8 were later confirmed as SARS infections. OBJECTIVE: Our series documents the difficulties encountered at autopsy during the initial phases of the SARS epidemic, when the pattern of infection and definitive diagnostic laboratory criteria were yet to be established. DESIGN: Autopsies were performed by pathologists affiliated with the Center for Forensic Medicine, Health Sciences Authority, Singapore. Tissue was accessed and read at the Tan Tock Seng Hospital, Singapore, and at the Armed Forces Institute of Pathology, Washington, DC. Autopsy tissue was submitted to the Virology Department, Singapore General Hospital, for analysis, and in situ hybridization for the SARS coronavirus was carried out at the National Institute of Infectious Diseases, Tokyo, Japan. RESULTS: Thirteen of 14 patients showed features of diffuse alveolar damage. In 8 patients, no precipitating etiology was identified, and in all of these patients, we now have laboratory confirmation of coronavirus infection. Two of the 8 patients presented at autopsy as sudden unexpected deaths, while the remaining 6 patients had been hospitalized with varying lengths of stay in the intensive care unit. In 3 patients, including the 2 sudden unexpected deaths, in situ hybridization showed the presence of virally infected cells within the lung. In 4 of the 8 SARS patients, pulmonary thromboemboli were also recognized on gross examination, while one patient had marantic cardiac valvular vegetations. CONCLUSIONS: It is unfortunate that the term atypical pneumonia has been used in conjunction with SARS. Although nonspecific by itself, the term does not accurately reflect the underlying dangers of viral pneumonia, which may progress rapidly to acute respiratory distress syndrome. We observed that the clinical spectrum of disease as seen in our autopsy series included sudden deaths. This is a worrisome finding that illustrates that viral diseases will have a spectrum of clinical presentations and that the diagnoses made for such patients must incorporate laboratory as well as clinical data.

Adult↗

Changing trends in cataract surgery in Singapore.

AIM OF STUDY: To determine the incidence of cataract surgery in Singapore, both island-wide as well as at the Singapore National Eye Centre (SNEC). We also evaluated the changing techniques of cataract surgery performed locally. METHODS: We analysed all cataract operations performed in Singapore over a 10-year period from 1985 to 1996 using data obtained from Medisave claims. We also analysed data of all cataract operations in SNEC between 1992 and 1996 retrospectively, with emphasis on patient demographics and the changing surgical techniques. RESULTS: Data from Medisave claims revealed a significant increase in cataract operations from 5,679 in 1986 to 12,177 in 1995. There was a similar increase in SNEC with a rise from 3,714 in 1992 to 7,516 in 1996. This increase was disproportionately greater than the increase in the number of local surgeons over the same period. The incidence of cataract surgery rose from 2.25/1,000 in 1986 to 4.02/1,000 in 1995. Patients older than 60 years accounted for 75% of cases, with a rise in patients older than 80 years from 2.73% in 1992 to 11.43% in 1996. SNEC data showed that the incidence of phacoemulsification rose from 1% in 1992 to 25% in 1996. CONCLUSION: There is a rising incidence of cataract surgery in Singapore, particularly in the elderly population. There is also a significant change in the pattern of cataract surgery with a sharp rise in the incidence of phacoemulsification over the last 5 years. These findings have an impact on future planning considerations regarding ophthalmic manpower and resources in Singapore.

Adolescent↗

Prevalence and risk factors for refractive errors in adult Chinese in Singapore.

PURPOSE: To determine the epidemiology of refractive errors in an adult Chinese population in Singapore. METHODS: A disproportionate, stratified, clustered, random-sampling procedure was used to select names of 2000 Chinese people aged 40 to 79 years from the 1996 Singapore electoral register in the Tanjong Pagar district in Singapore. These people were invited to a centralized clinic for a comprehensive eye examination, including refraction. Refraction was also performed on nonrespondents in their homes. Myopia, high myopia, and hyperopia were defined as a spherical equivalent (SE) in the right eye of less than -0.5 D, less than -5.0 D, and more than +0.5 D, respectively. Astigmatism was defined as less than -0.5 D of cylinder. Anisometropia was defined as a difference in SE of more than 1.0 D between the two eyes. Only phakic eyes were analyzed. RESULTS: From 1717 eligible people, 1232 (71.8%) were examined. Adjusted to the 1997 Singapore population, the overall prevalence of myopia, hyperopia, astigmatism, and anisometropia was 38.7% (95% confidence interval [CI]: 35.5, 42.1), 28.4% (95% CI: 25.3, 31.3), 37.8% (95% CI: 34.6, 41.1), and 15.9% (95% CI: 13.5, 18.4), respectively. The prevalence of high myopia was 9.1% (95% CI: 7.2, 11.2), with women having significantly higher rates than men. The age pattern of myopia was bimodal, with higher prevalence in the 40 to 49 and 70 to 81 age groups and lower prevalence between those age ranges. Prevalence was reversed in hyperopia, with a higher prevalence in subjects aged 50 to 69. There was a monotonic increase in prevalence with age for both astigmatism and anisometropia. Increasing educational levels, higher individual income, professional or office-related occupations, better housing, and greater severity of nuclear opacity were all significantly associated with higher rates of myopia, after adjustment for age and sex. CONCLUSIONS: The results indicate that whereas myopia is 1.5 to 2.5 times more prevalent in adult Chinese residing in Singapore than in similarly aged European-derived populations in the United States and Australia, the sociodemographic associations are similar.

