MEDICAL SCHOOLS IN MALAYSIA - FOR BETTER OR FOR WORSE?

Your article in the StarBizWeek on “Medical College Shakeup”, is certainly timely after  certain Medical Colleges has shamed Malaysia by recent bad publicity for allegedly not paying staff salaries and not settling their contractual dues. If the medical schools involved do not feel ashamed, we Malaysians and Malaysian doctors feel shame. It is certainly not our Malaysian Culture to be know across the world for  this. Recently there is also the irresponsible statement by the deputy minister to cut down on places in Public medical school when the problem is with private medical schools.

Private Medical Education is now a business.

I am writing to highlight this very important issue that Medical Education has now become a business, important only for the bottom line of the company owning the licence. One of the person you interviewed, unashamedly said that it was important for his company to have a medical school, because it is good for their branding, in other words to give their business a better name. There seemed to be  no concern about helping Malaysia produce better doctors for the rakyat.

The wrong reason to have medical schools

There is now 33 medical schools of various sizes and track record. The majority are privately owned. I understand that there are licences, already issued for another 7-8 more. Part of this mushrooming of medical schools is because of the often quoted statistic that we should have a doctor: patient ratio of 1:400 which is better than a 1^st world country.  This data is used to justify having more medical schools. Let us not forget that doctor patient ratio is never a stand alone statistics to measure healthcare standards.

We must see the healthcare needs of each country. Just simply aping another high income economy healthcare needs is too simplistic. The specific healthcare needs of each country is different. In high-income countries this ratio is relevant to  different disease patterns and a healthcare expenditure nearer or in excess of 10% GDP. We in Malaysia spend only about 4.6% GDP on our Healthcare, with a doctor : patient ratio of 1:800 and yet have similar  healthcare outcomes . Basically we have a good healthcare system and do not need a 1:400 doctor :patient ratio. Healthcare outcomes are more important statistics than just a simple doctor:patient ratio. You get to see a doctor ( he is there ) but he is so poorly trained that he cannot help you. You maybe worse off than no doctor.

There is certainly no need for 33 medical schools, many of doubtful quality, producing more than 3,500 medical graduates, many of which are also of doubtful quality. This falling medical students standards is currently also affecting the standards of our public medical schools. What we need is 4 to 5 well-funded, well-staffed good medical schools ( preferably Public ), together producing about 1,000 medical graduates annually, forming an annual increase of 5,000 new medical graduates ( together with those returning from overseas ).

  

The state of affairs in some medical schools

Do any of you know the state of affairs in many private medical schools?

Many have few permanent full time staff. They hire contract doctors to teach. Some medical colleges time these contract medical teachers arrival to coincide with the arrival of the regular checks by the Ministry of Higher Education / MMC committee. This gives a false picture for the inspecting team. Once the inspection is over, many contract teachers are also send back.

The students that we admit into medical schools are also of much lower standard. Many of them do not have the linguistic and technical skills needed to be a doctor. Many are products of “spoon fed” teaching methods. In established medical schools around the world medical students are not  spoon-fed. They must be able to think and work out a problem. This method is important as medical students (future doctors) must be able to work out the complexities of a patient’s sickness based on varied symptoms and signs.

The problem is that these students are unable to switch overnight from one system to another. Not to mention that many of the contract teachers themselves are from countries where “think for yourselves” is also NOT a strong point. So now we have a requirement not to spoon feed and students and teachers who know nothing except the spoon feeding method. That compounds the problem. Our secondary educational system is to blame.

So how do medical schools short of teaching staff fill up their time table? Take a look at the time table of many medical schools. They have the headings “ self directed learning” and “ ward work” without any guidance and any supervisor. Some medical school time table for their final year, does not even cover 50% of the core curriculum. When queried the answer we prefer not to “spoon-feed them”. We want to  “ let them study on their own”. Guess where the students are?  Many are anywhere except the ward and the library. Then they might as well just mark everyday “self directed learning” and the students just buy a thick medical textbook and study on their own. Just turn up for the exam. It will save the parents plenty of money. Is this the kind of medical school that we want? Is this the way we want our future doctors to be taught?

