Monday, November 29, 2010

Too Many Students, Too Many Doctors, Can We Cope?

Too Many Students, Too Many Doctors, Can We Cope?
Dr David KL Quek,

MMA News, December 2010, President's Page

“WHAT does the world expect from doctors? Are the expectations of others the same expectations we have of ourselves? Has our training and experience so far equipped us for the world in which we now practice? These issues cause tension for many of us. We live and practice in a risk-averse and failure-intolerant society – not just in medicine, but generally, and this leads to many paradoxes.” Dr Sue Ieraci[1]

Too Many Medical Graduates overwhelm our Training Capacity
The MMA has long been expressing our concern about the uncontrolled and haphazard growth in medical graduates from the ever-increasing number of our local medical schools (30) and programmes (40+), as well as the many hundreds, who are returning from overseas, annually.
This year alone we had more than 3,650 medical graduates reporting for internship training and provisional registration. For the next few years, we are projecting some 4,000 to over 5,000 medical graduates coming on-stream annually, toward the decade ending 2020!
The Ministry of Health wants to quickly reduce the doctor-population ratio (now 1:903) to the so-called developed nation status norm of 1:400, to achieve a total doctor number of more than 85,000 (for a projected population of 35 million) by 2020. We are now just over 31,000 doctors including provisionally registered interns. That is one of its KPIs (Key Performance Indicators)!
Sure we would all love to be classified as a developed economy in every way possible, including rising income, greater productivity, excellence in standards and quality of life, and human development measures. Every Malaysian would love this ‘developed’ status, because we would all be better for it! But to base this purely on the numbers’ game is probably off the mark—it’s the quality and the efficiency of service, which should truly matter.
Thus, the MMA says that this goal of trying to achieve so many doctors in so short a time is way too fast, and too soon! Before too long, we would be facing not just a serious glut of doctors, but also a possible erosion of standards, mainly because our infrastructure and our current and projected training and supervising personnel, cannot cater to such a huge influx of medical graduates, in so short a time!
As many would now know, the medical graduate is different from other professions, where because of stringent regulatory, patient safety and medico-legal concerns, students under training cannot be allowed to practice sufficiently independently on their own, and thus have very limited hands-on experience.
All medical graduates are expected to further hone their experience and skills in internship and residency (medical officership) programmes following graduation, before they can be fully registered as medical practitioners and certified to practice autonomously. Depending on the discipline or specialty that one wishes to pursue, the duration of residency or apprenticeship programme varies. Even then for some highly specialized disciplines, post-specialist experience (and ongoing further training) is critical to ensure the highest standards of skills required to function as acknowledged experts.
Our unique professional learning-teaching structure dictates that the fresh medical graduates would need more in-depth practical training and closer supervision. Clearly this is crucial because in many instances we are dealing with extremely narrow tolerable margins of errors and possible life and death encounters. Medical mistakes and lapses are thus not acceptable options, and the consequences are too dire for society or the patient and/or their families to bear.
Each and every medical graduate must therefore, experience that arduous if rigorous and particular apprenticeship-internship programme, and be personally certified as safe and competent by a host of supervising seniors, to ensure that the final product is sound and safe for our Malaysian rakyat, or for that matter, for any other patient anywhere around the world!
We are not simply crying ‘wolf’ or protecting our ‘turf’ and numbers, as some officials have belittled and decried our concerns. We have been accused of being inward-looking and not interested in the bigger picture, the national agenda and our aspired developmental goals. This is farthest from the truth. But it is particularly because we are so deeply concerned that we have repeatedly expressed our trenchant views that we cannot afford to do this in such a manner, without casting our entire health system into the cold shadows of quality and safety concerns.

