Reforming Malaysia's medical education system

The glut of doctors and the contract system has caused much grief in society and the medical profession.

In previous weeks, I’ve proposed a better set of targets for the doctor-to-population ratio.

I’ve also proposed a practical basket-of-solutions to reduce the number of medical schools and students, and to improve how we select medical students through a single admissions test.

To complete the picture, let’s look at ways to improve the quality of medical education in Malaysia.

We will focus only on the quality of undergraduate medical education in local schools, because it’s logistically and legally impossible to increase the quality of foreign schools.

I will propose a philosophy of reform and a basket-of-solutions that can easily incorporate ideas from other people.

The lifelong medical education for graduate doctors will be discussed in future articles.

As previously discussed, because the Malaysian government cannot easily regulate the quality of foreign schools, we can choose to regulate the quality of their graduates through new entrance (Medical School Admissions Test) and exit (Common Licensing Exam) barriers.

When reforming the medical education system, we must think of the current system as an intermediate step to a better system and not the end-state itself.

The system must continuously improve, for three reasons.

One, the necessary medical knowledge increases exponentially every year.

Two, the health system that these students graduate into will be different from that which existed when they started medical school.

Three, the mindset, psyche and resilience of medical students change every few years, e.g. the Millennial doctor is different from the Gen X doctor.

Reforming our system requires a short-term solution to the inconsistent quality of the current 32 local medical schools and a long-term strategy to future-proof them.

The bad news is, even immediately fixing the short-term problem will show the fullest benefits only in 2025, i.e. when the next batch of first-year students graduate in five years.

Let’s call these two objectives Doctor 2025 (short term) and Doctor 2035 (long term).

On to Doctor 2025

The first and most obvious short-term solution to improve the quality of local medical schools, is to close down failing schools.

This should not be controversial, as our laws already allow it.

The Malaysian Medical Council (MMC) has a 132-page guideline on how to accredit a Medical Degree programme, on top of Malaysian Qualifications Agency (MQA) guidelines.

The MMC guideline is remarkably detailed, e.g. minimum of one lecturer to four students, maximum of eight students per group for bedside teaching, a 70/30 breakdown between medical and non-medical academic staff, and a 60/40 breakdown between full-time and part-time staff (who must teach more than five hours per week).

The accreditation is valid for five years, with all schools having to be re-audited after that period.

Withdrawing the accreditation is possible, although no schools have ever been suspended or banned, despite Institute of Health Management Malaysia data from 2014 showing that some private schools have 11% of their students not meeting the minimum academic criteria.

In other words, some schools are breaking the law, and they are still operating!

This task is not difficult. MMC and MQA can audit all schools over a 12-18 month period. We can even prioritise “failing medical schools” using new criteria such as “highest percentage of HOs (house officers) being extended or dropping out due to non-workplace issues”.

A short grace period of six to 12 months can be given before closing schools.

The work of the auditors must be insulated from political pressure, to send a strong signal that the health of Malaysians is too important for politics.

For fairness, existing students can be transferred to another school and the failing school can be taken to court under existing civil law, for appropriate refunds of school fees.

The second solution is for the Health Ministry (MOH) to centrally pair medical schools with public hospitals for their clinical postings.

The problem is that some public hospitals are currently hosting more than one medical school, leading to over-crowding of students and reduced learning opportunities.

This happens because private schools negotiate directly with the hospitals or State Health Departments, instead of Putrajaya. They often prefer public hospitals in the west coast of Peninsular Malaysia, probably because their students want to be in urban settings.

Centralising this decision in Putrajaya is crucial to maximise teaching opportunities, allow more specialists to engage in education, and improve social cohesion when paired with the newer specialist hospitals in Sabah, Sarawak or Kelantan.

The third short-term solution is to clarify existing MOH policies on using MOH specialists as “adjunct lecturers”.

Currently, private medical schools remunerate MOH specialists to teach their students.

This should be allowed, but a balance is needed between three public service objectives for a specialist: patient care, training junior doctors and teaching medical students.

Specialist retention is also an important consideration, and remunerated teaching can help with retention.

Finally, the Hippocratic Oath requires that a doctor teaches other doctors and MOH should encourage it as an appropriate part of a specialist’s workload.

Further on to Doctor 2035

These short-term solutions must continue into the long term.

It must be accompanied by all previously discussed solutions to reduce the number of medical schools and students, and to improve the selection of medical students. Given their synergistic nature, fixing one problem helps to fix another.

To get us to Doctor 2035, there are a few long-term solutions.

The first is to commission a report similar to the Flexner Report, a book-length report published in 1910 that shaped the American and Canadian medical education system into the one that we still recognise today.

This report should contain the over-arching strategies and philosophies for Malaysia’s medical education system for the next 50 years.

It should contain the usual elements like curricula and skills of a doctor, but also introduce new elements like self-correcting mechanisms, the mix of public/private education, the different cultures of different generations and the right mix of paternalism/autonomy.

Other long-term quality improvement solutions are responses to the tectonic changes within medicine, health systems and societies.

One, we must accept that it’s increasingly impossible to teach medical students everything there is to know about medicine in five years.

Instead, we must teach them to manage the knowledge overload by moving away from rote memorisation, and teaching critical appraisal and data processing skills.

Another good skill to have is “learning how to learn”.

Two, as doctors are more than just diagnosticians, we must teach them that there is a world outside scientific medicine.

Brief introductions to health systems, funding mechanisms and health economics are inherently beneficial, and will also teach humility and a sense of awe.

Finally, the doctors of 1995, 2035 and 2045 will have different generational zeitgeists, but will work together in the same clinic.

Our medical education system must embrace the cultural and age differences, and prepare for teamwork of a completely different kind.

Studying medicine is one of the higher callings in life, and the trust and respect given to doctors is testament to that.

There will be no magic solutions to the optimal number of doctors we need, to reduce the number of medical schools and students, to select better medical students or to improve the quality of medical schools.

What we have is a basket of solutions to get the correct number of doctors – all well-trained and well-selected – in order to get the health that we deserve.

Dr Khor Swee Kheng has postgraduate degrees in internal medicine and public health, and has worked in five health sectors across three continents. He is currently reading Public Policy at the University of Oxford. The views expressed here are entirely his own.

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Healthcare , policy , governance , doctors , students , education


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