Medical education at crossroads

By Saman Gunatilake

MBBS, MD, FRCP, FCCP, Hon FRACP
Emeritus Professor of Medicine, University of Sri Jayewardenepura
Consultant Neurologist

One of the most quoted phrases of Karl Marx, the German philosopher and political theorist, popularly known as the ‘Father of Communism’, is “History repeats itself, first as a tragedy, second as a farce”. This quote has made its way to common usage through the years, especially the initial part of ‘History repeats itself’. Marx’s words seem to be a good fit for many occasions and the current attempts to restart private medical schools is one such situation. Whether Sri Lanka today is ready to venture into private medical education is a highly debatable issue at present and for a start it would be worthwhile to look back at the past.

History of Private medical schools

North Colombo Medical College (NCMC) was the first privately funded medical school in Sri Lanka. It started in 1980. Since its inception the NCMC came under criticism and opposition of many socialist elements in the island, and especially the state university student bodies. Their slogan was stop privatising medical education. These protests reached a peak in 1989 and university and medical faculty education was disrupted badly with student strikes and protests being a regular scenery. Soon after, the NCMC was nationalised with the government sending the army to occupy the buildings at Ragama stating security reasons. Its board was replaced by a Competent Authority, Prof. Carlo Fonseka. He continued as the first Dean when the NCMC was transferred to the University of Kelaniya as its Faculty of Medicine in 1991.

History repeated in 2008 and, as Marx said, this ended up in tragedy. The South Asian Institute of Technology and Medicine was established in 2008 by Dr. Neville Fernando with the aim to provide tertiary qualifications in medicine, engineering, and information technology, management and finance, and information communication technology and media. The institute was initially affiliated with the Nizhny Novgorod State Medical Academy (Russia), the Asian Institute of Technology (Thailand) and Buckinghamshire New University (England), awarding degrees through those respective institutes. In 2011 SAITM applied for recognition from the University Grants Commission (UGC) as a degree awarding institution, with the ability to award its own degrees. The UGC, in 2013, granted SAITM a degree awarding status despite protests from the Inter-University Students’ Federation (IUSF) and the Government Medical Officers’ Association (GMOA). These protests continued for months and student education came to a standstill, students not attending lectures and exams. MBBS courses dragged on and exams were delayed by over a year and as a result even the running of hospitals were affected. GMOA strikes disrupted patient care in hospitals countrywide. Even the parents of state medical school students formed a body to fight the issue after seeing the plight of their sons and daughters. Following a fast unto death campaign performed by the parents of State Medical Students, on 8th Nov 2017, the Government of Sri Lanka, decided to abolish SAITM, suspend the new enrollments immediately. Students who were doing the medicine course in SAITM and their parents too were in a very dire situation. Their course too dragged on and most had to spend up to 10 years before they qualified by joining overseas universities and the Kotelawala defense university medical faculty. The staff who were teaching in the SAITM were left to their own means. So, wasn’t this a tragedy in the real sense? If this is repeated it will be a farce in Marx’s words. Farce is defined by some as foolish show, mockery, a ridiculous sham. It seems the government probably misinformed by and together with a few retired academics are planning to repeat history. To understand why I say so, we need to have an in-depth knowledge of what the medical course entails.

Current status of medical education

MBBS courses in our medical faculties are very similar and run on similar curricula approved and monitored by the University Grants Commission and the Sri Lanka Medical Council. MBBS course is quite different from most other courses as it deals with ill living human beings. Major difference which non-medics are ignorant is that of the clinical training. More than 50% of the course involves training in hospitals in the last three years out of the total five years. Government has taken a decision to increase the numbers taken for medical courses and also to start two fee levying privately run medical schools. No one would be against this as a principle. Country needs more doctors and no question about it, also in the last 12 months many young and specialized doctors have left the country making some hospital sections even to close down.

First let’s consider the training in state medical schools and why new admissions cannot be increased freely. Clinical training in the last 3 years involve working in hospitals in all days of the week, some Sundays and some nights. From the days I was a medical student and till recently a batch of students would have about 150 students. They are divided into groups of about 12-15 in each group and are allocated to each ward to work under the supervision of a hospital consultant. If the group had 150 there would be about 12 groups. Training would be for a period of 2 months in major specialties like Medicine, Surgery, Paediatrics and Obstetrics and for 2 weeks in others like Cardiology, Neurology, ENT, Neurosurgery, Orthopaedics etc. A group is limited to 12 to 15 because that is about the maximum a hospital ward could accommodate and also suitable for bedside teaching. A ward in a state hospital generally have about 40 to 60 beds and so a student will be given to be in charge of 3 to 5 patients at a given time to study and discuss with senior doctors in the ward till those patients are discharged and then a new patient will be allocated. This is a very dynamic process that changes daily. If the student numbers are increased this system will fail as the hospital has only a limited number of wards, patients and teachers. Prior to increasing student numbers hospital facilities have to be increased to suit the increase. This involves long term plans like increasing available number of hospital wards, beds and trained teachers. If the numbers were increased without paying attention to availability of adequate infrastructure standards will go down. Our MBBS graduates have a good standing internationally and the degree is recognized by the UK and Australian medical councils.