Foreign and Local Medical Schools Malaise
Of late, our qualms are spooked by rising complaints that some of these foreign graduates are of dubious quality and training, especially those from questionable medical schools, which programmes have been formed purely as business concerns. These medical programmes seemed to have blossomed of late, to cater for the lucrative foreign medical students from third world countries, or as luck would have it, even from middle-income nations such as Malaysia.
We have Russian, Indonesian or Ukrainian universities offering medical programmes strictly for foreigners in the English language just for the sake of it, when many if not most of the teaching staff have problems even speaking, much less mastering the English language. Medical graduates are expected to leave upon graduation and not practice in the host country! So, one wonders as to the commitment and trustworthy responsibilities and duties of such medical schools!
Whether the standards, communication skills and didactic quality are as good as expected, is therefore difficult to determine, although on paper, the programmes appear to meet the minimum standards of most medicals schools around the world.
So for parents and students wishing to invest in such medical programmes, please seriously reconsider the options, it’s not just the medical degree from ‘any’ university, but ‘the’ prestige and quality of the medical university or college that truly matters!
Therein lies the difficulty for quality assessment of these programmes, and the Malaysian Medical Council faces a fiduciary dilemma of having to balance a hard-nosed strict sanctions approach to deny or to approve such standards based on a minimum of requirements, and then possibly sacrificing some quality parameters, or earn the wrath of parents, medical school agents and politically-linked investors/detractors.
Actually these concerns also apply to some of the local private medical schools, which have sprouted up recently. Our own mushrooming newer local medical schools and programmes unfortunately also appear to suffer such predicaments. The pressure is to have as many medical student numbers and intakes as possible to cater to the demand rather than worry about the quality of the medical graduate, or the capacity to deliver in terms of teaching staff and the necessary appropriate standards of excellence.
Non-clinical teachers (many not registrable as doctors in this country to practice) are imported from our neighbouring nations to fill the quota of our chronically short teaching staff. Young professors are elevated, as are instructors promoted, without adequate quality assurance standards, to simply provide the minimum teacher-student ratio. Sometimes these are contracted on part-time ad hoc basis, and tasked with scheduled but unregulated point-of-contact teaching hours, which short-sell the impact of the teaching quality.
Thus, we hear of anonymous complaints of disparate and substandard teaching and learning experiences. Many students are left on their own to muddle along, in what are increasingly known as “self-learning” modes and even that touted catchphrase of “instilling of self-responsibility and maturity”! Except that many of our young charges are not quite mature or ready enough for such unsupervised learning! But perhaps, I wrongly underestimate them, in which case, I humbly apologise…
But sadly, unless the student is exposed to better medical schools and teaching, they would not have known any better. My own niece, who was enrolled in one local private medical school for one semester before transferring to the National University of Singapore, faced a huge educational and cultural shock! The quality of teaching and programmes are worlds apart, but luckily she is coping well because clearly NUS did their homework when assessing which exceptional student to accept into their very high standard medical school!
But alas, do our medical students have any recourse to complain? I fear not, because there is simply no mechanism to do so, neither is there, any straightforward comparison—thus, caveat emptor is the buzzword!
Whereas some of our neighboring universities are pushing their standards higher and higher, while chasing the globalised expectations of excellence and prestige, we in Malaysia appears to be doing the opposite—just provide the seats because there is great demand, produce the numbers and let the quality deliver itself, as if economics alone would suffice to temper the emboldened but invisible hand of the market for profits!
Conversely, and out of sync with many developed nations around the globe, our students are clamouring for more and more medical seats. The lure of becoming a doctor appears an unquenchable one for many a young Malaysian chasing that vocational dream to become a professional, with a supposedly assured job post-graduation. The oft-painted picture that the doctor would not starve and would almost always be assured of having a decent, somewhat respected, even luxurious quality of life, remains the colour-blinded vision of many an aspiring student! Sadly for many, the reality is quite the opposite.

