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PROCEEDINGS OF FORUM
“TRAINING FUTURE DOCTORS:
HAVE WE GOT IT RIGHT?”
Organised by Physicians for Peace & Social Responsibility
held on Saturday 29 November 2008 in
Institut Pengurusan Kesihatan, Bangsar, Kuala Lumpur
The primary objective of this Forum was to obtain an analytical and critical response on the many issues facing medical education in our country from the perspectives of training our future doctors to fulfill professional and national requirements.
The Forum participants included the Directors-General of the Ministry of Health and Ministry of Higher Education, and representatives from these ministries, senior academic and administrative staff of local public and private medical schools, , professional bodies and other decision-makers and stakeholders.
The following conclusions on the respective topics have been summarised from keynote addresses, plenary lectures and group discussions during this Forum.
A. MEDICAL SCHOOLS
1. The standards and requirements for medical education set by the Malaysian Medical Council (MMC) and the Malaysian Qualifications Agency (MQA) for medical schools, public and private, in the country are presently generally adequate. However, there appears to be evidence of failure in the implementation of some of these standards in certain areas. These have been identified (mainly the strength and quality of academic staff and teaching facilities) and the attention of relevant schools has been drawn to these shortcomings.
2. Continuous monitoring of these shortcomings, and their rectification, has to be conducted by the Malaysian Medical Council to ensure that standards, requirements and quality of medical education are maintained.
3. In some areas of the standards set by the Council review appears to be necessary to update these standards to universally accepted levels.
4. Teachers in medical schools, both local and recruited from foreign sources, sometimes seem to have different approaches to teaching medical students. This should be corrected by the medical schools by making special efforts to ‘teach the teachers’.
5. The shift of focus should be to produce quality Future Doctors to meet the needs of the community and the country as a whole rather than to bring out large numbers of poorly trained doctors.
6. There is a need to cap the number of medical schools in the country, both public and private, and also to gradually reduce such intake over a given period of time and then to maintain an optimum doctor: population ratio for the country. The schools in our country should ultimately be capable of producing the required number of doctors for the country.
7. The present shift from discipline-based traditional curriculum to integrated curriculum which is system-based brings forth problems of teaching by academic staff inexperienced in the new curriculum. This requires concerted effort to ‘educate’ teachers in this new method.
B. PUBLIC MEDICAL SCHOOLS
1. The overall performance of public medical schools is satisfactory, though there are weaknesses in some areas.
2. Full government support to provide clinical teaching is an advantage. When a public medical school is in dire need of staff, secondment from the Ministry of Health helps to achieve and / or maintain the number of full time faculty members.
3. However, there is limited availability of public healthcare facilities in the country which can be used as teaching hospitals at the same time. The accreditation of suitable teaching hospitals and private hospitals may be considered.
4. The teaching of medical students is affected by multi-tasking of academic staff, primarily the clinical staff who have difficulty in balancing healthcare service commitments with research and teaching of students.
5. Performance of medical schools should be monitored by obtaining objective feed-back from hospital consultants under whom housemen are posted. The monitoring should cover all relevant aspects of pre-graduation training (like students’ own assessment of their schools, attitude and aptitude, knowledge and skills).
C. PRIVATE MEDICAL SCHOOLS
1. The role of private medical schools is to complement efforts by the public schools to fulfil the national requirements thereby achieving the projected number of doctors for the country over a specified target of time.
2. There must be strict criteria for implementing and monitoring standards in private medical schools.
3. Most established private medical schools which have graduated doctors seem to be able to fulfill the above role in spite of various shortcomings.
4. However, the increasing demands of the country to produce doctors must not be at the expense of proper maintenance of expected norms and standards of teaching, and must be balanced by the availability of academic staff resources, and physical facilities for both pre-clinical and clinical undergraduate teaching.
5. There is an apparent commercial interest for corporate bodies to establish medical schools in the country. This was perceived by the forum as an unwelcome trend. The Government should view and consider such moves from the perspective of standards and quality of medical education. For the present, there should be a general moratorium on establishment of private medical schools.
6. Students should not be allowed to hop from one private or public medical school to another unless the student has given good reasons to the satisfaction of, and and has received formal approval from the Malaysian Medical Council.
