Sunday Times 2
Separate the long term medical standards issue from SAITM
View(s):By Dr. Channa Ratnatunga
I was surprised to read a news caption in the Sunday Times of 5th February, that the deans of the medical schools are ruminating whether they should meet the President about the ruling given by the Court of Appeal re. SAITM. The same article highlights that no less than five “business types” are waiting in the wings, to start medical schools no sooner the ok is given! As somebody who has spent his whole working life as a medical educationist and is very concerned about retaining the standards we have achieved, I felt I should give vent to my concerns.
A pragmatic plan to solve the current impasse between the SLMC, the students of State Medical Schools, the Union of Government Doctors (GMOA) and SAITM supported by the ruling of the Court of Appeal must be looked at unemotionally and rationally. Further it ill behoves the future of the medical profession, if its acolytes take umbrage, by rabid and uncouth street protests on a court order. The profession is considered to be an erudite and cultured community.
I write as I think it is mandatory to distinguish the two issues. One is the need to maintain the quality of medical training in Sri Lanka as a long term goal. The other, that of SAITM, as a private medical school and their legitimate request to society to accept responsibility and to ensure its current students are dealt with fairly and honourably. The latter though of importance in the short term, pales into insignificance when due weightage is given to the former.
Taking first, the long term goal, it is obligatory on our part that the current quality standards be persisted with as it has paid us good dividends. Our medical standards over the years have tamed or eradicated the scourges of the early nineteenth century. Malaria, typhoid, cholera, dysentery, syphilis, yaws, small pox, filaria and polio, they are no more. We yet face some preventable disorders, the virus diseases like rabies, dengue, and AIDS. Chronic bacterial disease like tuberculosis and leprosy are yet with us. Add to this the care of those who suffer the legacy of a stressful life, of mental ill health, alcoholism, drug addiction, and suicides, add to it the management of trauma caused by assault and road traffic accidents, there is a need to focus our attention anew. It is made worse by the current epidemic of diabetes, obesity, CKD and other disorders, such as cancer, heart disease and strokes that are rampant in our society. The doctor’s plate is full.
To manage, to prevent and try to minimise such national concerns, requires a trained, but compassionate and committed workforce to be able to grasp the protean ramifications of such maladies. That the calibre of individuals recruited to do medicine, to say the least must come from the top drawer. This is to ensure that the health statistics we have achieved so far, are maintained and improved on. They should possess the personal infrastructure of both nature ie the natural ability, and nurture to imbibe a complex knowledge and training that even the basics require five years of hard and intensive training.
To ensure that they are trained to this pitch is the responsibility of the SLMC. No wonder that the doctors are up in arms to preserve this paradigm, they must not be faulted. They know the consequences of allowing business sentiments, politics, abuse and corruption into what has been up to now a pristine territory. We have only to look at our giant neighbour to know what can happen when responsibility is taken away from the watchdog.
The SLMC’s regulatory control is a ‘sine qua non’ as far as most doctors are concerned. It is not our intent that we like to maintain, our registration, as a exclusive preserve of the medical profession but we feel it our bounden duty to ensure that all members of the Sri Lankan community are protected by trained medical personnel.
Now that the report of the parliamentary oversight committee dealing with the expansion of medical education, has reached the public domain, there are many ideas in it that have aroused my interest, it includes some good ideas and is worth perusal. I will extract some data from it, I hope with impunity, as I propound my case for expansion of medical education without incurring such wrath as we have seen from the medical profession. Change we must, but weather too, the storm that follows by those unwilling to step out from their comfort zones and think outside the box.
Government financial constraints at present make necessary that, private medical education is the only way to achieve the goal of the planned, 1 doctor per 1,000 population. It is a fact that we have about 17,000 doctors, but we need about 25,000 more to get anywhere near this optimum ratio. At the present rate of training by our State medical schools of about 1,000 per year, we will need another 20 odd years at best to reach targets. Mind you, we have not taken into account the rate of attrition, caused by retirees from service, and active and passive poaching of the trained intellectual elite, ie doctors, by economically advanced countries which is going apace.
This ratio per population must apply to each district or province as it will only then give better equity of service, envisaged.
The educational experience in many of the SLMC recognised foreign medical schools has been found unacceptable. This can be concluded by the large percentage of the so called trained, failing to achieve even the basic standards as tested by local exams like the EPRM, conducted to evaluate foreign qualified doctors.
The Sri Lankan Government using our own trained human resources and state hospitals can give a better private medical education, with higher standards. A private-public partnership as is envisaged, to bear the costs of initiation of this program.