Houseman glut, too few Training Hospitals
Recently, even the mass media has stumbled into this problem of overflowing doctor glut—especially young interns, notwithstanding the usually announced shortage of doctors in MOH public health facilities. ‘Houseman Glut: Too many new doctors and too few hospitals to train them’ claims the front page of national newspaper The Star.[2]
The MMA is fully aware that there are severe shortages of medical officers and specialists in the MOH public sector health facilities, including many district hospitals and klinik kesihatan’s. The long queues for outpatient services are testimony to the fact that too many needy patients throng the overcrowded services. There is unfortunately a maldistribution of doctors in many urban locales, which contribute to this inequitable scenario.
We encourage better distribution mechanisms so that needy remote sites are better staffed with well-qualified doctors and other healthcare providers. Mandatory posting to remote and unpopular sites may be the way forward, but this should be done with adequate care and promise that such hardship postings be rewarded by a reposting back for further specialist training and/or preferential rewards and promotions, after a stipulated period.
The MMA has been pushing for better hardship allowances and incentives to encourage doctors to be compensated for their ‘sacrifices’. But the truth is that this is way short of the reality and practice on the ground, thus that perception of never having enough doctors in service…
But now, zooming back to our current scenario in our major hospitals, we see a changing picture. Each of our regional hospitals now has in excess of 200 to even 300 house officers (HOs)! Now that the HO programme has been extended to 2 years, to cover at least 6 to 8 important disciplines, this would mean some 20 to as many as 50 HOs being distributed at any one time, per department! 
For busy departments such as internal medicine and surgery, this is currently not a problem. We’ve been informed that some 7 to 10 HOs go on-call per time, and thus there appears adequate work and patients to experience with. On-call duties come round once every 3 to 4 days, sometimes once a week. For smaller disciplines, there are indeed not enough patients and cases to learn from, with sometimes 3 to 5 interns sharing one single patient! In a smaller city e.g. in Melaka Hospital, each HO covers one ward which may take in as few as 4-5 patients to as many as 10 patients per call, with the former being more the norm. Still we hear that some of our young HOs are complaining that this is too much work!
In the not too recent past, most HOs are expected to triage, take in, clerk and examine, order and trace appropriate investigations, treat under supervision, some 15 to 20 patients per on-call take. It is arguable that this is too much to handle proficiently, but most mature doctors look at this as a much-needed experience to hone the minimal skills and competency of the doctor under stress and pressure.
I know that if I were to comment that in 1979, when I was on call in Medicine or Surgery, there were just 2 or 3 HOs, with a daily on-call take of some 50 to 70 patients, many would question the quality of our patient-doctor encounters those days, but I certainly learnt more and became the better for it. That was in the Johor Bahru General Hospital (now Sultanah Aminah Hospital, JB). And our active on-call duties were one in 3 to 4 days, occasionally 1 in 2 even, so go figure the ‘rich’ experience! Sure we were tired and exhausted after each call, but did we learn!
But I’ve been informed by one consultant physician in charge, that these days our patients are far more demanding and the quality of care expected from each HO is so much more, so I will concede that much. But one wonders if there is too much of a good thing, and here again most senior doctors would go along with the view that the more experience one gains or develops, the better equipped one becomes of any profession, but especially that for the doctor.
Of course, we appreciate that physical and mental exhaustion of young trainee doctors, or for that matter any doctor, are fraught with dangers of making more medical mistakes and mishaps. This is well-recognized and that is why in many developed countries around the world, we now have residency or trainee work directives, which categorically mandate no more than 80 hours work per week, or no more than 12 to 16 hours of continuous duties at a stretch.
But more workload also implies that there should be better guidance and clearer lines of duties and responsibilities needed from supervising seniors. This makes greater demands on medical specialists and consultants, which should be more structured and may be even demanded. We are aware that many younger returning specialists are not too keen to supervise and teach trainee HOs or others, but this is an unfortunate if misplaced attitude.

