This article is written by: Dr Kate Carter, Kai Li Chia, Vanessa HY Teo, Louisa Goodchild, Eunice Eun Hwa Yang, Catherine Bowen, Emma Cowley, Keith McCormick, Manjari Lahiri, Peter PM Cheung, Deborah E Turner
This article outlines the development of a new clinical academic partnership in Singapore, which can be used as a framework for establishing research pathways for podiatrists in different settings and countries.
The benefits of research activity by clinicians are well recognised, with research activity linked to better patient outcomes, increased patient satisfaction and improved healthcare performance [1-3]. To increase research activity in clinical practice, a key objective for healthcare services is to develop research capabilities within the workforce, with clinical academic career progression embedded in strategic workforce plans [4].
Clinical academic roles are defined as roles that combine advanced clinical practice with research activity and research leadership [5]. However, the culture of clinical practice environments often limit opportunities for clinical academic development [6], resulting in a strong clinical bias amongst advanced practitioners with limited focus on research [4]. Lack of research time [7], challenges in accessing professional development in research skills and no clear career pathway other than moving into senior managerial positions [4], have been highlighted as significant barriers to clinical academic practice [8,9]. To overcome these challenges, clinicians, employers and academic institutions need to work collaboratively to develop capabilities among clinicians in research in a formal and sustainable way [4,10].
Key barriers to increasing the number of research–active podiatrists in Singapore include the absence of local academic institution links for podiatrists to access support and guidance. Clinical academic partnerships are essential to support the establishment of relevant research, research capacity building and to support the implementation of research findings into practice [4,11-15]. This article outlines the development of a new clinical academic partnership in Singapore, but as earlier stated, it can be used as a framework for establishing research pathways for podiatrists in different settings and countries.
In Singapore, podiatry undergraduate and postgraduate programs are not offered in local universities. Instead, Singapore’s Ministry of Health Holdings (MOHH) offers Healthcare Scholarship funding for students to study a Bachelor’s and/or Master’s degree in podiatry at universities in the UK or Australia.
A bond period of six years mandatory employment within a public sector healthcare cluster hospital in Singapore commences immediately following graduation. As a result, most podiatrists practising in Singapore have obtained their professional qualification from the UK or Australia. Consequently, there is no local access to podiatry-specific academic support, no established podiatry research networks, no podiatry-specific university resources, and limited local podiatry-led post-graduate training opportunities.
Despite the continuing growth of both public and private sector podiatry services across Singapore, delivering a broad range of practice from limb salvage in acute settings through to sports and musculoskeletal care in adults and children, Singapore has produced only a limited podiatry-led clinical research output [16-23].
There are approximately 126 podiatrists currently working in Singapore with 96 working in the public health sector, the majority of which comprise an early-career workforce (<6 years postgraduate) [24]. There is one podiatrist to every 47,426 per head of population in Singapore [24] compared with one to every 5500 in the UK [25] and 4464 in Australia [26]. A high attrition rate among Singapore podiatrists working in the public sector has been previously reported in unpublished work conducted by the Podiatry Association Singapore and MOHH [24]. This suggests that better postgraduate career development and research opportunities are required to increase staff career satisfaction, fulfillment and retention.
The COVID-19 pandemic significantly disrupted the education and clinical placement of podiatry students throughout 2020 and 2021, resulting in universities having to adapt to online and remote delivery of course content whilst continuing to deliver and facilitate clinical training.
In 2020, second-year undergraduate podiatry students from Singapore who were enrolled at Queensland University of Technology (QUT) in Australia, Vanessa Teo and Kai Chia, were unable to return to Australia from Singapore due to a COVID-19 travel ban. To ensure seamless continuation of their degree training, they transferred to the podiatry programme at the University of Southampton (UoS) in the UK. The transfer was instrumental in the formation of a collaboration between the National University Hospital (NUH) in Singapore, UoS and QUT, since the podiatry department at NUH provided a bridging clinical placement that helped to support international students continue clinical studies during the COVID-19 disruption.
Dr Kate Carter, a principal podiatrist at NUH, is a member of an integrated multidisciplinary rheumatology clinic, and completed her PhD at Western Sydney University in Australia with Professor Deborah Turner, her primary supervisor, investigating inflammatory foot involvement among those with psoriatic arthritis.
Professor Turner, a professor in podiatry at QUT, has published extensively in the field of rheumatic foot disease and has maintained a close working relationship spanning six years with Dr Carter related to research and student placement programmes. Professor Turner continues to provide Dr Carter with post-doctorate academic and research mentorship.
Professor Catherine Bowen is the head of the Active Living Research Group and lead for the Optimization of Foot and Ankle Research program at UoS. Professor Bowen has published extensively in the field of inflammatory and musculoskeletal foot pathology and was awarded an adjunct professorship at QUT (2020-2023) by invited appointment to develop collaborations and capacity in podiatry-led research between QUT and UoS.
