There is increasing concern about the variation in the quality of doctors entering the workforce.
The reasons are related to the curriculum, training and clinical exposure in medical schools, as well as the doctors’ values and respect for diversity in the population. Both these factors impact on patient safety and the future of medical practice.
There were about 18,700 students in local medical schools in 2014 – about 7,600 in 11 public medical schools and 11,100 in 21 private ones.
In addition, it has been estimated that there is a similar number of Malaysian students in foreign medical schools.
The number of beds in the Health Ministry (MOH) hospitals is about 37,000.
Based on the ratio of one medical student to five hospital beds, MOH hospitals can only cater for about 7,400 medical students in their clinical years.
Yet in 2014, there were about 10,000 such students, a mismatch that inevitably impacts on the quality of training. This mismatch is likely to worsen in the next five years and beyond.
With the marked increase in the number of provisional registrations and the inability of some doctors to complete their training in two years, a backlog has resulted, with a waiting time of six or more months for houseman posts.
A mismatch between the number of houseman and medical officer posts is also developing.
When the cost of producing one doctor is 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 developed economies have shown that a small percentage of doctors account for the majority of complaints and medical errors, where human factors are involved.
Poor quality doctors inevitably contribute to medical errors, morbidity, mortality and consequential increase in healthcare expenditure.
The current problem of housemanship training – and medical officer training, which is developing – has its genesis in medical schools. It raises questions about the quality and quantity of medical graduates.
The resolution of the problem can only be possible if a comprehensive approach is taken. Ad hoc measures will not solve the problem.
Moratoria, increasing the number of hospitals for housemenship, and fast-tracking of housemanship training 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.
There are several options that can address the quality of medical education, patient safety and quality care; and which will also address the issue of the supply of doctors.
These measures have to be applied to both local and foreign medical schools.
The moratoria on the establishment of new medical schools in Malaysia, which has been around since 2005, should be strictly implemented. This includes the number of new medical schools and programmes.
In addition, a comprehensive review of the intake of medical students of each medical school is needed to ensure that there is sufficient capacity to provide quality education.
This is particularly so with several medical schools where students learn episodic care and not continuity of care from less than adequate numbers of teaching staff, some of whom are not eligible to be registered on the National Specialist Register.
This will include review of admission quotas, double intakes, twinning and franchise arrangements.
Sharing of teaching staff between medical schools and/or other healthcare programmes, especially in the clinical years, cannot be permitted.
Entry requirements need to be enhanced to include academic qualifications and aptitude assessments.
Assessments and monitoring of medical programmes have to be comprehensive, consistent and stringent.
There has to be a robust mechanism to assess the quality of assessment by the assessors of the medical programmes.
The above measures may lead to mergers, acquisitions, and even closures of some local medical schools. Licences of medical schools that have closed should be cancelled and not be tradable.
The number of medical schools listed in the 2nd Schedule of the Medical Act has to be reviewed.
Foreign medical schools that admit students who do not possess the minimum entry requirements for local medical schools, and/or whose graduates have not performed during their housemanship should be derecognised.
Regulators in many developed and developing countries require the passing of an examination before graduates are permitted to practise, e.g. United States, Australia, and even Indonesia.
The General Medical Council of the United Kingdom is considering a licensing examination for all applicants, including graduates of British medical schools.
The proposal to have a local licensing examination by the Malaysian Medical Council (MMC) has been around for about two decades. It has not moved because of resistance from interested parties.
A licensing examination has to include all who intend to practise in Malaysia.
Quality graduates will have no problems passing such an examination, which is akin to the final-year medical school examination.
Mediocre or poor quality graduates may have a problem.
The question for those not in favour of a licensing examination is, “Would you want to be treated by a poor quality doctor?”; and that for medical schools is: “How confident is the medical school about the quality of its graduates?”
Comprehensive medical manpower planning has to be evidence-based, transparent and include all stakeholders.
It is essential that the targets are robust and regularly reviewed by all stakeholders.
The medical profession has been, and is, unaware of manpower plans, except the target of a doctor:population ratio of one in 400 by 2020, the basis of which is unknown.
The current wait for houseman, and soon, medical officer posts, indicates that there are serious deficiencies in manpower planning.
Various organisations are involved in medical manpower planning. They include the Education and Health ministries, the Economic Planning Unit and the Public Services Commission.
The MMC has not been involved in manpower planning. It recommends to the Health Minister the qualifications that can be recognised.
All these parties have to move in tandem to address the quality and patient safety issues. Input from medical organisations and consumers would be necessary.
A moot and frequently asked question is: “Is there political will to address the problems of patient safety, quality of medical education and medical manpower supply?”
To date, there is still no cogent response to this question posed by many concerned doctors, who are also patients or potential patients.
Society and future generations are owed a healthcare delivery system that is founded on patient safety and quality of care.
Good quality doctors have a crucial role to play in healthcare delivery. 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, and is, a matter of life and death.
Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. The views expressed do not represent that of any organisation he is associated with. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.