On August 1, 2007, Duke University Medical School effectively expanded its entering class of students from 100 to 126 without adding any new auditorium seats, lab benches, faculty, or costs to its campus in Durham, North Carolina. Instead, these 26 medical students will study according to the Duke curriculum at a site almost precisely on the opposite side of the globe under the auspices of a new entity called the Duke–National University of Singapore (NUS) Graduate Medical School (GMS).
A Brief History of the Duke–NUS GMS
The story leading up to this founding event began in 2000 when an advisory group headed by Lord Oxburgh from Cambridge, United Kingdom, counseled senior ministers of the Singapore government on measures to enable their small island nation to succeed as a regional hub for biomedical sciences and industry. The “Oxburgh report” recommended the establishment of a new medical school to educate physician–scientists and clinician–investigators in Singapore modeled after the postbaccalaureate (MD) medical education that prevails in the United States. This would be distinctive from the MBBS system that is the primary method of medical education in Singapore and throughout most of Asia, in which students enter medical school directly after completion of high school. A new “graduate medical school” in Singapore was thus proposed as a component of a national investment in biomedical sciences that also included the establishment of the Biopolis,1 which houses a national biomedical research hub of both public and private institutions, a competitive grant program modeled on peer-review standards of the U.S. National Institutes of Health, and investments in their existing academic and health care institutions. To establish a new medical school, the Singapore government sought a U.S. medical institution to partner with the NUS. No formal competitive process was announced, but Singaporean representatives engaged in discussions with the leadership of a number of American academic medical centers. Negotiations with Duke University School of Medicine followed initial overtures from Singapore and began in earnest in 2001. A formal contractual agreement was signed in 2005 to found the Duke–NUS GMS2 and to enroll the first students in 2007. The agreement calls for Singapore to invest, during seven years, approximately $350 million from its ministries of education, health, and trade and industry. About one third of the funds are designated for the construction of a new research and educational facility to house the school, with the remainder for faculty and staff salaries, start-up research funding, travel, information systems, and other infrastructure needs. Duke committed to provide leadership, faculty, staff, curriculum, and operating systems to meet an aggressive timetable of milestones. The vast majority of these operating funds are expended in Singapore, though costs of services provided from Durham are reimbursed to Duke.
The Duke–NUS GMS was formally chartered on July 1, 2005, under the leadership of the dean (R.S.W.) and senior vice dean (P.J.C.) from Duke. The first Singaporean to join the faculty was the vice dean for clinical and faculty affairs (K.C.S.). Because one individual served concomitantly as dean of the school of medicine at Duke and dean of Duke–NUM GMS, this placed governance of the both the Durham campus and the Singapore campus under a single chain of command. The senior vice dean relocated his family to Singapore to take on the responsibility for day-to-day management and supervision of other group leaders, and the dean led by means of quarterly trips to Singapore and regular electronic communications. The early recruitment of the vice dean for clinical and faculty affairs, who was also head of the National Cancer Centre in Singapore, enhanced relationships with members of the local medical community and accelerated the ability of the dean and senior vice dean to function within the medical and cultural environment of Singapore. A physician–educator (R.K.K.) was recruited from the University of California–San Francisco in the spring of 2006 to become vice dean for medical education, and the chairman of Duke’s department of psychiatry and behavioral sciences (R.K.K.) relocated to Singapore to round out the academic leadership team in 2007 as executive vice dean. Close coordination with the NUS has been led by the active participation the provost of NUS in several key governance committees. Figure 1 shows the organizational structure of the Duke–NUS GMS.
The current budget and facilities of Duke–NUS GMS have been designed to support an academic faculty of approximately 50 full-time educators and investigators and a part-time teaching faculty of 100 to 150 clinicians. Target enrollment into the four-year MD curriculum was planned at approximately 25 in the inaugural class and 50 per year thereafter, of whom an estimated 20% will pursue both the MD and PhD degrees. The 2007 entering class comprises 26 students who are citizens of seven countries (Singapore, Malaysia, Indonesia, China [Hong Kong], India, Philippines, and the United States). They are honors graduates (median GPA 3.7) of leading universities of Singapore, the United States, the United Kingdom, and Australia, and they were selected from several hundred applicants. Students who successfully complete the four-year course of study will be granted a joint medical degree from Duke and NUS on graduation.
