Sunday Star, December 12, 2010, pgs E10, E11, E13
By RICHARD LIM and LOH FOON FONG
Concerns persist regarding the quality of medical graduates and the Government is preparing a number of initiatives to finetune the system.
HOW hard is it to tell the difference between a sleeping patient and a cyanosed one who is on course to meet his maker?
Observing the simple rise and fall of one’s chest would be a good start. Checking for a pulse would be another and observing that the patient has turned blue is an absolute must.
However, the obvious did not happen in the case of one Pak Abu, who was deemed to be sleeping by house officers.
Fortunately, an observant doctor on his last rounds came into the picture and Pak Abu was resuscitated.
The three house officers in charge, who graduated from Russian and Ukrainian universities, were reprimanded for negligence, and things went from bad to worse when it was discovered that they did not know the basics of resuscitation or what an oxygen face mask was.
The doctor who blogged about this was among the many who had been highlighting the urgent need to ensure the quality of housemen vis-a-vis their increasing numbers which was highlighted in The Star’s front page report two weeks ago.
The phenomena stemmed from the large number of medical students – at home and abroad – as well as the Health Ministry’s decision to increase the duration of housemanship, from one year to two years.
An overcrowding of housemen has occured at some of the nation’s 39 training hospitals, and senior Hospital Kuala Lumpur (HKL) consultant physician Datuk Dr S. Jeyaindran said that a houseman would normally look after four patients now — down from 10 five years ago.
“The concern is that these interns are seeing fewer patients and hence, have fewer opportunities to carry out adequate procedures.
“In some hospitals, there are more housemen than patients,” said Dr Jeyaindran, who is also the head of medicine at the Health Ministry.
Following the influx of housemen, senior doctors have sounded the alarm that an over-emphasis on numbers could come at the expense of quality.
They were particularly concerned with medical graduates from Russia, Ukraine, Indonesia and India, whom they said lacked core knowledge and basic expertise in treating patients.
Although all medicals schools should share a universal purpose - saving lives - differences in pedagogy and clinical procedures put some graduates on the back foot when they return to Malaysia.
And this was the case for a Ukrainian university graduate who endured a torrid time in his attachment at a local hospital.
“Many doctors were unhappy that we (housemen from Russia and Ukraine) don’t follow the British system,” he said.
“The terminologies we used were not accepted although they denote the same meaning. This led some to develop the misconception that graduates of Eastern European medical schools lack the necessary knowledge to perform,” he said.
A source said that the emphasis on the study of diseases was also different to a certain extent, as medical schools in a particular country would naturally cater to the common ailments of its citizens.
He added that housemen who studied medicine in Eastern Europe lack exposure to tropical diseases and had to brush up on their theoretical and clinical knowledge upon their return.
If there are already so many problems with accredited foreign universities, what should we expect of unaccredited institutions — with poor living conditions, inadequate facilities and lecturers of suspect quality?
And there is the eyebrow raising issue of foreign medical schools accepting students with Arts backgrounds.
The problem is not a new one. In 2005, the Crimea State Medical University was de-listed by the Malaysian Medical Council (MMC) for doing exactly that, among other things.
Giving credit where credit is due, the MMC acted upon complaints by whistle-blowers and the problem was rectified.
Task forces were sent out to check on errant medical schools overseas and warnings were served to foreign medical schools which were found wanting.
The adage goes, “When the going gets tough, the tough get going.” But who are the tough and where do they go?
A houseman who spoke to The Star on condition of anonymity joked that the tough are those who are hell-bent on receiving an MBBS even though they lack the necessary grades.
And in that advent, there would only be one logical place to go to – an unrecognised medical school abroad.
This process normally involves the services of agents who talk parents into parting with hundreds of thousands of ringgit to enrol their child into a shoddy institution – pocketing a fat commission fee in the process.
It must be noted that many parents are often fooled by a ruse, and this was the case for one Ukrainian graduate.
“The agent told me that the university would be recognised ‘soon’, but I’ve graduated and it still hasn’t happened,” he said.
Hitting out at the unscrupulous practice, Higher Education Minister Datuk Seri Mohamed Khaled Nordin urged potential medical students to tread with caution whenever agents come into the picture.
“The ministry does not appoint or recognise agents,” he told The Star. “We have no link with them and we are not responsible for their activities in sending low quality students overseas.
“Continuous reminders to the public are given through the ministry’s website.”
Back to the shady world of wheeling and dealing, agents are often identified by their insistence that students would not need to obtain a non-objection certificate (NOC) – a certificate issued by the ministry to qualified students – in order to study at various medical schools overseas.
In the past, such advertisements were even seen in papers, and agents made a killing by preying on unsuspecting – and often the uninformed – parents.
Shedding light on the topic, Higher Education director-general Prof Datuk Dr Radin Umar Radin Sohadi said that the NOC, in effect for the past eight years, was a mechanism to prevent parents from getting cheated by agents.
“The NOC is only issued to students who will read accredited medical programmes overseas.
“Additionally, it is a mechansim for sponsors to award scholarships or loans. In most countries, the NOC is also needed for visa renewal,” he said.
Review of criteria
Although greater understanding of the NOC’s significance has helped matters over the years, a recent case involving Mansoura University in Egypt showed that agents are still very much in business.
A taskforce that was sent to the university discovered that a sizeable number of Malaysian students did not possess the NOC.