Colombo, Peradeniya, Galle, Jaffna, Jayawardenepura, Rajarata and Eastern are well established medical faculties. Of them Rajarata and Eastern are still understaffed and don’t have professors in most departments. Recently Rajarata had to close down the paediatric unit due to lack of specialist consultants. Sabaragamuwa (Ratnapura), Wayamba (Kuliyapitiya), Uva (Badulla) and Moratuwa are new faculties started recently and have enrolled students. Sabaragamuwa students are ready to start their final year but the final year clinical attachments haven’t been sorted yet and the final year departments have no staff to teach and they have no hospital wards under them. They are struggling to find qualified staff and have no proper buildings to house their laboratories, and lecture halls. Departments have only one or two permanent members. Universities need to attract young and bright lecturers but the opposite is the truth, there is no suitable background for them to join these faculties and many are leaving the country for overseas jobs.

These new faculties are facing the issue of finding suitable hospitals for student training. Most hospitals that are suitable for training are already being used by established state faculties. Most days of the week students spend the mornings in the hospital and attend lectures and tutorials in the faculty and return to hospital for seeing patients. For this the hospital and faculty have to be close to each other. The new faculties are in a crisis situation finding hospitals for training of their students. These shortages will escalate student unrest. Hostel facilities are another important issue as students in a faculty are from all parts of the island. There have been requests from authorities to increase the intake of students to Colombo and Galle and from what I know to increase the intake to 300 from the current 150-200. This is an impossible task. Lectures can be done on line, but in medicine, surgery and other hospital specialties the most effective modes of training are using small group discussions and bedside teaching. Students need to spend time in operating theatres watching operations, but the number that can be allowed in to an operating theatre is limited due to risks of infection. Such ad hoc increse cannot be done without compromising on the training and overcrowding of hospital wards. Patient welfare is also an important area to consider.

When too many students are in a ward, patients will be disturbed by students trying to examine them and this would cause negative responses from patients and their relatives. With all these drawbacks and the apparent collision course the state medical faculties are heading, new private medical schools are to be established with government approval. Where would this lead us to?

New Private Medical faculties

In Sri Lanka, becoming a doctor is still the number one choice for most students. Therefore, there is a bigger demand than that can be catered for. So, the parents who can afford seek entry into overseas medical schools pay exorbitant fees. They are studying medicine in China, Russia, eastern Europe, UK, Malaysia, Australia and India, to name a few. Some argue that the country can save foreign exchange if these students can be educated locally. Many would wish for private medical education in Sri Lanka and that is a very reasonable one. But are we ready for that as a country, and is this the opportune time? From what I have said before it is apparent that starting state medical faculties in the recent past had been done without proper plans and foresight. Where are we going to find clinical teachers and hospitals to cater private medical schools? Clinical teachers have to be selected from high achievers. They should have adequate experience in teaching, proper postgraduate qualifications and outstanding academic records. Parents would not pay fees if the faculty is not up to international standards. Obtaining international recognition too would be a difficult task. This would be a problem that would be faced by even the new state medical faculties. If the terms are attractive state medical faculty teachers may join the private medical schools. That would make the situation in state faculties much worse. When there are no suitable hospitals for training of state medical students where would you train private students? This would result in student protests and student rivalry and even clashes. Result: history repeats, as a farce or tragedy again? There are some private hospitals mainly in Colombo suitable for student training but may not be adequate. Hospitals have to be in close vicinity to where other teachings are done, or else the hospital should provide facilities for lectures and other non-clinical work. The urgent need is to look after the already established medical faculties. Some may even run the risk of losing their local and foreign medical council recognition. From what I know at present the situation in some are terrible and need urgent attention. Starting a private medical school or two will not help to earn dollars to save our bankrupt economy. Time to venture into Private medical schools would be when we have recovered economically and our state faculties are doing well. The question is how long will that be?