Now, when medical students reach Year 3, they have to begin to learn to begin their junior clerkship. Meaning they must learn to clerk ( interview ) patients to try and work out what disease the patient is suffering from. MOST OF THE PRIVATE MEDICAL SCHOOLS DO NOT HAVE THEIR OWN HOSPITALS.  So they borrow the use of Public Hospitals.   Now there are some public hospitals in Kuala Lumpur who have medical students from 2 or 3 medical schools walking the corridors. The patients are utterly fed up and many refuse to co-operate with the medical students. So the medical students do not have enough patients to practise their interviewing techniques and medical examination. The medical students also do not get enough opportunities to observe procedures and new treatment methods.

Without your own hospital, private medical schools cannot attract good medical specialist to teach, because medical specialist wants to continue to practise their skills. So the medical specialists that teach in private medical schools are part-timers. A specialist who is no longer in practice clinically, is a theory only medical teacher devoid of clinical relevance. All the while, medicine is progressing by leaps and bounds. My colleague in your article called them “deskilled”. There are many specialist teachers in private medical schools who are de-skilled.

So now, you have a poor quality students, studying under a “no spoon feeding system” which is alien to the students. The students have to adapt overnight by hook or by crook. The students are taught b mainly “deskill” medical teachers ( except for a few ). What do you think will be the end result? 

It is important that by law, all private medical schools must have their own privately funded teaching hospitals to provide for service and teaching. This will allow for better clinical materials, better supervision of students, and better clinical teachers.

What are the implications of poorly trained medical graduates?

If the medical graduates are too many and poorly trained, it is very difficult to redress this in the housemanship years. Here too we see the problem of too many housemen and not enough supervisors and clinical material. That will mean that when they are medical officers, they are still not ready for independent clinical work. So when they go to district hospitals and rural hospitals, they cannot cope and so “safe doctors” will refer everything (short of cough and cold ) to the district hospitals and general hospitals, further clogging up the system. The daring gung-ho ones will try on their own giving rise to complications and in some cases death. Currently there is a rising number of patient complaints in Public Hospitals.

What then is the solution?

To begin with, there should be NO MORE LICENCES FOR MEDICAL SCHOOLS.  Those private medical schools that are small without adequate teaching staff should be asked to merge. Either merge or close and have your students transferred to another medical school. The cost of all this will have to be borne by the school themselves. This is an important first step.

 Laws must be passed to allow setting up of private hospitals to be used for medical education. Of course, such laws must be properly drafted so that private hospital patients are protected.  We need better trained medical students but not at the expense of compromising private medical care. Some “carrots may have to be given to these “ private medical teaching hospitals”.

The relevant monitoring and enforcement agency in the Ministry of Education must keep a close watch on staffing in private medical schools, especially their teaching staff numbers and quality.

All graduates from all medical schools will sit for a common qualifying exam. Medical schools whose graduates do poorly, will need to be closely monitored and their license reviewed.

The ministry should also hold regular meetings with student bodies and teaching staff of private medical schools to get feedback. Parents of medical students should be advised to take a more active interest in their children’s medical education. Do not just pay the school fees ( which is a lot ) and do not care what happens. Help the country. Help your child be a better trained doctor.

It should be the policy of government not to allow the commercial interest of private medical schools to override public interest. Medical schools objective must be to train doctors to take good care of our citizens, particularly our workforce to that we have a healthy good work force to drive our economy.  To close an eye to the commercialisation of medical education will be a unmitigated disaster for the future healthcare system of Malaysia.

This article was written in respond to the recent many articles in the press highlighting the problems in Medical Schools and the Deputy Minister's statement ( subsequently refuted by the DG MOH ) that the government is thinking of restricting the number of enrolment to public medical schools.

This article was send to the Editor of STAR last night.