To date, 30 academic faculty have been recruited, including 12 from institutions in the United States (Duke University School of Medicine, Yale University School of Medicine, University of Chicago Pritzker School of Medicine, University of California–San Francisco School of Medicine, Medical University of South Carolina, University of Utah School of Medicine, Vanderbilt University School of Medicine, and University of California–Irvine School of Medicine) and the remainder from Singaporean entities, including a number of clinical faculty from the national health service. An administrative staff of 100 will work within the organizational structure. Our ability to deliver a first-year curriculum in 2007 based on Duke’s program with less than two years of preparation in Singapore required the active and enthusiastic participation of many faculty and staff from the Durham campus, and a similar level of engagement by Singaporean physicians, primarily from the SingHealth System, one of two branches of the publicly supported national health system in Singapore.
In lieu of the departmental structure common to most American medical schools, research activities of the Duke–NUS GMS are being organized according to a two-dimensional matrix of biological/clinical themes (signature research programs in the areas of cancer, cardiovascular disease, neurological disorders, eye disorders, and emerging infections) and research modes (discovery, translation, and clinical); additionally, a program in health services research will be established (Figure 2). The strategy and quality of the research mission are overseen by a scientific advisory board, with representation from the United States, United Kingdom, and Australia.
The Duke–NUS GMS currently resides in temporary quarters while construction of a permanent 230,000-square-foot facility is under way at a site immediately adjacent to the Singapore General Hospital, a 1,500-bed hospital that will serve as the primary clinical teaching facility. The Duke–NUS GMS permanent facility will be named in honor of local philanthropist Tan Sri Khoo Teck Puat in recognition of his family’s gift of 80 million Singapore dollars (approximately $50 million); an amount equally matched by the Singapore government. This facility is located adjacent to the historic college of medicine building, which currently houses the Singapore Ministry of Health. The college of medicine building was the home from 1926 to 1986 of Singapore’s original medical school, which currently is located on the campus of the NUS a few miles away. The Khoo Teck Puat Building will place all of the educational, research, and administrative activities of the Duke–NUS GMS in a single location, except for direct contact with patients.
The charter of the Duke–NUS GMS calls for the dean to report directly to an independent governing board, comprising representatives from Duke, NUS, the sponsoring ministries, the national health system, and prominent members of the Singapore business community. The MD degree to be awarded to graduates of the Duke–NUS GMS will carry the full imprimatur of both Duke and NUS. The chancellor for health affairs (V.J.D.) and the president of Duke made visits to Singapore during the period of active negotiation with the government, and the chancellor serves on the Duke–NUS GMS governing board as Duke’s senior representative.
The scope of the mission of the Duke–NUS GMS is focused entirely on medical education and research, though it functions in a close relationship with SingHealth,3 which manages three hospitals and a full array of primary care and specialty services and is comparable in scale with the Duke University Health System. The senior executives of SingHealth, as well as the physician leadership of the various medical boards, departments, and divisions, are active participants in Duke–NUS GMS committees, and several have taken faculty appointments based on major effort allocated to teaching and/or research functions of the school. Physicians employed by SingHealth will comprise the majority of clinical teaching faculty of the GMS, and clinical clerkships for Duke–NUS GMS students will occur primarily within patient- care facilities of SingHealth. We also anticipate a rich network of collaborations, particularly in clinical, translational, and health services research investigation.
Why Duke for Singapore, and Why Singapore for Duke?
