Quality first, not quantity

Recent media focus on the number of housemen and the attitudes of some of them raises questions about the quality of medical education, and by extension, the quality of healthcare patients will be receiving in the future.

ONE of the basic principles taught to all medical undergraduate and postgraduate students is Primum non cere, ie, first do no harm. It is a reminder to doctors to always consider 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.

Prior to World War II, the doctor’s responsibility to the patient was relatively simpler. It involved making a diagnosis and prescribing a treatment, which the patient may or may not respond to, depending on the patient’s physical state, and the illness he or she was suffering from.

It was not very different from a lottery. Medical knowledge and the range of diagnostic and therapeutic modalities then were limited. Specialists and other healthcare professionals, apart from nurses, were almost unheard of, and their services were only available to the well heeled.

There has been an explosion in medical knowledge, and the range of diagnostics and therapeutics has increased tremendously. Healthcare is one of the fastest growing sectors of many economies and is provided in many instances by a team of healthcare professionals, led by the doctor.

Specialists and specialty services are available in almost every nook and corner of the country, and if not available, access is provided by the state through ambulances and flying doctor services in the more remote areas.

Modern healthcare, however, is not without risks. The publication of To err is human by the Institute of Medicine in the United States in 1999, and similar reports from the United Kingdom and Australia, drew attention to adverse events that resulted from medical errors, the causes of which were human factors and system failures.

It is now generally accepted that the incidence of adverse events from hospitalisations is about 10%, with single digit figures for mortality and morbidity.

This was summed up succinctly by Sir Cyril Chantler in 1998: “Medicine used to be simple, ineffective, and relatively safe. Now it is complex, effective, and potentially dangerous.”

Recent media focus on the number of housemen and the attitudes of some of them raises questions about the quality of medical education, and by extension, the quality of healthcare patients will be receiving in the future.

The solutions announced to date are interim measures that do not adequately address fundamental issues which have their genesis upon the students’ admission into medical school. This article seeks to draw the reader’s attention to some of the issues and challenges that need to be addressed.

Learning medicine

There are more applications for entry to medical schools worldwide. Many young people want to become doctors, whether of their own volition, or at the behest of their parents.

High academic qualifications are the sole criteria for admission to all public medical schools in Malaysia, except University Sains Malaysia (USM), which requires an interview as well.

In general, the private medical schools also require high academic qualifications and an interview as well. Some also require applicants to pass an aptitude test.

Although the minimum academic qualifications for entry into medical schools are prescribed by the Malaysian Qualification Agency (MQA), there are claims of non-compliance by some private medical schools. There are also claims that some private medical schools take in more students than permitted.

The situation in foreign medical schools is varied.

Medical schools in advanced economies adhere strictly to high academic requirement, as well as assessments of the aptitude of the applicants.

However, some medical schools in developing countries admit students whose academic results would not even qualify them to enter a university in Malaysia for other courses with lesser entry requirements. Many of such students gain entry through 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 standards 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.

The issues and challenges that need to be addressed include:

? Should academic qualifications be the sole criteria for entry into medical schools?

? What is the role of interviews and/or aptitude tests?

? How robust is the monitoring of the compliance of Malaysian medical schools to the MQA’s minimum entry qualifications?

? How robust is the monitoring of the adherence of foreign medical schools to the MQA’s minimum entry requirements?

? What should be done to Malaysians admitted to local and/or foreign medical schools without MQA’s minimum entry requirements?

Medical schools

There are currently 24 medical schools providing undergraduate training for Malaysia’s population of 28 million (Source: International Medical Education Directory). Countries with similar populations like Australia (22 million), Taiwan (23 million) and Canada (34 million) have 19, 11 and 17 medical schools respectively (Source: United Nations).

Although there was a dichotomy between public and private medical schools in Malaysia previously, the margins have been blurred in the past few years. Some public medical schools have established twinning arrangements with universities abroad and the fees for students who enrol in such courses are not different from that charged by private medical schools in Malaysia.

Our ASEAN neighbours, Indonesia, Singapore, Thailand, and Philippines with populations of 238 million, 5 million, 67 million, and 94 million respectively have 35, 2, 12, and 41 medical schools respectively.

With the establishment of more medical schools already approved by the Higher Education Ministry, Malaysia may soon join the ranks of countries like Germany, Italy, and the United Kingdom who have 41, 42, and 44 medical schools respectively for populations of 82 million, 60 million, and 62 million respectively.

The issue is compounded by the fact that the government recognises more than 370 medical qualifications worldwide. The list of recognised medical schools was inherited from our colonial masters and added to over the years.