D. FOREIGN MEDICAL SCHOOLS
Accreditation of foreign medical schools should be periodically reviewed and the ability of a particular school to satisfy the standards and requirements of the Malaysian Medical Council should be graded in a stratified fashion.
2 Good medical schools should be those with standards and training as required by the Malaysian Medical Council.
3. If the standard of graduates of a particular foreign medical school is found to be poor, then there is a need to review the status of such a school. ‘Graduates’ from such a school should be required to pass some form of competency examination before being allowed to undergo housemen training in our country.
4, The need to institute a common qualifying examination for all medical graduates from foreign medical schools, irrespective of whether such schools are recognised or unrecognised, has to be considered by the Malaysian Medical Council. This is particularly so if there is wide variation in the teaching methods in these schools which affect the quality of ‘doctors’ graduating from them, and if such cannot be rectified by enforcing existing regulations and requirements.
5. The many recurring unpleasant and adverse reports on agents who facilitate recruitment and entry of Malaysian students, many of whom have sub-standard school leaving qualifications and who do not fulfil the entry requirements set by the Malaysian Medical Council, has to be seriously studied. Urgent remedial action need to be taken so as to ensure that the entry requirements of students into foreign medical schools are strictly complied with.
6. The assistance of the Malaysian embassies in respect of the above matter should be sought so that the role of agents can be completely replaced or substituted.
7. The role and function of the Pre-Medical Courses conducted by foreign medical schools, which serve to enrol students with sub-standard school leaving results, should be reviewed. Entry of students with pre-University requirements as stipulated by the Malaysian Medical Council should be strictly enforced.
8. Foreign medical schools are generally aware of the need to make curricular changes with the objective of achieving requirements of their own future national needs, but whether they are totally aware of the requirements of the universal Future Doctor or Tomorrow’s Doctor is not clear.
9. Medical students should not be allowed to hop from one foreign medical school to another. This is more so when students hop from an unscheduled medical school to a scheduled school, Approval for such transfers should be given by the Malaysian Medical Council only rarely and under very special circumstances.
10. As the number of local medical schools increases, the need to send good Malaysian students abroad to study medicine needs to be reviewed and such sending gradually completely stopped.
E. THE FUTURE DOCTOR
1. The current curriculum in local public and private medical schools is being continually revised to inculcate values of communication skills, lifelong learning, ethics and attitudes of Tomorrow’s/Future Doctor. Attitudes of students may not change during the medical course but behaviour can be modified to obtain the expected qualities of the Future Doctor.
2. These qualities need to be evaluated by survey and perception by the medical schools if not already in force.
3. The importance for medical students to map the teaching on personal and professional development to learning outcomes must be stressed.
4. Assessment of medical students must integrate all learning outcomes.
5. The importance of life-long learning methods throughout the professional life of the Future Doctor needs to be instilled and ingrained into the medical students from the very beginning of, and right through, the medical course.
6. The training of the Future Doctor in the medical schools is primarily for the “undifferentiated, generally competent doctor” to provide healthcare service for the country. This continues through the period of houseman training, though there is ample opportunity at this stage for the new doctor to identify and develop his/her own specific interest in specialty training.
7. The forum debated the question of whether the two-year clinical apprenticeship during houseman training was too long and whether this was needed for the Future Doctor to develop competency. It was concluded that this length of training was necessary as many clinical skills (like prescribing, writing operation/clinical notes, etc) were not adequately developed in the medical school because of various shortcomings and lack of opportunities.
8. It was concluded that mentoring during houseman training was critical to the development of competency and to enhance attitudes and professionalism in the Future Doctor. Mentoring has to be ‘personally conducted’ with a specific specialist.
9. Research understanding is an important characteristic of the Future Doctor who needs to practise evidence-based medicine. This should be instilled into medical students but should not be ‘over done’, as the development of clinical skills is more important at this stage of training.
F. GENERAL MATTERS
1. Medical Curriculum
a. There is some problem with migration from the traditional curriculum to problem-based learning (PBL) in medical schools.
b. It is perceived that no medical school is conducting a truly PBL curriculum because of administrative difficulties, as medical faculties are basically department-based according to ‘system’, example Anatomy, Physiology, Pathology, etc.
c. There is evidence that basic science departments are consciously teaching applied clinical or clinic-pathological importance of basic science subjects during the “pre-clinical” segment of the course. However, the reverse does not seem to be the case when students reach the clinical phase. During this phase, teaching tends to be primarily disease-oriented with little reference to basic science topics relevant to the disease.
d. PBL encourages thinking, team building and communication but evidence for knowledge acquisition is not very clear.
e. A ‘hybrid PBL-Traditional’ curriculum may have to be considered as a better practicable option.
