Tuesday, June 15, 2010

Thoughts on Medical Education






The future lies in what the present leadership plans. As such prediction of future of Malaysian medical education scenario can be accurately done by judging the trends over the last few years, reflecting the thinking of medical education leadership in the country. The needs of medical education have and will never change i.e. to produce competent clinicians to serve the health needs of the population.

Published data has shown that Malaysia has done extremely well in improving the state of health of its population, marked by impressive data on indicators such as Infant and Maternal Mortality and the indices to the Millennium Development Goals.

The dramatic improvement of our health care indicators must surely be partly attributed to the rapid increase in the number of doctors serving the population, flooding the system from various training establishments. 24 medical faculties are now actively training doctors for the country, compared to 3 medical schools for a period of 16 years from 1963 to 1979. This exponential increase is made possible through the Private Higher Education Act 1996 which allowed the setting up of private higher institutions and medical schools, in addition to faculties attached to public universities. Currently the numbers of private medical faculties outnumber public faculties by 1.4:1. The numbers of newly graduated doctors have more than doubled for the last 4 years. 978 provisional registrations were given to house officers in 2006, 1426 in 2007 and 2516 in 2008. When combined with the number of medical graduates trained and recognized in 370 medical schools overseas, the estimated number of new doctors can exceed 3000 per year as newer local faculties start graduating their medical students, competing for housemanship training in less than 50 approved training centres nationwide. This surge of numbers of new doctors poses a new challenge to medical education. Housemanship is a period of practicing new skills acquired during basic medical training and is seen as an essential continuation of formal medical education from higher learning institutes. Without a parallel increase in number of housemanship centres and the availability of suitably-trained trainers, the competencies, readiness and experience of fully registered doctors entering the career pathway in Malaysia may be seriously flawed, posing a risk to the quality of health delivery.

In a preemptive effort to ensure quality in medical education, a National Board of Accreditation; the Lembaga Akreditasi Negara (LAN) was established in 1996 almost at the same time as the passing of the Private Higher Education Act. Although the initial reason was to oversee the educational approaches of private medical colleges, this mission has evolved into a more ambitious plan of overseeing the standards of education of all universities and colleges in public and private sector. In 2007, LAN was replaced by the Malaysian Qualification Agency (MQA) through the Malaysian Qualification Act of 2007. The aim was to establish a far ranging desire and authority of monitoring standards of educational programs and institutions. At the same time, a common criterion for accreditation of medical schools was established. The standards are contained in the ‘Guidelines on Standards and Criteria in the Accreditation of Basic Medical Education Programme in Malaysia’,revised and approved by the Malaysian Medical Council in August 2007 together with the establishment of “ A Joint Technical Committee for the Accreditation of Medical Programmes” responsible to oversee all matters pertaining to accreditation of medical schools either locally or abroad. As can be seen, within 10 years of liberalizing the education system, a firm criterion for ensuring quality medical education was established in the country. This augurs well for the future of quality medical education provided the judgments made by the various technical committees involved in accreditation of medical schools are free from factors beyond what is stipulated in the published referenced documents.

A quick check in our medical schools will reveal that all local medical schools have been visited by our national accreditation teams. Some have been reprimanded for taking in more students than what has been stipulated based on the permitted ratios; others have had their annual intake suspended for breach of rules. Well financed public medical schools have not been spared. Some have had to extend the duration of training for their students when accreditation teams discovered that their declared program fell short of the training requirement.

Such firmness of accreditation teams gives a sense of confidence to the public that a credible system is indeed in place to ensure that medical schools in Malaysia adhere to a set international standard. I have, in my travels visited many medical schools worldwide and I am privileged to state here that the schools in Malaysia are certainly under stricter scrutiny compared to some overseas institutions that we send our students to over the past years. If this trend continues there is some guarantee that Malaysia will be able to compete in medical education with most established medical schools in the world.

Another check reveals that Malaysian medical schools are not short of innovations and are certainly at the ‘edge of technology’ in their approach to medical education .Accreditation requirements of ‘outcome-based’ makes medical schools scramble to make that loud pronouncement. Fanciful clinical skills lab are mostly in place, despite wide availability of patients in clinics and wards who are ever so ready to be involved in training and teaching of medical students.. Assessment system becomes trendy and fashionable. There are now talks of using the ‘Virtual Curriculum”, simulated patients, and open book assessments. Various types of MCQs, OSCEs, MEQs, SAQs , BAQs and SEQs are made available, all in line with international ‘norms’, making everyone feels good and comfortable.