The original rationale for a new medical school as recommended by the “Oxburgh Report”—the education of physician–scientists and clinician–investigators—made Duke’s unique curriculum (Chart 1) a special attraction to planners in Singapore. This basic structure dates from the 1960s at Duke, and it remains unique in several respects. Preclinical education is delivered in a single year in four basic blocks, with a “practice course” running through the entire first year to prepare students for clinical rotations in the second year. The third year is devoted to independent scholarship conducted with a faculty mentor and includes a thesis requirement. In the fourth year, students return to active clinical apprenticeships on an elective basis. More recent modifications to this basic framework were added in the form of several one-week “clinical core” sessions during the second year to ensure a consistent experience by all students in certain critical areas, and by the addition of a “capstone course” that reunites each class to ensure they are well prepared for postgraduate medical education. Duke requires all students to pursue a full year of research during the four years that lead to the MD degree. In exporting the curriculum to Singapore for Duke–NUS GMS students, a variety of new distance learning technologies have been introduced, complemented by a greater emphasis on team-based problem-solving exercises. Affiliation with the Duke Clinical Research Institute, with its experience in coordinating large-scale clinical trials and in facilitating career development for clinician–investigators engaged in patient-oriented research, and Duke’s proximity to North Carolina’s Research Triangle Park, a major site for biomedical business development, were viewed as additional positive factors. Singaporean decision-makers, however, have pointed to Duke’s willingness to commit its medical school dean and key senior faculty to lead the project personally, and to consider the venture as a strategic priority rather than a conventional outreach or exchange opportunity, as perhaps the most important feature from their perspective.
From the Duke perspective, why and how did such a distant venture justify such a major investment of Duke’s human capital and energy? Foremost was Duke’s ambition to become an active participant in the globalization of biomedical sciences, medical industries, and health care. Duke leaders have expressed strategic goals that include exposing learners to a greater diversity of cultures, beliefs, and practices in the health care arena, so that students and faculty, in Durham and in Singapore, have a special richness of experience and understanding of globalization trends and of their opportunities and risks. The partnership with Singapore provides Duke with new opportunities to learn and gain value from the expanding influence of Asian nations in science and medicine. In addition to the GMS, Duke’s aspirations in this regard are reflected by the founding in 2006 of the Duke Global Health Institute.4
Duke expects to derive value from the Duke–NUS GMS venture in other ways. Preparing its curriculum for export already has yielded opportunities for curricular review and innovation that would otherwise have been difficult to implement at Duke and that may have a significant impact on how medical education is delivered in the future. To keep the basic science instruction in Singapore similar to that at Duke, a new educational paradigm grounded in student-directed and faculty-guided learning options has been developed. Duke–NUS GMS students independently review a menu of streamed videos of Duke’s lectures and PowerPoint presentations combined with appropriate reading materials, including selected articles from medical journals and handouts. On-site didactic lectures in the classroom have been almost entirely eliminated, such that direct encounters between faculty and students occur primarily in small-group discussions, labs, and highly interactive learning sessions centered around a modification of the “team based learning”5 educational technique, dubbed TeamGMS. Students work in teams to solve problems posed by faculty, using the information they have been asked to learn independently before class. TeamGMS allows the faculty to focus their teaching time in class on expanding, illustrating, and demonstrating the application of the knowledge the students have just acquired rather than simply delivering content via lectures. Students must become actively engaged with the material and are challenged by the faculty to develop the critical-thinking and communication skills that are important for future academic careers.
Some current medical students in Durham assert they chose to attend Duke because of special opportunities to study abroad and to build relationships with overseas colleagues. Each of the incoming Duke–NUS GMS students has a “big brother/sister” from among Duke medical upper-class students, and we anticipate bidirectional travel of students between Durham and Singapore for research and clinical learning experiences. Six student government leaders from Duke participated in the Foundations Course that opened the school year for incoming Duke–NUS GMS students in August 2007. During each academic year, beginning in 2007–2008, two Duke students from Durham will be awarded scholarships to spend their entire research year working with a Duke–NUS GMS faculty mentor and interacting with Duke–NUS GMS students in Singapore. Opportunities will exist for Duke–NUS GMS students to pursue their research year in Durham and for MD/PhD candidates to choose a Durham mentor for their PhD years. Students on each campus may elect to pursue clinical rotations in both locales. Thus, we have expanded options for Duke students to have overseas learning experiences and increased the talent pool of individuals working under the Duke banner in both locations.
