On April 11, 2019, Health Minister Datuk Seri Dr Dzulkefly Ahmad told the Dewan Rakyat that only about 70% of new doctors complete their housemenship within two years. The remainder receive an extension on their housemenship posts, causing a backlog and decreasing the number of available training posts for the new, incoming housemen.
This is a cause for concern. It not only raises questions about the quality of the medical graduates, but also medical education itself and the social accountability of medical schools.
Am often-asked question is whether medical schools are producing doctors “fit for purpose”. Should medical schools not be held accountable when so many graduates are unprepared for housemenship? What is the value being provided for the large amounts of public and private funds expended in medical education?
The World Health Organisation (WHO) defined the social accountability of medical schools in 1995 as “the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region and/or nation they have a mandate to serve.
“The priority health concerns are to be identified jointly by governments, healthcare organisations, health professionals and the public.”
The Global Consensus for Social Accountability of Medical Schools in 2010 identified health needs and the effects of medical schools on those needs. These ten areas are:
• An anticipation of society’s health challenges and needs.
• The creation of relationships to act efficiently.
• The spectrum of health workforce required and the doctor’s expected role and competencies.
• The fostering of outcome-based education.
• The creation of responsive and responsible governance of the medical school.
• The refining of the scope of standards, research and service delivery.
• The support for continuous quality improvement in education, research and service delivery.
• The establishment of mandated mechanisms for accreditation.
• The balancing of global principles with context specificity, and
• Defining the role of society.
The terms “socially responsible”, “socially responsive” and “socially accountable” are used interchangeably, but have different meanings.
Charles Boelen and colleagues explained the distinctions in a 2012 paper published in the e-journal Education for Health as follows: “A socially responsible medical school is one that is committed to what faculty intuitively considers as the welfare of society.
“The intention to produce ‘good practitioners’ is based on an implicit identification of society’s health needs. A socially responsive medical school is one that responds to society’s welfare by directing its education, research and service activities towards explicitly identified health priorities in society.
“In this case, the faculty intends to produce graduates possessing specific competencies to address peoples’ health concerns, such as the ones covered under the notion of ‘professionalism’.
“The socially accountable medical school goes one step beyond as it is not only taking specific actions through its education, research and service activities to meet the priority health needs of society, but also working collaboratively with governments, health service organisations, and the public to positively impact people’s health and being able to demonstrate this by providing evidence that its work is relevant, of high quality, equitable (and) cost-effective.
“As far as the quality of its graduates is concerned, its aim is to produce change agents with capacity to work well on health determinants and contribute to adapting the health system.”
Examples to illustrate the differences were also given in the paper. The socially responsible medical school is one that offers courses that focus on the determinants of poverty and health disparities.
The socially responsive medical school engages its students throughout the course in community-based activities to ensure that all students acquire well-defined competencies to care for the most vulnerable.
The socially accountable medical school goes beyond the above commitments, is aware of the health system’s challenges and positions itself as an important actor to influence health policies through active collaboration with key stakeholders.
A socially-responsive medical school will ensure its students experience community-based activities that teaches them to care for the vulnerable in society, like the doctor in this filepic does voluntarily for the homeless in Kuala Lumpur.
All medical schools claim excellence in their visions and missions. But are the words matched with deeds? Can each and every medical school state publicly whether they are socially responsible, socially responsive or socially accountable, and their reasons for stating so?
While economics and financials are important for private medical schools, should the public good not be equally important? How is the profit imperative reconciled with the public good? Should the quality of students who enter medical school matter?
What about the quantity and quality of the teaching staff, as they are role models for students?
Does the quality of medical education focus on the core educational needs of a doctor, providing him with the knowledge, attitude and skills necessary to address public health and clinical challenges today and tomorrow?
The boards (or councils), deans and teaching staff of universities or university colleges that have medical schools have a duty to society to address these issues, and if they have not, it is time to get started.
It is in the interest of every medical school to produce graduates “fit for purpose” for its long-term sustainability. Students today are not like those of yesteryear as they share their experiences online.
If medical schools are not up to the mark, their enrolments will decrease with time, which some schools are already experiencing. Mergers, acquisitions and closures are not just on the horizon, but a stark reality today.
Have regulators assessed which Malaysian medical schools are socially responsible, socially responsive or socially accountable? If they have, should it not be publicised so that potential medical students and their parents will have an opportunity to make informed choices? If not, it is time to get started.
How robust is the accreditation process for Malaysian medical schools? Has there been an independent evaluation of the utility of accreditation? If so, should the report not be made available to all stakeholders? If not, it is time to get started.
The International Federation of Medical Students Associations’ position is that medical students should be advocates for social accountability as it “is an opportunity to contribute to the building of best medical education practices and improving the health of our communities and countries”.
Towards this end, they have come up with a simple toolkit to assess the social accountability of individual medical schools, as well as identify their problems and opportunities for improvement.
Only about 70% of medical graduates complete their housemenship on time, causing a reduction in the number of available housemen posts for the next batch of medical graduates.
Take home message
The obsession with quantity has to cease. The public interest is better served by fewer good quality doctors than large quantities who are deficient in knowledge, skills and attitudes. The statements from Medicine’s icons are just as relevant today as in their times.