Hippocratic Miscue—not enough Patients, Supervision, Teaching
The Hippocratic approach clearly dictates that we owe it to our younger charges to teach and to impart our knowledge and skills; this is an integral part of our medical mandate to enhance skills and professionalism for the entire medical fraternity!
The Hippocratic Oath clearly demands that doctors have a duty toward our younger trainees …to teach them this art – if they deserve to learn it – without fee and covenant: to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and taken an oath according to the medical law…”[3]
Teaching actually enhances learning and improves personal and skill development, especially clinical acumen—in order to teach well, the teacher is forced to be clearer in thought and knowledge, and possibly better in skills!
In many University departments, younger specialists are required to sleep over and be responsible for all on-call admissions and patients. Thus, this extra step of coverage would offer greater safety and lesser chance for mistakes for patients, while also giving the trainee HOs or junior medical officers, better supervision. But with so many HOs and so few specialists, there is that lesser time of contact for close or personal supervision or personal one-on-one training…
It has once been said that most doctors learn best via the approach of “See one, Do one and Teach one”.[4] While this is in principle a mode of learning much in the tradition and philosophy of medicine, it is no longer considered enough. This approach is not acceptably safe: there is too much leeway for spotty and chancy learning without structured supervised practice and training. With the glut of trainees and HOs, there may not be enough personal contact and teaching to derive the best benefits of learning from this form of apprenticeship, so long a part of our medical ethos!
In a much quoted landmark paper, Tan and others stated that: The traditional teaching of ‘See one, do one and teach one’ residency training programme is no longer an acceptable and safe practice today. It is critical that every doctor who is performing any surgical procedure on the patient, must be rigorously trained, supervised and assessed to be competent before operating independently on the patient.” They advocated a more rigorous approach, which necessarily implies that there must be enough patients, enough supervision and enough workload and practice for the trainee, i.e. a structured Teaching, Education, Surgical accreditation and Assessment (TESA) residency programme for Obstetrics and Gynaecology training in Singapore.[5]

