Ensuring everyone gets good doctors.
ONE of the basic principles
taught to all medical students and doctors is Primum non cere – first, do no
harm. It is a reminder that an intervention can lead to harm to the patient,
however well-intentioned it may be.
This principle is even more
relevant today than in yesteryears.
Healthcare today is complex and
more effective than before. However, according to the World Health
Organization, the likelihood of harm is high, with a one in 300 chance of being
harmed by healthcare compared to one in 1,000,000 chance of being harmed while
in an aircraft.
Data from developed countries
reveal that one in 10 hospitalised patients are harmed because of adverse
events or errors. Similar data has been found in local studies.
The future of patients and their
families depend on what doctors say and do. Imagine the good and harm that can
result from doctors’ actions and inactions.
The media focus on housemen in
recent years raises questions about the quality of medical education and
training, as well as the challenges in ensuring that everyone gets good
doctors, and by extension, the quality of healthcare patients will be receiving
in the future.
Studying medicine
There are more applications for
entry to medical schools worldwide. Many young people want to become doctors,
whether of their own volition, at the behest of their parents, or for other
reasons.
Until 2011, high academic
qualifications were the sole criteria for admission to all public medical
schools except University Science Malaysia (USM), which required an interview
as well.
Since 2011, the Malaysian Medical
Council’s (MMC) guidelines require all applicants to local medical schools to
pass an interview to assess the applicant’s aptitude.
Although the minimum academic
qualifications for entry into medical schools are prescribed by the MMC and the
Malaysian Qualification Agency (MQA), there are still reports of non-compliance
by some private medical schools. There are also reports that some private
medical schools take in more students than permitted.
The situation in foreign medical
schools is varied. Medical schools in advanced economies require high academic
qualifications and aptitude assessments. However, some medical schools in some
developing economies admit students whose academic results would not even
qualify them to enter a Malaysian university for other courses which require
lesser academic qualifications.
Many such students gain entry
through the good offices of the agencies of these medical schools.
It is necessary to emphasise that
selection for entry into medical school implies selection for the medical
profession. Findings from studies worldwide confirm that although some students
have achieved the academic qualifications required for entry into medical
school, they are not suitable for a career in medicine.
It is in the interest of the
public and such students that they should not gain admission, rather than to
have to leave the course or the profession subsequently.
Feedback from some public local
medical schools indicate that more than 50% of students do medicine because of
parental or peer pressure, glamour, hope of financial rewards later, etc.
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Can such
students end up as good doctors?
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Should the
quality of students doing medicine be of concern to the public?
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What should be
done to those admitted to local or foreign medical schools without minimum
academic qualifications?
The message to parents that good
examination results do not make a career in medicine suitable for their progeny
has to be repeatedly emphasised. There is nothing worse than getting into a
profession that is unsuitable for one’s personality.
Medical schools
There are currently 34 medical
schools for Malaysia’s population of 28 million, compared to nine and 12
medical schools in 2002 and 2007 respectively. Sixteen new medical programmes
commenced in 2009 and 2010.
Data from the Avicenna Directory
maintained by the University of Copenhagen, in collaboration with the World
Health Organization and the World Federation for Medical Education (WFME), show
that countries with similar populations like Australia (23 million), Saudi
Arabia (28 million) and Canada (35 million) currently have 26, 16 and 16
medical schools respectively.
Our ASEAN neighbours, Indonesia,
Singapore, Thailand and Philippines, with populations of 238 million, five
million, 65 million and 92 million respectively have 35, two, 19 and 54 medical
schools respectively.
Germany and the United Kingdom
have 41 and 38 medical schools respectively for populations of 82 million and
62 million.
The issue is compounded by the
fact that the government recognises more than 370 medical qualifications
worldwide. This list was inherited from our colonial masters and has been added
to over the years.
In addition, graduates from
unrecognised medical schools can sit for the Medical Qualifying Examination
(MQE) and, upon passing, will be registered by the MMC. The examination, which
used to be the final year examination of the University of Malaya, National
University of Malaysia and University Sains Malaysia, is now also conducted by
13 other universities.
The recent announcement that
there is no limit to the number of attempts at the MQE raises fundamental
questions about the quality of some of these doctors. Where in the world can
someone be permitted unlimited attempts at any examination, let alone in
medicine?