Adult↗

The need for drug and poison information--the Singapore physicians' perspective.

INTRODUCTION: There appears to be a significant prevalence of poisoning and adverse drug reactions in Singapore. However, the resources needed by physicians to assist them in the management of such cases are limited. This study examines the information resources currently utilised by medical professionals in assisting them in the management of poisonings and adverse drug reactions. The preferred features of an ideal Drug and Poison Information Centre in the local setting were also explored. METHOD: A questionnaire survey involving all practicing physicians in Singapore to find out the current information resources utilised for Drug and Poison Information and the need for enhanced resources and its preferred form was looked at. RESULTS: A total of 1,071 practicing physicians responded forming 24% of all physicians in Singapore as of December 1997. Of these, 636 (61.3%) were general practitioners and the rest specialists. The main sources of poison information were Drug Index of Malaysia and Singapore or DIMS (73.7%), standard textbooks (70.1%), fellow colleagues (44.6%) and pharmacists (41.0%). In the opinion of most (82.4%), one well run and efficient Drug and Poison Information Centre was adequate for the whole island. The majority (58.9%) preferred that experienced individuals who could be consulted upon in times of need man such a service. CONCLUSION: The study shows the need for enhanced drug and poison information resources. The local physician community also expects guidance and expert advice from a specialist. With this in mind, it is worthwhile examining in depth the issues surrounding poison and adverse drug reaction management and the need for readily accessible Drug and Poison Information resources in Singapore.

Adverse Drug Reaction Reporting Systems↗

Sequence and phylogenetic analysis of SH, G, and F genes and proteins of Human respiratory syncytial virus isolates from Singapore.

To study the genetic variability and molecular epidemiology of Human respiratory syncytial virus (HRSV) occurring in Singapore, nucleotide sequencing of three membrane-associated genes (SH, G and F) of four local isolates was performed. Comparison of their nucleotide and amino acid sequences with those of the prototype strains A2 (subgroup A) and CH-18537 (subgroup B) indicated that the Singapore isolates belong to the subgroup A. Comparison of the Singapore isolates with the reference strain A2 showed that whereas the G protein was the most divergent with up to 15% difference, the F and SH proteins showed less diversity of only up to 4%. Each gene exhibited its distinct variable and conserved regions. The N- and O-glycosylation sites within the G protein of the isolates were analyzed to ascertain their potential implications on the antigenicity of the viral glycoprotein. Based on the second variable region of the G protein, phylogenetic analysis of the Singapore isolates with 91 previously identified genotypes of subgroup A revealed that more than one genotype (GA2 and GA5) may circulate in the local population at a given time. This epidemiological study reflects the pattern of genetic relationships between the HRSV isolates from Singapore to those from other parts of the world.

Adult↗

Aged care services in Singapore--an overview.

INTRODUCTION: Aged care services have been rapidly and systematically established in Singapore over the past two decades in anticipation of the challenges that will accompany the rapid ageing of our population. This paper presents an overview of the geriatric services that have developed in Singapore, funding for these services, and aged care-related training programmes for doctors and nurses in Singapore. METHODS: A non-systematic review of journal articles, local conference proceedings and state publications was undertaken. RESULTS: Geriatric services have evolved rapidly with the establishment of 3 acute geriatric medicine units covering the different sectors of Singapore. Apart from the provision of acute medical care for older persons, geriatricians have also been increasingly involved in the enhancement of community aged care services under the Framework for Integrated Health Services for the Elderly. Concurrently, community services for the elderly have blossomed under the leadership provided by various voluntary welfare organisation. Innovative systems of funding the healthcare needs of older persons have also evolved over the past few years. In recognition of the increasing needs of our ageing population, the medical training curriculum is being continually reviewed to enhance the skills of medical practitioners in Singapore. CONCLUSION: Over a short span of 20 years, a comprehensive framework of services has been developed to meet the needs of our ageing population. While much has been accomplished, there is a need for continuous review of our services and healthcare policies to identify areas for further improvement.

