By Dr. Ng Swee Choon
Aug 27, 2014
COMMENT Medical colleges in the country have been hogging the headlines of late. Certain medical colleges have shamed us publicly and internationally for allegedly not paying staff salaries and not settling their contractual dues.
If the medical colleges involved do not feel ashamed, we Malaysians and Malaysian doctors feel the shame. It is certainly not our Malaysian culture to be known across the world for this.
Recently, there was also the irresponsible statement by Deputy Education Minister P Kamalanathan to cut down on places in public medical colleges when the problem is with private medical colleges. Private medical education is now big 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 persons interviewed, unashamedly said that it was important for his company to have a medical college, because it is good for their branding. In other words, to give their business a better name.
There seems to be no concern about helping Malaysia produce better doctors for the rakyat.
There are now 33 medical colleges of various sizes and track records. The majority are privately owned. I understand that there are licences, already issued for another seven to eight more medical colleges.
Part of this mushrooming of medical colleges is because of the often quoted statistic that we should have a doctor to patient ratio of 1:400, which is better than a first world country. This data is used to justify having more medical colleges. Let us not forget that the doctor-patient ratio is never a standalone statistic to measure healthcare standards.
We must understand the healthcare needs of the country. Just simply aping the healthcare needs of another high income economy is too simplistic. The specific healthcare needs of each country will be different.
In high-income countries, this doctor-patient ratio is relevant to different disease patterns and a healthcare expenditure nearer or in excess of 10 percent of the gross domestic product (GDP). We in Malaysia, with a doctor-patient ratio of 1:800, spend only about 4.6 percent of our GDP on healthcare, but 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, but he is so poorly trained that he cannot help you. You may not be worse off than not seeing the doctor.
There is certainly no need for 33 medical colleges, many of doubtful quality, producing more than 3,500 medical graduates, many of whom are also of doubtful quality. This falling standard of the medical students is currently also affecting the standards of our public medical colleges.
What we need is four to five well-funded, well-staffed good medical colleges (preferably public institutions), 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 colleges
Do any of you know the state of affairs in many of the private medical colleges in the country?
Many have few permanent, full time staff. They hire contract doctors to teach.
Some medical colleges time the arrival of these contract medical teachers to coincide with the arrival of the regular checks by the Ministry of Education/Malaysian Medical Council committee. This gives a false picture to the inspecting team. Once the inspection is over, many contract teachers are also sent back.
The students that we admit into medical colleges 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 colleges 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 colleges short of teaching staff fill up their time-tables? Take a look at the time-tables of many medical colleges. They have the headings “self-directed learning” and “ward work” without any guidance and any supervisor.
Some medical colleges’ time-tables for their final year of study do not even cover 50 percent of the core curriculum. When queried, the answer is, “we prefer not to spoon-feed them, we want to let them study on their own”.
Guess where these students are? Many are anywhere except in 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 exams. It will save the parents plenty of money. Is this the kind of medical colleges 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.
No private college has its own hospital
None of the private medical colleges have their own hospitals! So they borrow the use of public hospitals.
Today, there are some public hospitals in Kuala Lumpur that have medical students from two or three medical colleges walking the corridors. The patients are utterly fed-up and many refuse to cooperate with the medical students.
So the medical students do not have enough patients to practise their interviewing techniques and medical examinations. The medical students also do not get enough opportunities to observe procedures and new treatment methods.
Without their own hospitals, private medical colleges cannot attract good medical specialists to teach, because medical specialists want to continue to practise their skills. So the medical specialists who teach in private medical colleges 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 in an article in Malaysiakini called them “de-skilled”. There are many specialist teachers in private medical colleges who are de-skilled.
So now, you have poor quality students, studying under a “no spoon-feeding system” that is alien to the students. The students have to adapt overnight, by hook or by crook. The students are taught by mainly “de-skilled” medical teachers (except for a few). What do you think will be the end result?
It is important that by law, all private medical colleges 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.
Implications of poorly trained medical graduates?
If the medical graduates are too many and poorly trained, it will be 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 materials. That will mean that when they are become full-fledged medical officers, they will not be prepared for independent clinical work.
So when they go to district hospitals and rural hospitals, they cannot cope and so the “play 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 colleges that are small and without adequate teaching staff should be told to merge. Either merge or close and have your students transferred to another medical college. The cost of all this will have to be borne by the colleges themselves. This is an important first step.
Laws must be passed to allow the 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 colleges, especially their teaching staff numbers and quality.
All graduates from all medical colleges must sit for a common qualifying exam. Medical colleges whose graduates do poorly must be closely monitored and their licences reviewed.
The ministry should also hold regular meetings with student bodies and teaching staff of private medical colleges 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 fees (which is a lot) and do not care what happens. Help the country. Help your child to be a better trained doctor.
It should be the policy of government not to allow the commercial interests of private medical colleges to override public interest. The objective of medical colleges must be to train doctors to take good care of our citizens, particularly our workforce, so that we have a healthy, good workforce 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.
DR NG SWEE CHOON is a senior doctor in Selangor and he penned this out of great concern for the state of healthcare in the country.