First, do no harm

  • Health
  • Sunday, 13 Jan 2008


Medical schools have to accept some responsibility for the shortcomings in the quality ofthe graduates and their impact on healthcare delivery, particularly when it costs so muchto train a doctor. - AP

SINCE time immemorial, healthcare provision has been evolving. The practice of Medicine has traditionally changed at a glacial pace – until the past half century when rapid and enormous advances occurred.  

New diagnostic methods and interventions have made it possible to deal with the treatment and prevention of ill health in a more effective and definitive manner.  

Cognizant of the need for medical education to keep pace with the enormous changes in medical practice, healthcare organisations and the medical profession have responded accordingly.  

This was motivated by the need to ensure that medical students and doctors possess the necessary skills required for life-long learning in a practice that is virtually exploding with new information. 

Desirable doctors 

No one chooses to be sick. Sometimes, one cannot choose the healthcare facility where one is to be treated or the attending doctor, even if affordability is not a factor.  

The attending doctor has to provide the right care to the right patient at the right time, and more importantly, ensure compliance with the first dictum of medical practice i.e. Primum Non Nocere (First, do no harm). Hence, the quality of the doctor is crucial. 

The objective of medical education is to train people and equip them with the necessary knowledge, skills and attitudes to respond to the health needs of the people they serve with care and compassion and to assist them and the state to achieve their health objectives.  

Any undergraduate medical curriculum has to produce desirable features in future doctors so that they can work at any level of healthcare provision.  

In 1994, the concept of the five-star doctor was propounded. Such a doctor, with the attributes listed below, is expected to serve all health systems and services. 

Attributes of the five-star doctor 

Care provider, who considers the patient as an integral part of a family and the community, provides high standard clinical care (excluding or diagnosing serious illness and injury, manages chronic disease and disability) and personalises preventive care within a long-term, trusting relationship. 


Decision maker, who chooses which technologies to apply ethically and cost-effectively while enhancing the care that he or she provides.  


Communicator, who is able to promote healthy lifestyles by emphatic explanation, thereby empowering individuals and groups to enhance and protect their health. 


Community leader, who having won the trust of the people among whom he or she works, can reconcile individual and community health requirements and initiate action on behalf of the community. 


Team member, who can work harmoniously with individuals and organizations, within and outside the health care system, to meet his or her patients’ and community’s needs. (Source: Boelen C. Frontline doctors of tomorrow. World Health, 1994, 5:4-5.) 


Teaching doctors 

Most medical schools worldwide are funded by the state. What each society expects of medical schools is determined by the public, governments, health professionals and educators. 

It would not be unfair to state that, at the very least, all societies expect medical schools to be responsible for the quality of its graduates, irrespective of whether the medical school is public or private. 

The World Health Organization (WHO) published its monograph Defining and measuring the Social Accountability of Medical Schools in 1995. It defined the social accountability of medical schools as “the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve. The priority health concerns are to be identified jointly by governments, health care organisations, health professionals and the public.” 

The definition assumes that there are collaborative relationships between medical schools and policy makers, communities, health professionals and health administrators.  

In short, a medical school that is responsive to societal needs and which acts proactively to meet those needs. 

A framework was developed by WHO to assist in the evaluation of the progress of medical schools towards fulfilling their social accountability. There are four values in this framework: 

Relevance – the degree to which the most important health problems are addressed. 

Quality – the ability to think critically, practice evidence based Medicine, communicate effectively and conduct oneself ethically 

Cost effectiveness – obtaining maximum benefit from limited resources 

Equity – delivery of quality health care to all who need it.  

The values above relate to the domains of education, research and services, which are the primary functions of medical schools, and for each domain, focus on planning, doing and impacting. 

Various criteria have been developed and are used in measuring the social responsiveness and accountability of medical schools. These criteria have enabled medical schools to evaluate themselves and/or measure changes over time.  

At the same time, it has facilitated the accreditation of medical schools, which is an external evaluation, and the registration of its graduates for medical practice.  

Accreditation has been carried out in Malaysian medical schools for about a decade. It was started, by the Malaysian Medical Council, as a pilot project in medical schools in the public sector and was later extended to medical schools in the private sector.  

Currently, accreditation is carried out by a Joint Technical Committee comprising representatives from the Malaysian Medical Council and relevant governmental agencies.  

Initially, the accreditation criteria used were subjective, but it has become objective in recent times. 

This article focuses on the domain of education, not because research and services are not important, but because it is particularly relevant to the current issue of the extension of housemanship. 


The housemanship (provisional or pre-registration) year has been part and parcel of medical training for more than half a century. It is a period when the fresh graduate puts into practice the knowledge, skills, attitudes and behaviours learnt; gain new knowledge and skills; and develop further professional attitudes and behaviours under the supervision of consultants.  

At the end of each posting, the supervising consultant has to certify that the housemen has completed the posting satisfactorily. Objective criteria are used in the assessment by the consultants.  

The disclosure by the Health Ministry that 603 housemen were not considered suitable for full registration, after a year of housemanship, from 2001 to 2005 (The Star, December 4, 2007) troubled many in the medical profession. 

That there is such a large number comprising about 10% of all housemen should be of concern not only to the medical schools but also to the public and government.  

It is disturbing to read media reports of claims by housemen that they are just a pair of hands and that training is minimal or absent. Equally disturbing are claims by some consultants that housemen cannot be found in the wards or clinics after office hours except those on call. The reports on “pencil doctors” a few years ago were also disturbing.  