Hippocrates (460-377 BC) stated: “When-ever a doctor cannot do good, he must be kept from doing harm.” Avicenna (AD 980-1037) said: “An ignorant doctor is the aide-de-camp of death.” And Sir William Osler (AD 1849-1919) said: “The best preparation for tomorrow is to do today’s work superbly well.”
Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
Healthcare is heavily regulated. There are 33 laws listed on the Health Ministry’s website (www.moh.gov.my).
The only Act that specifies standards for healthcare facilities and services is the Private Healthcare Facilities and Services Act (PHFSA), which has been in force since 2006.
Private Healthcare Facilities and Services Act
The PHFSA was enacted for the purposes of ensuring the integrity of healthcare professions, professionalism, quality of care and patient safety, and social and national interests.
The person in charge of a healthcare facility or service, who is a registered medical or dental practitioner, is liable, upon conviction, to a fine, imprisonment or both for several offences.
They include establishment, maintenance and operation of an unregistered clinic; failure to fulfil the prescribed responsibilities of a holder of a certificate of registration and person in charge; using the healthcare facility for any purpose other than that for which the certificate of registration is issued; non-compliance with an order of the Health director-general to close the healthcare facility; failure to comply with directives on quality and standards issued by the Health director-general; entering into contracts or arrangements with managed care organisations that changes the powers of the doctor in the medical management of patients, changes the role and responsibility of the Medical Advisory Committee, contravenes the Code of Professional Conduct of the Medical/Dental Council and/or contravenes the PHFSA, its regulations or any other written law; failure to provide information to the Health director-general about contracts or arrangements with managed care organisations; failure to provide information required by the Health director-general; employment of unregistered or unqualified staff; treatment provided by a person other than a registered doctor/dentist; non-availability of a registered doctor/dentist during the opening hours of the clinic; failure to comply with the regulatory requirements for orders for diagnostic procedure, medication or treatment; billing procedures; ensuring a patient’s rights; patient medical record system; infection control; basic emergency care services; and storage of vaccines.
A doctor was imprisoned under the PHFSA in 2008. A dentist and a dental facility was charged under the PHFSA in 2016.
Whilst the PHFSA applies to the private sector, the Federal Court has applied the same standards of care to both public and private sectors.
The Federal Court statement on the standard of care is: “The test propounded by the Australian case in Rogers v Whitaker and followed by this Court in Foo Fio Na in regard to standard of care in medical negligence is restricted only to the duty to advise of risks associated with any proposed treatment and does not extend to diagnosis or treatment.
“With regard to the standard of care for diagnosis or treatment, the Bolam test still applies, subject to qualifications as decided by the House of Lords in Bolitho.” (Zulhasnimar Hasan Basri & Khairina Puteri Sariman v Dr Kuppu Velumani Anor 2017)
The duty to warn stated in Rogers v Whitaker (1992) is: “The law should recognise that a doctor has a duty to warn a patient of a material risk inherent in the proposed treatment; a risk is material if, in the circumstance of the particular case, a reasonable person in the patient’s position, if warned of the risk, would be likely to attach significance to it or if the practitioner is or should reasonably be aware that the particular patient, if warned of the risk, would likely to attach significance to it. This duty is subject to the therapeutic privilege.”
The duty regarding diagnosis or treatment stated in the English case Bolam v Friern Hospital Manage-ment Committee (1957) is: “In the case of a medical man, negligence means failure to act in accordance with the standards of reasonably competent men at the time…
“Putting it the other way around, a man is not negligent, if he is acting in accordance with such practice, merely because there is a body of opinion that would take a contrary view.”
The qualifications to Bolam stated in Bolitho v City and Hackney Health Authority (1997) is: “The use of these adjectives – responsible, reasonable and respectable – all show that the court has to be satisfied that the exponents of the body of opinion relied on can demonstrate that such opinion has a logical basis.”
The law should recognise that a doctor has a duty to warn a patient of a material risk inherent in a proposed treatment. — 123rf.com
Health, Education and Defence Ministry facilities and services
The Health, Education and Defence Ministries’ facilities and services comply with the relevant ministry’s directives on standards.
However, no such document(s) are available in the public domain.
In addition, non-compliance does not incur a fine, imprisonment or both, as there is no statutory provision for it.
One healthcare standard
The Federal Constitution states that all persons are equal before the law.
The PHFSA imposes a statutory duty on facilities, services and registered medical/dental practitioners in the private sector.
There is no similar imposition on the public sector. Is this fair? Are there two healthcare standards – one for the public sector and one for the private sector?
If the answer is in the affirmative, it raises the question as to why patients in the private sector are protected by statute, but the patients in the public sector are not.
Are patients in the private sector privileged? Are patients in the public sector not entitled to the same statutory protection?
After all, the Common Law does not distinguish patients in the public sector from those in the private sector.
A single death in a private healthcare facility led to a criminal prosecution. What happens if the death(s) occur in a public-sector facility?
The PHFSA also raises the question as to whether it is in line with the Constitutional provision of equality before the law.
It is time for the PHFSA to be amended for it to apply to all healthcare facilities and services irrespective of whether they are in the public or private sector.
If the public-sector facilities currently do not comply with these standards, then they should be upgraded until they do.
Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. The views expressed do not represent that of any organisation the writer is associated with. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.