In 2022 Dr Emma Cowley visited NUH in Singapore to build on foundational work previously undertaken by Keith McCormick (Program Manager for Podiatry and Director of Internationalisation for the School of Health Sciences at UoS) and Professor Bowen to establish UoS practice placements in Singapore.
The UoS was awarded Turing Funding two years in succession to support students from all backgrounds to travel abroad for placements. Initially these placements were conducted in SingHealth, and NUH are also interested in supporting the placement model moving forward under Dr Carter’s team’s supervision, with a view to widening the initiative to other AHP professions including occupational therapy and physiotherapy. With the placement relationship strengthened, and common research interests identified, Dr Cowley was a natural fit to move into a research supervisory role within the team.
This triangle of close professional links between the three clinical-academic staff teams led to the development of a collaborative research strategy targeting BSc. (Hons) research projects linked to initiating a clinical podiatry-led program of work at NUH in Singapore. The strategy aims to inspire future podiatrists to specialise in rheumatology-related subjects, where the allied-health professional role is either poorly defined or lacking, and to support undergraduate student research in order to provide the foundation for a much-needed research capacity and capability of podiatry in Singapore.
Online supervisory meetings with Professor Bowen or Dr Cowley, Dr Carter and Professor Turner, typically lasted approximately one hour and were arranged on a regular basis using Microsoft Teams from 2022 to 2023. The time-zone differences dictated the meeting schedule of 8am in the UK, 4pm in Singapore and 6pm in Australia.
A Research Collaboration Agreement [Reference: RITM0450258] was established between the three institutions in order to overcome potential organisational and procedural challenges that can commonly arise between different organisations.
Some key areas requiring attention included intellectual property, data management and governance, budget and agreed deliverables. Ground rules and expectations for responsive communication and good working relationships were agreed at the outset. Supervisory meetings were both audio-recorded and minuted, both being archived on Microsoft Teams. Links and documents, such as published articles, were shared and stored using the Teams dashboard.
The research that the students undertook involved a secondary data analysis of the disease-related burden of inflammatory arthritis in Singapore using data collected at the NUH multidisciplinary rheumatology clinic, which comprises a rheumatologist, rheumatology nurse specialist, podiatrist, occupational therapist, physiotherapist and medical social worker.
This project provided the students with a unique multidisciplinary perspective on disease burden linked to health socioeconomic factors, comorbidities, activities of daily living, exercise participation, social support and coping strategies. Analysis of part of the NUH rheumatology data set enabled the students to fulfill their academic study objectives. These were divided into distinct and different, but intrinsically linked, research projects for the students to enable joint and independent working.
Students took an active role during meetings and were asked to lead discussions and provide peer-review and critical appraisal of work produced. Two rounds of BSc. (Hons) research projects have been supported through this collaboration so far.
Louisa Goodchild, a British podiatry student from UoS, and Eunice Yang, a Singaporean podiatry student from QUT, in the second round have established a peer-support relationship across 12,000 miles using web-based and audio-visual resources. Finally, students have presented their study rationale, methods and findings to the NUH senior consultant rheumatologists who undertook part of the clinical data collection. Fulfilling medical disciplinary input helped the students to strengthen critical analysis and reasoning skills and to refine their project write-up. Qualitative student feedback has been overwhelmingly positive, and is publicly available.
Professors Turner and Bowen have both achieved international recognition in their respective roles for championing allied health-led research. Involvement in this joint project has further built on an established track record in leading strategic multi-professional programmes of research.
Dr Carter was awarded an adjunct position at both QUT and UoS, enabling her to access digital resources, including data analysis software and the online library, as well as to maintain formal teaching experience, knowledge of the undergraduate curriculum, assessments and research components.
To date, this programme of work has resulted in four abstracts successfully accepted for poster presentation at the Australian Podiatry Association conference in June 2023 and the Royal College of Podiatry conference in the UK in November 2023, and four planned research publications in peer-reviewed scientific journals.
The academic institutions involved in this current strategy were keen to support capacity and capability development of podiatry in Singapore, and to facilitate both extension of scope of practice (e.g. diagnostic imaging) and the development of clinical research skills in the workforce.
It is important to recognise that in a small field of practice such as podiatry-rheumatology, unless there is worldwide collaboration between groups and harmonisation of approaches to research on the global stage, it will be difficult to achieve the statistical power to effect meaningful change in population research.
Other institutions can replicate this presented framework for international collaboration in podiatry, which focuses on research work that directly benefits podiatry services in Singapore whilst strengthening the research culture and capacity for the future workforce.
Key benefits of a collaborative clinical-academic partnership include:
References
Ethical approval was obtained from the National Healthcare Group Domain Specific Review Board Singapore (Reference: 2022/00037).
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