My classmates and I always remember our housemenship year. Whilst it was hard work, it was also a time when we learnt to put into practice what we learnt in medical school.  

Some of our consultants were good teachers; some were less so. Some were excellent at expressing themselves verbally; others expressed their skills with their hands. Some consultants did ward rounds before going home and some even came back at night to do ward rounds.  

We learnt from every consultant 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 consultants’ ward rounds, even after work, to learn from cases with interesting features.  

Those were not easy times. There were discussions and analyses, which made us better doctors because we learnt from our consultants and more importantly, ourselves. 

More measures are needed 

Extending the period of housemanship to two years would only provide part of the answer to the problems being encountered by the Health Ministry. The additional year will be useful to some “weak” housemen but the jury is out as to whether it will be useful all those who need assistance.  

It is an additional responsibility for the consultants. Apart from supervising housemen, medical officers and registrars, the consultants have other responsibilities, including the provision of service in the clinics and wards. 

Be that as it may, the consultants owe it to the public, their teachers and themselves to take on this responsibility.  

There is also a need for the implementation of a more robust mechanism to assess the quality of supervision provided to housemen by the consultants.  

The communication and relationship between consultants and housemen need to be strengthened so that housemen should never feel that there is any impediment to their asking or requesting for advice or assistance from their superiors at any time of the day or night. 

The housemanship training programme and the assessment of the doctor’s progress needs to be strengthened with more structure and objectivity. The weaknesses need to be rectified. This requires proactive approaches by consultants and administrators. 

The root causes of the current problems need to be addressed. Medical schools have to accept some responsibility for the shortcomings in the quality of the graduates and their impact on healthcare delivery, particularly when it costs so much to train a doctor. 

Attitude, behaviour, responsibility and interpersonal skills play a vital role in the making of a desirable doctor. It is difficult to inculcate all the qualities required into an individual within the five to six years of university education.  

In most instances, medical education can shape existing values towards the preferred outcome. However, all students enter medical school with the varied values of society. Hence, the selection of the right applicant to undertake undergraduate medical education is crucial. 

The selection criteria and admission policies have to take into consideration multiple individual and social factors and not just the examination results obtained by an applicant.  

Many medical schools in the developed world have provisions for these factors in their selection criteria, imperfect though it may be. Such selection criteria and admission policies have to be clearly defined, consistent, defensible and free of bias. The selection processes have to be published and made available to all applicants. 

Where an interview is used, it should be structured to be as objective and fair as is possible.  

Medical schools should analyse the outcome of the selection process so that it can be modified if necessary. An appeal mechanism should be in place. 

The message to parents that good examination results do not make a career in Medicine has to be repeatedly emphasized. There is nothing worse than getting into a profession that is unsuitable for one’s personality. 

Measures have to be taken to address shortfalls of the existing medical curricula in some medical schools. Some of them are: 

·Overexposure of students to ill patients in hospitals. The learning situation in the hospital is quite different from the working environment for the majority of doctors. 

·Predominance of subject-oriented curriculum linked to high technology Medicine places a heavy burden on medical students to retain knowledge. 

·Medical ethics, equity and human rights have limited or no place in training. 

·Communication between teachers and students is usually one-way. There is limited dialogue between the two and students’ experiences are ignored. 

·Curative based training makes students believe that drugs are powerful weapons. Students often fail to realise that it is essential to tackle the social roots of ill health. The social, economic and cultural dimensions of ill health are often not addressed.  

The lack of emphasis of social, economic and cultural perspectives in undergraduate training occur because the pattern of healthcare provision is considerably influenced by the market economy.  

If the doctor accepts the logic of the market, when providing care, they can never practise with an understanding of the basic social nature of ill health and little attention will be given to the assessment of population needs and outcome measurements. 

Ethical behaviour 

Those who enter Medicine have to maintain high standards of integrity, competence and compassion for those in their care. They will have to recognize the separate, inviolate nature of the individual whom they will meet in the clinic, ward, operating theatre, labour ward or outside the health care facility.  

The patient should always be treated with respect and responsibility because he or she is a human being born free and equal in dignity and rights.  

The inclusion of medical ethics with adequate human rights and cross cultural inputs into existing medical curricula will widen the capabilities of a medical student to be better trained in the healing art. 

The expansion of medical schools in Malaysia in the past decade has been phenomenal. Where the total number of medical schools, a decade ago, were in single digits, there are currently 21 medical schools with very large numbers of undergraduates and post-graduates.  

In spite of the fact that there was and still is a marked shortage of medical educators, the expansion of medical schools has continued. 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.  

Many in the medical profession have wondered whether there has been more emphasis on the quantity instead of the quality of the graduates. The consequences in other areas of studies may not be that significant, but in Medicine, 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. 

There has to be enhanced communication between the Health Ministry, who employ the doctors and provide the healthcare services, and the medical schools, which produce the doctors for the delivery of the services.  

The feedback provided by the Health Ministry to medical schools, regarding the skills, knowledge, attitudes and competency that all their graduates require to deliver healthcare services, have to be acted on. Society deserves nothing less. 

In concluding, the powers-that-be owe it to society to always remember two quotations of Sir William Osler, the father of modern Medicine i.e. “Medicine is learned by the bedside and not in the classroom. Let not your conceptions of disease come from words heard in the lecture room or read from the books. See and then reason, and compare and control. But, see first.” 

“No bubble is so iridescent or floats longer than that blown by the successful teacher.”  


  • Dr Milton Lum is Chairperson of the Commonwealth Medical Trust. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed by the writer do not represent that on any organisation that he is associated with. 

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