Aged↗

Polypharmacy and inappropriate medication use in Singapore nursing homes.

INTRODUCTION: At present, 7.2% of the population in Singapore is in the geriatric age group, which will increase to 18.4% in the year 2030. The frailest segment of the geriatric population live in nursing homes. They suffer from multiple co-morbidities requiring multiple medication use. Polypharmacy and inappropriate medication use have been considered as quality indicators for nursing home care. As no data of these indicators are available in Singapore, this study was planned to assess the prevalence of polypharmacy and inappropriate medication use in Singapore nursing homes. MATERIALS AND METHODS: A total of 454 residents in the geriatric age group residing in 3 randomly selected nursing homes were involved in the study. Case notes were reviewed for demographic information, clinical history and medication use. The data were analysed for polypharmacy (5 or more medication orders) and inappropriate medication use (based on established criteria). RESULTS: Residents were on an average of 5.32 medications. Polypharmacy and inappropriate medication use were seen in 266 (58.6%) and 318 (70.0%) residents, respectively. There was significant association between polypharmacy and inappropriate medication use [P < 0.001, chi2 = 82.56 at 95% confidence interval (CI)]. The most common medication-related problems were the use of medication without proper indication (n = 302), significant potential for adverse drug reactions (n = 281) and drug interactions (n = 141). CONCLUSION: The prevalence of polypharmacy and inappropriate medication use is high in Singapore nursing homes. Current practice of medication use in the nursing homes may lead to significant adverse drug reactions and drug interactions. A multidisciplinary approach involving geriatricians, nursing home physicians, nurses and pharmacists may potentially reduce polypharmacy and inappropriate medication use in Singapore nursing homes.

Aged↗

Trends in cancer incidence among Singapore Malays: a low-risk population.

INTRODUCTION: Inspection of trends in cancer incidence in ethnically or geographically diverse populations is important for the understanding of cancer patterns and also to provide clues for aetiologic studies. There is little information on cancer incidence among Malays, a low-risk population. The population-based cancer registration system in Singapore offers the opportunity in this regard. MATERIALS AND METHODS: A review of all newly diagnosed cancer cases among Singapore Malay residents in the period 1968 to 1997 was conducted to determine the time trends using data from Singapore Cancer Registry. Age-standardised incidence rates and average annual percentage change, using Poisson regression, were calculated. RESULTS: During the 30-year study period, a total of 9101 incident cases of cancer were diagnosed among Malays in Singapore. The 3 most common sites of cancer were lung, liver and colorectum in males; and breast, colorectum and ovary in females in the period 1983 to 1997. Leukaemia was among the top 10 cancer sites in both sexes. Malays generally experienced lower cancer incidence rates compared to Chinese, but rates have been increasing at 1.5% to 2% annually. Statistically significant increases in incidence were observed for most of the cancer sites. The incidence of nasopharyngeal carcinoma increased, while there were no significant changes in the general population. CONCLUSION: The relatively lower cancer risk among Singapore Malays might be attributed to genetic factors or closer adherence to a more traditional lifestyle. This study provides a baseline for comparisons with other populations with diverse cancer risk patterns in order to obtain a better understanding of possible aetiologic factors.

Asia, Southeastern↗

The founding of the medical school in Singapore in 1905.