The findings were alarming and the Higher Education Ministry was particularly concerned as Mansoura – fully accredited by the MMC – receives government-sponsored students from the Public Services Department (JPA) and Mara.
It was later disclosed that the students had enrolled with the help of agents, and concerns were raised as agents now had accredited universities in their clientele.
Commenting on the case, a source in the MMC said the agents were pushing their luck by hoping the Government would not reject the graduates as the universities are accredited.
There are currently 926 Malaysian students in Mansoura. The varsity’s homegrown medicine programme has 493 students while the remainder are reading a twinning programme involving the University of Manchester.
Mohamed Khaled said that a joint working group between Malaysia and Egypt had already been set up to discuss and review the criteria of students that would be sent to Egypt for medical programmes in the future.
Under the new ruling, only qualified students – those who possess the minimum academic results and NOCs – will be considered for medical programmes in Egypt.
The ministry’s swift action appears to have effectively countered the movements of agents in Egypt and the establishment of similar committees with other nations might just nip the problem in the bud.
But as they say, change is the only constant and one wonders whether it is a case of check or checkmate for the agents.
The home front
Although foreign universities took most of the brunt, local higher education institutions did not escape unscathed.
A private provider was alleged to have lowered entry requirements in order to fill its initial student intakes, and others were alleged to lack experienced teachers and adequate facilities.
Other concerns include the increasing number of medical programmes offered by private providers, with some offering up to two intakes a year instead of the usual one.
In his blog, Malaysian Medical Association president Dr David Quek said that private providers prioritise public demand over the capacity of delivery in terms of teaching staff and appropriate standards.
Dr Quek said that the increasing number of private institutions had resulted in a shortage of experienced senior clinical staff, and junior specialists who lack experience are hired to teach students.
He added that non-clinical teachers, who cannot be registered as doctors in Malaysia, were imported from neighbouring nations to fill the quota of teaching staff.
As for students, Dr Quek said that many were left on their own to muddle along.
A senior consultant who declined to be named also said that the establishment of private medical schools – at an average rate of one or two a year – over the last decade had lowered the entry requirement of students since these schools required numbers to be profitable.
Others experessed concern that the promotion of Malaysia as a medical hub would add further strain on public hospitals as talent was expected to move to the private sector.
Concerned senior doctors are urging the Government to intervene before it is too late.
Many advocate amending the Medical Act 1971 to make the Medical Qualifying Examination compulsory for all students, as students from recognised schools could also fall short of expected standards.
The removal of the list of recognised basic medical degrees - in the second schedule of the Act - was also proposed.
However, the doctors are divided when it comes to implementation.
Some propose that only graduates from foreign schools should be affected as the entire procedure would be easier to monitor.
However, a consultant said that the standard of final exams in local universities varied widely, and some varsities attempt to pass as many students as possible to look good on paper.
Currently, the exam is only administered to students from unrecognised foreign medical schools.
A senior doctor said the idea of the amendment has been discussed with the Health Ministry, but a solution had not been implemented because local universities wanted to be exempted and prestigious universities in Britain and Australia would likely object as well.
A medical lecturer who declined to be named said that the criteria of the qualifying examination should be made known in advance so that students know what was required of them.
Highlighting the case of a top student from a Ukrainian university who failed the exam, the lecturer said that the different methods of training was an obstacle too big for some.
“No matter how diligent and conscientious students are, the chances of them passing the exam seems next to impossible,” he said.
He said that different examination formats, a student’s unfamiliarity with local practices and the lack of training in medical school were possible causes of their failure.
The Government has taken note of the grouses and Mohamed Khaled confirmed that a five-year moratorium on medical programmes in Malaysia was being prepared by the Higher Education and Health Ministries.
“The moratorium is in the final stage of preparation and it will reduce or stop higher education institutions from offering new programmes as the current capacity will be able to meet national targets,” said Mohamed Khaled.
The move is similar to the Higher Education Ministry’s freeze on the number of nursing colleges in the country.
And the moratorium isn’t the only catalyst for change.
The debate on the quality of housemen has made it to the Dewan Rakyat and Health Minister Datuk Seri Liow Tiong Lai said last Monday that six hospitals — in Kuala Krai and Tanah Merah, Kelantan; Segamat, Johor; Lahad Datu, Sabah, Bintulu and Sarikei, Sarawak — would be upgraded to specialist hospitals which train housemen.
With the new avenues, house officers could be deployed in a more efficient manner. Liow said measures had already been taken to ensure quality.
The minister said that the ideal specialist to houseman ratio was 1:5 and each houseman should take care of 14 hospital beds, depending on discipline.
Liow also said that his ministry would be getting 58 contract specialists from Egypt, India and Pakistan next month to supervise housemen.
Liow added that his ministry would look into the possibility of amending the Medical Act 1971 to make the Medical Qualifying Examination compulsory for all medical students.
That said, the relevant ministries have responded with strong statements of intent in the past week and the challenge now is for the Government to strike the right balance.
A balance which ensures that the pursuit of national goals – achieving a doctor to patient ratio of 1:400 by 2020 and the rise of Malaysia as a medical hub – does not compromise the quality of healthcare service in any way.
The road ahead will be tough and if the number of grouses pertaining to the houseman glut are anything to go by, the balancing act will be a fine one indeed.