2. Improving Human Resources and Facilities for Teaching
There should be incentives for all clinical teachers, whether in academic institutions or in public healthcare facilities, to be more conversant with basic medical sciences for vertical integration e.g., [Anatomy : Surgery] or [Pharmacology : Medicine], and be able to teach basic sciences from the clinicians’ perspective.
There should be incentives for medical academics who have to provide professional service on top of teaching (two jobs for the price of one), as they should be suitably rewarded for the extra job.
There should be incentives to retain academic staff in teaching institutions, including expatriate staff. Exchange programmes involving academic staff from local and established foreign medical schools will be helpful.
The process of appointment of suitable local staff as well as expatriates seeking positions in local medical schools should be accelerated.
The number of hospitals accredited for clinical teaching of medical students should be increased. The inclusion of suitable private hospitals as teaching hospitals and suitably qualified and experienced private specialists for teaching medical students should be considered. This would be the steps to overcome some of the shortcomings in these respects.
3. Selection of Students for the Medical Course
a. There are currently no universally or worldwide acceptable or tested selection criteria for entry into medical schools
b. The current criteria using academic school grades have their shortcomings but still should be employed, as the details of passing/excelling in relevant subjects, like science, mathematics and English, do indicate inherent intelligence and the ability to cope with the academic pressures of medical education. Co-curricular activity involvement should also be taken into consideration.
c. What needs to be assessed is the attitude and aptitude for pursuing a medical course and eventually graduating as a doctor. Some useful scientifically based psychological evaluation system has to be explored in this respect. Of assistance are school co-curricular portfolio, character inventory tests, confidential reports by referees, and interview with aspiring students.
d. The current 2-year Matriculation programme is supported but should be more varied to suit future academic pursuits of the students. This includes the need to introduce key studying skills needed in the study of medicine.
e. The monitoring and counselling of medical students during the course should be carefully and objectively structured. Students found unable to cope in the first two years should have the opportunity to take a mid-programme exit examination, with the award of a basic medical-science degree.
4. Sending Students to Overseas Medical Schools
a. The continued sending of students should be seriously reviewed.
b. It is felt that the country has enough public and private medical schools at the present time, and any increase in intake of students in them to meet national demands must receive support from the Government with injection of funds to upgrade their human resource and teaching facilities.
c. There are good foreign medical schools with established teaching traditions and the possibility of selectively inviting them to establish campuses in our country should be explored. The competitive edge provided by such foreign medical schools in our country will further help to improve our own public schools and existing private schools.
d. Existing accredited foreign medical schools with anecdotal poor quality in respect of teaching methods, experience of teachers, learning outcomes and system of evaluation should be urgently evaluated. The system of evaluation should be based on academic values and not be influenced by other extraneous factors.
e. The evidence of poor quality of teaching and training in foreign medical schools must be properly and objectively evaluated and documented to offset any overpowering criticisms from interested parties. A clear process of ‘de-accreditation’ should be worked out by the Government on the recommendations of the Joint Technical Committee for Accreditation of Medical Schools and the Malaysian Medical Council.
5. Inter-Organisational Cooperation in Medical Education and Training
a. There are challenges in reconciling the provision for teaching and service objectives in the same location so that the objectives fully complement each other.
b. Flexibility in human resource deployment – multiple or joint appointments in service and teaching – are normal in other countries and could be a model in our country. This would mean that the Head of a clinical department in a public hospital could at the same time be the Professor in a similar department in the medical school. This would help to foster a border-less responsibility between teaching and service commitments.
c. There are major differences in the projection/forecast of doctor requirements for the next decade between Ministry of Health and Ministry of Higher Education. This would confuse the planning of the future of medical training in our country. It is important that a single projection be formulated taking into consideration all relevant factors and variables.
d. A Joint Medical Training Committee consisting of representatives from the relevant Ministries, the Malaysian Medical Council, the Universities and Medical Colleges (and other stake-holders) should be established to co-ordinate accreditation of schools and clinical training facilities, as well as facilitate academic human resource development. The Committee should also make projections for the future, and anticipate other related problems, so that there is uniformity in principles, concept, planning and implementation in all areas pertaining to Medical Education and Training in our country. As an example, a Director of Medical Education has just been appointed to oversee the implementation of the medical training in the United Kingdom.