A Call for More Structured Programmes for our Trainee/Junior Doctors
But the malaise of the entire system is not just one for House Officers, it applies to the wider scheme of all public sector hospitals, when it comes to career development of the young medical graduate or doctor. But this is clearly not peculiar to Malaysia alone.
In 2002, there was an ill-tested attempt to transform postgraduate medical education and training in the United Kingdom.[6] This ill-fated initiative called “Modernising Medical Careers” plunged the entire system of training application and implementation of junior doctors into complete disarray, with many good and qualified trainees failing to get job interviews. This heavily criticized debacle lasted some years until the Tooke Report in 2008 highlighted and recommended some 47 rectifications to offset the weaknesses of this scheme.[7]
Clearly reforming or transforming systems of training and post-graduate medical education carries grave implications, which should merit in-depth planning, with as little political interference as possible. This aspect of postgraduate education is well discussed by Prof. Victor Lim, Master of the Academy of Medicine of Malaysia, recently.[8]
So what should or could we do better?
It is clear now that with the ever-increasing numbers of medical graduates coming on-stream, there is a need to systematically address their training-internship programme, so that there is sufficient work and experience which can be imparted or shared. There has to be more structure and planning, and less ad hoc piecemeal slotting into whatever vacancies there are to be had.
Teachers, proctors and supervisors have to be identified and their job descriptions clearly spelt out so that proper log-books, minimum tasks and learning skills can be properly documented and approved. The objective must be to ensure that at the end of each posting to a discipline, the house officer would be certified as competent in some minimum core skills and also be safe as an independent medical practitioner, ready to embark on to another level of his or her career.
The MMA has been urging the training hospitals to ensure that there is a better-defined career path for each HO or trainee. After going through the mandatory rotations, there should be mechanisms to allow the trainee to embark on a planned rather than a haphazard chancy career development pathway. It is unfair to simply slot these freshly brewed medical officers into every available vacant discipline just to fill them, although of course some compulsory distribution to rural or remote postings would still have to be worked into the system as part of their national service.
But simply jostling these young medical officers into vacant and unpopular service areas without much supervision is also somewhat irregular, but may be inevitable. For those with clearer goals and determination, i.e. those who aspire for specialist training, they can be encouraged to take and quickly pass preliminary specialist examinations, so that they may be placed on fast track toward specialty training opportunities. Of course those who volunteer or who have been earmarked for remoter postings should be given priority to choices of specialty or advanced career paths, upon stipulated return.
Unfortunately our available seats for post-graduate specialist training are quite severely in short supply. Annually our major university and hospital trainee posts number less than 800, which means that increasingly, the greater majority of medical officers completing their internship, would be left by the wayside of unfocussed and directionless service. But what do we do with these exponentially growing numbers, which will be the majority of these unplaced junior medical officers?
Already the MMA has been queried if there are indeed sufficient places for MOs to train or to work towards some form of specialist training—many fear rightly that there would not be enough places, and competition for the rare postgraduate programmes, severe.
The MMA feels that such unprecedented numbers of medical graduates place a severe strain on the available system for such postgraduate medical training. We simply would not be able to cope and a time will surely come when, medical officers would have to compete even for simple service jobs. There may be no guaranteed placements with either internship programmes or any other programme!
The time may come when fresh graduates might have to apply and wait for vacancies, and they may also be selected based on other criteria such as graduates from more prestigious medical schools, those with better grades or honours, those with better testimonials from teachers/professors, or worse, those with political strings and cables!
But if there is more planning we believe we can transform these medical graduates into more competent doctors by ensuring that we have in place systematic training modules for general or family practice, emergency medicine, administration and health management, public health, etc. But we must get these in place before these unwieldy numbers overwhelm us totally!
The MMA therefore stands by its premise that there must be an urgent moratorium on the number of medical schools, or programmes. The rampant production of medical graduates must be drastically checked to ensure that only the best and most well-equipped can be allowed to continue. No medical school should be allowed to arbitrarily increase its intake or output, and neither must there be 2 or 3 batches of entry points, which makes a mockery of good high quality medical education, both undergraduate and postgraduate.
The ball is strictly within the feet of the Ministries of Health and Higher Education.
What do we want or wish for? Just the numbers game, or should we ensure more importantly, the product quality of medical doctors, and ultimately, the safety of our populace? There must be a better alignment and cohesion of purpose and vision, and not just reliance on whimsical bureaucratic or political expediency!
Who would you rather have at the end of the day to look after you when you are ill, when you are older and who would you perhaps entrust the healthcare of your children, your loved ones? Just a barely competent inadequately trained doctor, or the slightly stressed, overworked but experienced and highly skilled one?

[1] Dr Sue Ieraci, Public expectations of doctors need a reality check, in MJA Insight, 7 July, 2010. (accessed 28 Nov 2010)
[2] Loh Foon Fong. Houseman Glut: Too many new doctors and too few hospitals to train them, in The Star, Saturday, 27 November 2010, pgs 1, 4.
[3] Dr. John Patrick. Hippocrates and Medicine in the Third Millennium, (accessed 28 November 2010)

[4] Patricia J. Numann. See One, Do One, Teach One. J Fam Practice online. Contemporary Surgery (Editorial). (Accessed 28 November 2010)

[5] Tan TC, Tan KT, Tee JCS. An End to “See One, Do One and Teach One” Residency Training Programme – Impact of the Training, Education, Surgical Accreditation and Assessment (TESA) Programme on Medical Care and Patients’ Safety. Ann Acad Med Singapore 2007;36:756-9. (accessed 28 November 2010)
[6] Department of Health. Unfinished Business – Proposals for the Reform of the Senior House Officer Grade. London: Department of Health, 2002.
[7] Department of Health. Implementing the Tooke Report: Department of Health Update. London, DS, November 2008
[8] Victor Lim. Postgraduate Medical Education and Training. Berita Akademi, September 2010, pgs 1-2

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