To ensure a high standard of medical education in private medical schools, when established, they should be affiliated to State medical schools, and be overseen and supervised by them. They could be called eg Colombo Medical School (private), like Monash and Monash (private) in Australia.
After discussion with the stakeholders only reasonable profits as befits an educational project should be charged. Concessions for medical training for their kith and kin who do not have appropriate grades should not be tolerated.
They must ensure the Government share of monies due for offering government hospital services for private medical education should be utilised to both to upgrade the hospital and offer scholarships to those bright students who have high “Z” scores but are unable bear the tuition fees of a private (state) medical school in this country.
The SLMC must take charge of ensuring the quality of the medical education in these private (state) medical schools.
The SLMCalso must become a more proactive body. Once the training program on a private basis is available in Sri Lanka, stop sending students for training abroad or be very selective in recognising foreign medical schools. Current selection of students with mediocre grades, to foreign medical schools just because they can afford must cease.
For those students currently training abroad who have the grades, lateral entry could be discussed.
Selection of students to the private branches of state medical schools must be done entirely and transparently by the UGC.
Selection criteria utilised for this selection must be based on their Z scores, consideration being given to their ability to pay for such an education and their Z score. A cut-off mark as close as possible to the affiliated state medical school would be necessary. A minimum mark should be way above what is accepted by the current entrance to a university course of 2C’s and an S. It is envisaged that this will assuage the concerns of students in State medical schools, and give the teachers better material as students to teach.
We can develop an educational hub concept on this score. As our patients are very corporative and often carry “a variety of end stage disease”. Often these types of patients are not available in the advanced west, where they are often private and often unwilling to be examined by medical students. This will save large amounts of foreign exchange. Further the parents will have their children in this country.
The SAITM issue
The issue concerning students of the SAITM, must be handled firmly, with care and with credibility. The parents of these children were unfortunately misled by those in power in the previous Government. That UGC approval was granted is a fact and after consultation with the appropriate authorities who, they claim are now going back on their word given the green light to register at SAITM. Now that the appeals court has ruled that those who qualified must be given provisional registration, accepting it as the internship will invariably brush up any alleged defects as have happened.
The foreign qualified doctors have been selected for medical training, even without the requisite Z scores, come from a community that can afford to pay the exorbitant fees and the training does not reach the required standard as shown by local assessments. The local exams too arranged by the SLMC are never as vigorous as the state exams. Those who pass are registered by the SLMC. They are accepted by the GMOA as members. In the SAITM, those who at least have Z scores that are acceptable to seek entrance to a Sri Lankan university, are trained by the best but are blocked by the GMOA from getting clinical experience in local hospitals, and then the GMOA argue that they lack clinical experience! The government agreed to give the Homagama hospital for the SAITM student’s training, provided SAITM improves it/ pays. This was agreed to.
The GMOA in my opinion are not helping with the national needs. They have double standards for private medical education.
A pragmatic solution is required in the circumstances.
SAITM and the Neville Fernando Hospital (NFTH) should be taken over by the Government with the owners consent.Loans taken to build the hospital could be covered by the Government: It could be the private branch of the Colombo Medical School if they are willing to accept it.
The SAITM students in the mean time who are yet to qualify must be given an opportunity to do so by the current Government: standing firm, and giving them the privileges of clinical training in the Government hospitals nearby till the NFTH gets into full swing.
As a Government hospital the NFTH, being in a populous area, not charging fees would soon join the overcrowded, high turnover hospitals, that are the lot of all government hospitals. They however are havens for clinical exposure. The monies paid by the students at present in SAITM could be deducted from the cost to the Government of the Neville Fernando hospital when it is taken over.
The salaries of the teachers in the affiliated private medical schools must be the same as the state sector so that it will discourage the gravitation of staff from State schools to private medical schools.
Staffing of the private medical schools maybe a problem at first, but in Colombo and Kandy and possibly Galle it maybe not a major issue. If as it happens now, state medical school staff can take their sabbaticals in the private medical schools. Those retirees such as Consultants from the State sector medical schools and teaching hospitals will, I am sure be found to be suitable, as they can bring their vast expertise to the private medical school.
Kandy also has vast teaching resources, and an affiliated private medical school can be accommodated with advantage in proximity to the Matale or Gampola hospitals which are at present both in the teaching circuit. Nuwara Eliya hospital as suggested in the oversight committee report is unsuitable as it is two hours at least on the climb for the State hospital staff from Kandy or Peradeniya.
This is in my opinion a very viable plan.
(The writer was a Professor of Surgery at the University of Peradeniya.)