In spite of the marked shortage
of medical educators in Malaysia, the expansion of medical schools continued
unabated in the past five years, thereby exacerbating the shortage. The
majority of teaching staff in many medical schools are foreigners, some of whom
do not speak any of the local languages, and some with no previous teaching
experience.
It is not only the number, but
also the quality of medical educators that is crucial in producing doctors that
will make a positive impact on the public’s health. Medical educators are role
models for students. It is well known that a deficient doctor is reflective of
a deficient teacher; just as a child’s conduct is reflective of the parent’s.
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Do the local
medical schools take responsibility for the quality of their graduates? Are
they responsive to societal needs and act proactively to meet those needs by
addressing various issues that include selection criteria and admission
policies; curricular improvements with emphasis on the concept of social
accountability, medical ethics and human rights; and the quality and quality of
medical educators?
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Does the
quality of medical education focus on the core educational needs of a doctor,
providing him with the knowledge, attitude and skills necessary to address
public health and clinical challenges?
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Is this
achievable when medical education is so much driven by the profit imperative?
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What is the
quality of medical education in recognised local and foreign medical schools,
and how robust is its monitoring?
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What is the
role of agencies of foreign medical schools and how robust is their monitoring?
Housemenship
During the course of the newly
graduated doctors’ future practice, there will be continuing advances in
medical science and clinical practice, healthcare delivery and financing,
increasing expectations of patients and the public, and changes in societal
attitudes.
By itself, the basic knowledge
and skills taught in medical schools is insufficient. The housemenship period
is the time to start developing of the ingredients of the MMC’s “Good Medical
Practice” (http://mmc.gov.my/v1/docs/Good
Medical Practice_200412.pdf).
The young doctors have to learn
to always put the interests of their patients first, and that the doctors’
professional practices affect the experiences of patients and their families.
The skills of continuing professional development have to be developed so that
their practices can advance in accordance to changes in medical knowledge and
practices.
Prof TJ Danaraj, Foundation Dean
of Medicine at the University of Malaya, wrote: “There is a worldwide
acceptance of the views that the education of a physician extends over a
lifetime, each stage resting upon the preceding one, and each preparing him for
that which follows.”
Learning during housemenship is
significantly experiential. There has to be sufficient quality teachers for
this aspect of the young doctors’ training. The teachers, who are usually
specialists, have a crucial role to play as they are role models for young
doctors.
There has to be exposure to
sufficient numbers of patients for young doctors to gain the experience
required for independent practice. For example, they have to be exposed to the
different ways in which the common conditions, appendicitis and urinary tract
infections, present.
Failure to make an accurate
diagnosis will lead to threats to life in the former, and long term
consequences in the latter.
When there are few patients
relative to the many housemen, it will, inevitably, have a negative impact on
the latter’s training.
My classmates and I always
remember our housemenship year. Some of our specialists were good teachers;
some were less so. Some were excellent at expressing themselves verbally;
others expressed their skills with their hands. Some did ward rounds before
going home, and some even came back at night to do ward rounds.
We learnt from every specialist
and from ourselves; what to do and what not to do in differing situations. Time
was not a consideration. We finished our work before going home, whatever the
time was.
There were instances when we
would go to other wards or attend other specialists’ ward rounds, even after
work, to learn from cases with interesting features. Those were not easy times.
It was hard work, but our enthusiasm made the difference.
There were discussions and
analyses which made us better doctors because we learnt from our specialists
and ourselves. And, most importantly, we learnt how to learn.
The recent media report that “50%
of housemen in Sabah can’t cope, need retraining” (http://www.theborneopost.com/2012/05/17/50-of-housemen-in-sabah-cant-cope-need
retraining) is worrying.
Equally disturbing are media
reports of claims by housemen that they are overworked, training is minimal or
absent and there is “bullying” by specialists.
There are also statements by
specialists that some housemen work by the clock and that they do not even know
the names of some housemen assigned to their wards and clinics “because there
are so many of them”!
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What is the
quality of housemenship training and how robust is its monitoring? What is the
quality of healthcare that patients can expect from the large numbers of
housemen who need retraining?
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What happens
when they become Medical Officers after completing their housemenship? The
possible long term effects on the quality of healthcare delivery in the country
are indeed mind boggling!