In research, American medical schools are struggling under the current austerity of National Institutes of Health budget contraction, with no clear end in sight. The Duke–NUS GMS can offer exceptionally favorable start-up packages based on intramural funds (five years of full salary and benefits plus research support equivalent to an R01 grant, or more for senior investigators), as well as the opportunity to compete for peer-reviewed competitive research funding. Scientific talent and manpower are expanding in Singapore, including Singaporean researchers trained in the United States, United Kingdom, and elsewhere, and an influx of notable foreign scientists such as Sir David Lane, Sir Colin Blakemore, Alan Coleman, Edison Liu, Ed Holmes, Judith Swain, Neal Copeland, and Nancy Jenkins. Regulatory practices in research meet high ethical and moral standards that most U.S. investigators find comfortable and appropriate, but Singapore may provide opportunities in certain areas (e.g., primate research, human embryonic stem cells) where political or other constraints create barriers for U.S. scientists. Certain areas of patient-oriented research and health services research seem particularly promising in Singapore because of its stable multiethnic population, high levels of education and access to health care, and efficient system of health care governance and financing. At a time of a constrained domestic market for funding academic medical research in the United States, Duke’s overseas partnership provides department chairs and center/institute directors in Durham with additional opportunities for recruitment and program development in Singapore.
The Sustainability of the Duke–NUS GMS
Will this experiment in globalizing medical education succeed? The early signs are promising, but only a longer experience will tell. It has proven possible to attract highly qualified students and faculty, and the relationships between the key stakeholders have grown stronger as unforeseen obstacles have been overcome and as cultural differences have been examined and managed. The next two years will be pivotal; the experience of the initial class of students in their preclinical and clinical clerkship years will influence the new school’s appeal to prospective future students. We expect faculty recruiting to accelerate as we near the opening of the Khoo Teck Puat Building in 2009. The project has been adequately capitalized by Singapore government funds, at least for its start-up period, and there has been a gratifying response from the private sector in Singapore, with pledges of philanthropic support already exceeding $60 million (90 million Singapore dollars). Because the government matches private gifts to local institutions such as the GMS, the fledgling school’s future has been bolstered already by more than $120 million of endowment and expendable reserves in addition to its operating budget, which was provided by government funding.
Recruiting faculty to Singapore from U.S. medical schools has not been difficult. The excitement of a pioneering venture, stable research support, attractive compensation plans that include allowances for housing and travel, an interest in living in Asia, and a sense of adventure have been the common determinants of individual decisions to relocate by both senior and junior faculty. In some cases, a specific feature of the research environment in Singapore was believed to provide competitive advantage irrespective of resource availability.
The ministry of health and the Singapore Medical Council (which oversees licensing of physicians) have expressed a pleasing flexibility with respect to the structure of the postgraduate medical training experience that Duke–NUS GMS graduates will enter four years from now. Just as they have welcomed the dual existence of an American-style postbaccalaureate medical school to complement the successful and century-old MBBS program of the NUS, they are now proposing to create two pathways of specialty training leading to certification. A new pathway that mirrors the U.S. model of specialty residency and subspecialty fellowships, with intercalated periods of advanced research training, likely will run in parallel to the current British-style program of housemen and registrars. Singapore’s openness to new models should provide opportunities to optimize and coordinate the entire period of medical education (undergraduate and graduate) to produce fully prepared physician–scientists and clinician–investigators in the most efficient and effective manner possible. At present, the Liaison Committee on Medical Education (LCME) does not consider medical schools on foreign soil for accreditation. However, in view of the decision by other accrediting organizations from the U.S. biomedical sector (e.g., the Joint Commission) to extend their reviews to selected foreign entities, Duke–NUS GMS will seek LCME accreditation if the LCME adopts a similar position in the future.