However the the basic question remains. Are our medical students getting sufficient guided training and exposure to clinical medicine through clinical apprenticeship, role modeling and learning hands-on from experienced medical teachers in these medical schools?

Such data is difficult to obtain. I’d like to define ‘seasoned medical teachers’ as those medical specialists with more than just a fleeting moment ‘teaching and educating’ but have spent their lifetime practicing holistic clinical medicine; keenly witnessed by their students. A quick check reveals that more than 60 % of top level and senior specialists we have in the country are in the private sector, shielded from direct involvement of training medical students, due to the nature of their jobs and the expectations of their clients. Most , if not all of these specialists are renowned public figures in medicine and surgery ,and had formerly served in the public sectors, medical schools or public hospitals , swarmed by numerous medical students eager to get even the tiniest trickle of skills and experience they posses. Their move to the more lucrative private sector virtually cuts them off from passing on their wisdom and skills to students. Many of them feel uneasy in the beginning , a bit of guilt sometimes, but with passing of time, a set routine is established and calls for them to contribute voluntarily or otherwise to teaching of students is often drowned by other pressing needs; to attend to patients who their superiors and share holders now call ‘clients’. Clients as they are; they are always right and must be attended to at a moments notice.

This trend is not set to change, sadly. For as long as the public sector remains unattractive and unsympathetic to the plight of medical educationists ,calls on loyalty to the nation alone is not sufficient for experienced medical teachers to stay in the public sector , serving , teaching, setting assessments, vetting and researching. Even the most ethical and experienced medical teachers, like all others, have young families to raise, humble worldly lifetime ambitions to fulfill and time-honored targets to meet. Loyalty is most often assured if most of these minor worldly pursuits could be achieved through hard work and fair compensation. One begins as a fierce loyalist, and an idealist only to realize that this does not pay off except through accelerated presenile ageing, unbearable tolls on physical appearance and worst of all, for some; having to beg for scholarships to ensure decent education for their own children!

Our system has so far failed to recognize the pain and endurance of being a good medical teacher, a healthcare provider and in addition a renowned researcher, all in a single unfortunate soul surviving on a 24-hour day and night cycle of borrowed time. This oversight can indeed be costly; for if it continues, role modeling by senior medical teachers will be a thing of the past and be sorely missed .Gone will be the days when students see their senior physicians in the wards, in body and spirit talking and counseling patients, and witnessing the fine art of medicine and absorbing the richness of doctor-patient relationships. Seniors will simply not be there to be ‘exhibited’.

Medical teachers in research-intensive medical schools have several added perils. Foremost, is the need for them to excel, fitting in with the lofty institutional visions and complying with the ‘decree’ that they have to compete and surpass everyone in the world that their Vice Chancellors have come across during their kilometers of travels. They are expected to lay golden eggs, regardless of the feeds they receive. Golden eggs, brings golden rewards, and in turn ensure continuity of academic leaderships and the fine trimmings associated with it. Many medical schools have now started to give financial rewards to publication with Impact Factor, the proportion of which increases with the numerical value of the latter. Of course, to balance it all, many have started rewarding teaching excellence but through methodologies unfamiliar to clinicians. Many ask their medical educators to provide evidence of what kind of teaching they do and judgments will be made if the teachings faintly resemble that of a senior physics professor or a learned academic from social science. While research publications can certainly be evidenced, the thought of video taping daily teaching ward rounds or 8 hours worth of orthopedics surgery is too much to expect from these noble souls! As such, experienced medical teachers who teach and guide students in the busy wards, spending countless hours on their feet in operating theatres, have little to show as evidence; hence receive little recognition, except perhaps from God.

It appears that in order to remain visible in an academic hierarchy and be considered worthy, one has to conform to the well established performance index. If that index excludes the work of a senior clinician, then medical education, apprenticeship and role modeling will be left in the hands of the young, inexperienced mass of postgraduate students prowling the wards, or worse, to the far-too-many house officers in a single clinical department. Other academics may be in their cool and comfortable rooms, writing their next academic manuscript.

The future of this sort of medical education is bleak.