In addition, graduates from unrecognised medical schools can sit for the Medical Qualifying Examination (MQE) of the Malaysian Medical Council (MMC) and, upon passing, will be registered. The examination is the final year examination of the Universiti Malaya, Universiti Kebangsaan Malaysia, and University Sains Malaysia who conduct the examination on behalf of the MMC.

There are some who question the validity of these examinations. However, they have not provided any material to substantiate their suspicions. An analysis would reveal that those who fail the MQE usually have very poor results at SPM and STPM levels.

In spite of the fact that there was, and still is, a marked shortage of medical educators in Malaysia, the expansion of medical schools has continued unabated. Some private medical schools have teaching staff who are mainly foreigners from Myanmar, the Indian sub-continent, and the Middle East. Some of them do not speak any of the local languages, and some have 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.

Local medical schools are given time-limited accreditation after assessments by teams comprising representatives from the Malaysian Qualification Agency, Health Ministry, and the MMC.

However, it is impossible to accredit all the foreign medical schools recognised by the Government for manpower, logistical, and financial reasons.

Most governments in developed economies recognise their limitations in assessing the quality of medical education of foreign medical graduates. They require all those who want to practise medicine, particularly foreign graduates, 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.

Many in the medical profession have stated publicly their concern that there is more emphasis on the quantity instead of the quality of the 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.

The issues and challenges that need to be addressed include:

? How many doctors does the country need, and by extension, how many medical schools does the country need?

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

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

? Should not all medical graduates, particularly those from foreign medical schools, whether recognised or unrecognised currently, be required to pass a licensing examination before they are permitted to practise in Malaysia?

? What is the role of agencies of foreign medical schools and how robust is its monitoring?


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.

The MMC has listed five basic ingredients of Good Medical Practice. They are professional integrity, communication skills, ethical behaviour, treating patients with dignity, and being a team player.

By itself, the basic knowledge and skills taught in medical schools is insufficient. The housemenship period is the time to make a start in the development of the ingredients of Good Medical Practice.

Young doctors have to develop his or her professional competences, skills, and behaviours so that they are better placed to serve and improve the care and health of their patients. They 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.

In short, the housemenship period is a time when the newly graduated doctor transitions from theory to practice.

Learning during the housemenship period is not only from books and journals, but also experiential, with the latter playing a significant role. 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 case of the former, and long term consequences, in the case of the latter.

When there are few patients relative to the many housemen, it will, inevitably, have a negative impact on the latter’s training.

The statement of Sir William Osler, the father of modern Medicine, is particularly relevant: “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.”

Many specialists report 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. It is disconcerting to hear some specialists state that they do not even know the names of some housemen assigned to their wards and clinics “because there are so many of them!”

The issues and challenges that need to be addressed include:

? How many housemenship training hospitals does the country need?

? How many specialists are needed for housemenship training?

? What is the quality of housemenship training and how robust is its monitoring?

Too many doctors?

With the current rate at which Malaysian doctors are graduating from medical schools, both locally and abroad, the country will reach its overall doctor population target of one doctor for 600 population within three to four years, and a ratio of one doctor for about 400 population or less by 2020.

There will have to be 5,000 to 7,000 Medical Officer posts in the public sector available annually within the next five years for the young doctors after completion of their housemenship training, and after that it will be anybody’s guess.

If there are insufficient posts, how many can be absorbed by the private sector, which is already saturated in many areas?

There will be no employment problems for doctors of good quality, but the prospect of unemployment is a possibility for the mediocre, and possibly, some of the average ones.

When the costs to the state or to the individual of producing one doctor are considered, the question arises whether it makes economic sense to flood the market with doctors. The laws of supply and demand do not apply to doctors simply because doctors are not only suppliers but also play a significant role on the demand side of the equation.

Studies from the developed economies have shown that a small number of doctors account for the majority of complaints and medical errors, where human factors are involved. Poor quality doctors will inevitably contribute to medical errors, morbidity, mortality, and consequential increase in healthcare expenditure.

Going forward

The current problem of housemenship training has its genesis in medical schools. It raises questions and challenges about the quality and quantity of medical graduates, some of which have been discussed above.

The resolution of the problem can only be possible if a comprehensive approach is taken. Ad hoc measures will not solve the problem. Moratoria and increasing the number of hospitals for housemenship may be part of the solution, but they are at best, interim measures.

The fundamental issues have to be addressed before the situation gets out of hand.

Medical schools have to be held accountable for the quality of their graduates. The principle that society’s health is more important than profits has to be adhered to at all times, particularly by the private medical schools.

We owe future generations a healthcare delivery system founded on patient safety and quality of care in which quality doctors have a crucial role to play. The consequences of having significant numbers of poor quality personnel in other areas of human activity may not be significant, but in healthcare, it can be a matter of life and death for all the population.

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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