Government agencies
It may interest the reader to
know that several government agencies are involved in medical education. The
Ministry of Higher Education (MOHE) controls all medical schools. It grants
approval to establish a new medical school and through the Malaysian
Qualification Agency (MQA), it requires all medical schools to comply with
accreditation standards.
The hospitals of the Ministry of
Health (MOH) and MOHE provide housemenship training and employment for Medical
Officers upon its completion.
There are reports from some
specialists that they find it increasingly difficult to cope with the dual
tasks of providing care to patients and training housemen, with the former
always having to take priority over the latter.
Even the Ministry of
International Trade and Industry (MITI) impact upon the health sector. There is
linkage between goods and services in MITI’s trade negotiations with the World
Trade Organization (WTO), ASEAN and other trading partners. The concessions
permitting the presence of foreign ownership of private healthcare facilities
and practising rights for foreign doctors in Malaysia will inevitably have an
impact upon the quality of healthcare provided.
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It is
regrettable that there is no published national medical manpower planning
policy. How many doctors does the country need, and by extension, how many
medical schools?
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Do the MOH and
MOHE provide feedback to medical schools, regarding the skills, knowledge,
attitudes and competency of their graduates? What is the quality of the
feedback? Do the medical schools act on the feedback?
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How many top
notch foreign doctors will come to Malaysia to practise on a long term basis?
What mechanisms are there in place to assess the quality of foreign doctors
intending to practise here? Are there robust and valid assessment mechanisms in
place?
Malaysian Medical Council
The MMC’s function is that of
recognition of medical schools and professional regulation, based on its Code
of Professional Conduct and its guidelines.
The local medical schools are
given time-limited accreditation after assessments by teams comprising
representatives from the MMC and MQA. However, it is impossible to accredit all
the foreign medical schools recognised by the government because of manpower,
logistic and financial reasons.
Most governments in developed
economies acknowledge their limitations in assessing the quality of medical
education. They require all those who want to practise medicine, particularly
graduates from foreign universities, to pass a licensing examination.
Many Malaysian doctors who have
practised abroad, particularly those above 40 years, have passed these
licensing examinations without difficulty simply because of the quality of
medical education they received.
Why is there no licensing
examination when about half of the doctors commencing housemenship are
graduates of foreign universities?
The number of disciplinary cases
per 1,000 doctors dealt with by the MMC has increased in recent years. Although
it is less than that of Singapore, the question as to whether the increase is
due to the public’s increasing awareness of their rights, quality of care or
both is not easy to determine.
Like all medical regulatory
authorities worldwide, the MMC is addressing the issues of professionalism and
performance measurement. This is of relevance as it is crucial to the
enhancement of the trust of the public in individual doctors, in particular,
and the medical profession, in general.
What this means
Many in the medical profession
have stated publicly their concern that there is more emphasis on the quantity
instead of the quality of medical graduates. The consequences in other areas of
studies may not be significant, but in healthcare, it can be a matter of life
and death for a patient or potential patient, which means all the population.
Healthcare delivery is so complex
today that it is crucial to have doctors who put a premium on patient safety.
If one has to make a choice, the public interest is better served by fewer good
quality doctors than larger numbers who are deficient in their knowledge,
skills or attitudes.
Society deserves nothing less.
Everyone, whether students,
parents, medical schools, governmental agencies and the MMC, has a role to play
in ensuring that everyone gets good doctors. However, the onus on medical
schools, policymakers and regulators is paramount.
In concluding, everyone, particularly
medical schools, policymakers and regulators, should be cognizant of the
instructive statements of Hippocrates (460-377 BC), Avicenna (980 – 1037) and
Sir William Osler (1849-1919).
Hippocrates wrote, “Whenever a
doctor cannot do good, he must be kept from doing harm”, and Avicenna “An
ignorant doctor is the aide-de-camp of death.” Sir William Osler’s statement,
“The best preparation for tomorrow is to do today’s work superbly well” is very
apt for medical education and training.
Dr Milton Lum
Dr Milton Lum is a member of the
board of Medical Defence Malaysia. This article is not intended to replace,
dictate or define evaluation by a qualified doctor. The views expressed do not
represent that of any organisation the writer is associated with.
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