Good doctoring

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.

Can such students end up as good doctors?

Should the quality of students doing medicine be of concern to the public?

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.

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?

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?

Is this achievable when medical education is so much driven by the profit imperative?

What is the quality of medical education in recognised local and foreign medical schools, and how robust is its monitoring?

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"!

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?

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.

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?

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?

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 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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