This article traces briefly the origins of medical education in the early years of the Straits Settlements (Singapore, Penang and Malacca), which culminated in the founding of Medical School in Singapore in 1905. The first attempt was made in the early 19th century, when boys were recruited from local schools as Medical Apprentices to be trained as "assistant doctors". They were to assist the British doctors and doctors from India in running the medical services. This scheme was not successful. There are 3 landmark years in the evolution of medical education in the Straits Settlements, namely 1852, 1867 and 1904. In 1852, the Governor, to relieve the shortage of staff in the Medical Department, instructed the Principal Civil Medical Officer to organise a proper course of training for Medical Apprentices and to establish a local Medical Service. This scheme was also unsuccessful and the Straits Settlements continued to rely on doctors recruited from India. In 1867, the Straits Settlements were transferred from the India Office to the Colonial Office and became a Crown Colony. The Indian Government requested that all its doctors be sent back. This would have led to the collapse of the Straits Settlements Medical Service. As a stop-gap measure, the Governor offered the Indian doctors appointment in the new Straits Settlements Medical Service, and at the same time arranged with the Madras Government for boys from the Straits Settlements to be trained in its Medical Colleges. The first 2 boys were sent in 1869. In 1889, the Principal Civil Medical Officer proposed to the Governor that a Medical School should be founded in Singapore, but not enough candidates passed the preliminary entrance examination. The plan was shelved and boys continued to be sent to Madras for training. In 1902, the Committee on English Education proposed that a Medical School should be started in Singapore, but senior British doctors opposed this. On 8 September 1904, Mr Tan Jiak Kim and other local community leaders petitioned the Governor to start a Medical School, raised enough funds to establish the School and the Straits and Federated Malay States Government Medical School (predecessor of the King Edward VII College of Medicine, and the Faculties of Medicine, University of Singapore and University of Malaya) was founded on 3 July 1905.

Education, Medical, Undergraduate↗

Selection of medical students in Singapore: a historical perspective.

The selection of medical students in Singapore has been a contentious issue for more than 140 years. Initially, students were selected for Madras Medical College, the traditional source for medical officers in early Singapore, by a combination of an examination as well as an observed preceptorship at the General Hospital. With the establishment of the medical school in Singapore in 1905, the selection criteria have been progressively refined over the years. These have included a baseline academic threshold, linguistic competence and performance at an interview. In the past, other criteria such as gender and political suitability were important but at the present, only hepatitis B virologic status is a limiting factor for otherwise qualified applicants. Singapore's Ministry of Health reports an attrition rate of 10% from our medical school. This poses a challenge as there are far more qualified applicants for medical school in Singapore than there are places. This is a worldwide problem and locally, attempts are being made to further refine the admission process to ensure that the community as a whole is best served by the future doctors we select.

Achievement↗

Postgraduate medical education and specialist training in Singapore.

The Singapore Medical School celebrates its Centenary in 2005. This historical review is presented on Singapore's postgraduate medical education and specialist training programmes. The special informal role of the Alumni Association and its members during the early years and soon after World War II is highlighted. Postgraduate education and specialist training was more formalised only during the challenging years when Singapore became more autonomous and politically independent with the establishment of the Academy of Medicine, the School's postgraduate medical studies, the Singapore Medical Association, specialist societies and, more recently, the College of Family Physicians. Specialist training programmes and the process of specialist accreditation are also outlined. While Singapore has gone far towards developing a comprehensive programme of postgraduate medical education and specialist training, the process is still evolving and can be improved upon. As long as we keep pace with relevant and realistic strategies, the future for postgraduate medical training and specialist training should be assured.

Education, Medical, Graduate↗

2005 Distinguished Academician Lecture: Evolution of postgraduate medical education in Singapore--role of professional associations.

From 1910 to 1945, doctors in Singapore received postgraduate training through apprenticeship. During the early post-war period, some doctors in the public service were given scholarships to study in Britain and to obtain higher professional qualifications from the British Royal Colleges. The events that most influenced subsequent development of postgraduate education in Singapore occurred between 1956 and 1969: the formation of the Academy of Medicine and the Singapore Medical Association (SMA); organisation of courses for candidates preparing for examinations of the Royal Australasian and British Colleges; competition between the Academy and the University over responsibility for postgraduate medical education; the inauguration of the School of Postgraduate Medical Studies (SPMS); and the introduction of Master of Medicine (M Med) degrees in various medical specialties. From 1970 to 1999, there was expansion in several aspects of postgraduate medical education: SPMS awarded more than 2000 M Med degrees; the Singapore Medical Council (SMC) established a Register of Specialists and formed a Specialist Accreditation Board; the Academy formed Chapters in 10 specialties and developed Advanced Specialty Training programmes leading to Fellowship of the Academy of Medicine Singapore (FAMS); the SMA formed Societies in some 20 specialties; and a College of Family Physicians was inaugurated. There have been more developments from 2000 to 2005: the University restructured SPMS as a Division of Graduate Medical Studies within the Faculty of Medicine; the SMC implemented compulsory Continuing Medical Education; and the Academy converted 6 of its 10 Chapters into Colleges.

Education, Medical, Graduate↗