G. PRINCIPAL CONCLUSIONS AND RECOMMENDATIONS
1. Medical Schools and Teaching Facilities
a. The number of medical schools in the country, both public and private, should be capped. The setting up of new medical schools should be reviewed at such time in the future as appropriate after calculated consideration of all factors of national importance.
b. Existing schools should be improved with respect to academic strength and teaching facilities, so that any increase in intake of students to meet national demands can be accommodated and met by these schools. There should be a gradual move towards an optimal doctor population in the country solely sustained by existing medical schools. The number of doctors required should be reviewed annually or at least once in two years.
c. In view of the shortage of teaching hospitals in the country, the possibility of accrediting suitable private hospitals should be considered.
2. Medical Student Selection Criteria for Entry
The present selection criteria for students to enter medical courses based on academic school grades and co-curricular activities is acceptable, provided the criteria are strictly followed. It would be significantly useful to factor in methods of assessing aptitude, attitude and psycho-social personality and character traits into the entry selection.
3. Standards and Curriculum in Medical Schools
a. Shortcomings in the implementation of standards and curricular requirements for medical education set by the Malaysian Medical Council, as observed in both public and private medical schools in the country, should be addressed objectively and the schools should be advised regarding remedial measures. In this respect, the strength and quality of academic staff and teaching facilities should also be monitored closely.
b. The curricula of medical schools should be modified and/or adjusted to satisfy the requirements of Future Doctors. There should be a national forum to clearly define the qualities of the Future Doctor. Curriculum and training should be tailored to meet our national requirements.
c. The current emphasis on integrated system-based curriculum has its practical clinical advantages but its value has to be evaluated in terms of effectiveness, ability of academic staff to deliver, administrative shortcomings and eventual outcome. Perhaps a PBL-hybrid curriculum needs to be studied, evolved and implemented.
4. Teaching Staff
The academic teaching staff should be selected from local sources, including the large pool in the private sector. Experienced and senior expatriate academic staff from established foreign medical schools should be recruited as full time staff and remunerated appropriately. To improve the quality of staff, an exchange programme of academic staff between local schools and foreign institutions will be useful and should be considered.
5. Foreign Medical Schools
The teaching, training standards and quality of accredited foreign medical schools should be critically evaluated. The continued sending of our students to foreign medical schools should be reviewed. It is felt that this arrangement should be phased out.
6. Agents for Foreign Medical Schools
The role of agents involved in recruiting and facilitating students to study in accredited foreign medical schools should be phased out. This is primarily because the methods employed by these agents do not truly satisfy the pre-requisites set by the government and also run counter to national objectives.
7. Matriculation and Pre-Medical Courses
While Matriculation Courses run by Malaysian institutions preparing students for university courses within and outside the country are satisfactory, the same cannot be said of the Pre-Medical Courses run by foreign medical schools to “prepare” students for the first year of the medical course in these foreign medical schools. These courses are regularly advertised by agents as “short cut to medical courses”. The entry requirements are invariably not met, the course itself is very short and does not fulfill the objectives of a properly conducted Matriculation course.
8. Housemen Training
There should be objective assessment of housemen during the first year to indirectly evaluate the teaching standards of medical schools. The assessment should include the opinion of these new doctors about the teaching and training in their medical schools, the observed attitude towards health care delivery and their professional skills and knowledge; such assessment must be conducted by the senior specialists in the hospitals where the housemen are posted.
9. Inter-Ministerial and inter-organisational cooperation
Dialogue amongst Ministries and inter-organisational cooperation must be enhanced. Meetings should be held amongst such decision-making bodies and stake-holders so that matters pertaining to undergraduate and post-graduate training can be speedily ironed out. It is essential to establish targets and procedures by consensus, so that there is no confusion regarding achieving national goals.
Organising Committee
PPSR Forum: “Training Future Doctors: Have We Got It Right?”
24January 2009