What are the major risks? Not all of the recent partnerships between Singapore and foreign educational institutions have succeeded, and some degree of risk and uncertainty is inescapable. If the quality of Duke–NUS GMS students or the productivity of the Duke–NUS GMS faculty in research fails to meet expectations, we can rightfully expect the sponsoring ministries in Singapore to question their return on investment and to reconsider their funding commitment. Likewise, Duke’s leadership would certainly question the value of continuing the commitment if the expected standards of achievement are not being met. However, current leaders from both parties expect the relationship to be sustained on a long-term basis. The current contractual agreement between Duke and the Singapore government extends through 2012, and we expect to negotiate an extension well in advance of that date. Increasingly, Singapore is distributing its medical research support through competitive peer-review processes rather than by institutional block grants, thereby coming closer to what is familiar to U.S. medical schools. It is likely that a contract extension will continue some degree of block funding for research, but with a greater proportion of research support earned through competitive grant funding. The medical education component will require ongoing governmental support and/or major growth of endowment funds, because tuition revenues, as in the United States, cannot cover the full costs.
At present, we are aware of only one other example of a new medical school being established as a partnership between a U.S. medical school and a foreign government, and that is Cornell University’s program in the Middle Eastern nation of Qatar.6 Although we acknowledge that the Duke–Singapore venture is still at a very early stage, there are a few lessons learned so far that others with aspirations for global partnerships may find instructive. Duke’s ability to meet milestones in the Duke–NUS GMS project so far, and to build relationships that bode well for the future, has rested on several explicit decisions. Senior leaders of the institution at the highest levels became personally committed and engaged with the project at a significant level. Faculty representing the very best of Duke’s research and teaching pool were willing to relocate their families to the overseas location for a multiyear period. There has been frequent travel by Singaporean representatives to Durham, and vice versa, including visits to Singapore by many of Duke’s department chairs, senior faculty, administrators, and even trustees. Thus, the project has included an extraordinary level of personal familiarity involving scores of individuals from both parties, facilitating successful and prompt resolution of issues that were unforeseen in the framing of the original contract. Finally, the project was adequately capitalized with clear deliverables from both sides. Some of the contractual milestones and key performance indicators to be assessed in 2007, 2009, and 2011, as agreed on by Duke and Singapore officials, include number of faculty recruited from Duke and elsewhere; academic and professional standards of faculty; number of signature research programs established under strong leaders; student qualifications, enrollment, and performance; competitive grant funding; publications of high impact; and invention disclosures and patents.
The biggest challenge to the future of the GMS likely lies not in a failure of ambition or good will among the parties, but in the same fundamental tensions and pressures that also challenge medical schools and academic medical centers in the United States. All such institutions require a mutually supportive and respectful relationship between those responsible for delivering clinical care and controlling its costs, and those engaged in research and teaching. In Durham and in Singapore, these interests, though clearly aligned in the longer term, are often competing for effort, funding, and space in the near term. Singapore manages to provide high-quality and accessible health care to all of its citizens at an overall cost per capita (or as a fraction of gross domestic product) well below that of the U.S. health care environment. Its system has been tuned to a level of clinical efficiency that affords little time for academic pursuits by Singaporean physicians working in the major teaching and research hospitals. There is much ambition, but there are relatively few accomplished role models of physician–scientists and clinician–investigators who are a consistent feature of leading U.S. medical schools, and this must change to provide graduates of the Duke–NUS GMS with attractive career pathways in Singapore. Singapore has set itself on a path to expand its cadre of internationally distinguished academic physicians. This will be a challenge, but the cross-cultural dialogue within a truly global medical academic institution likely will bring forth creative ideas and solutions that otherwise may have been slower to emerge.