Wednesday, November 2, 2011

Private Medical Education – other aspects and issues

The letters published in "The Island" on the 18th and 24th Oct 2011 by Mr. Edward Gunawardena(EG) and Dr. S. Marasingh(SM) respectively, on the subject of ‘Private Medical Colleges’ (PMCs) are most welcome as they have dealt with different aspects of the subject mainly from their points of view. As a professional who has had ‘free education’ up to tertiary level and a parent of a foreign medical graduate (FMG) I have had the occasion to revisit or revise my concept of private medical education (PME) after exchanging views with professional colleagues and parents of FMGs who at present have no vested interests on this issue.

It is obvious that there has not been an enlightened debate on this subject as it often generates much heat and sound even among professionals with little light being shed. Hence this attempt to place before those interested some issues relevant to the subject but which have not been touched upon by EG or SM.

1. Does the country need more doctors?:

It was only about six years ago that a former Minister of Health Mr. Nimal Siripala de Silva stated that after 2010 the government would not be able to employ all doctors passing out from state medical faculties and that only internship training can be guaranteed for them. Officially no statement has been made thereafter by any Minister of Health to either confirm or contradict this statement. At present the local production of medical graduates is around 1,000 with another 100 to 200 FMGs being added to this number each year. This number is about the required amount to replace those emigrating, resigning, retiring or dying annually.

Further, one also hears of about eighty doctors being employed in the Ministry of Health to carry out non-medical and non-preventive health work-that is working as technicians or clerks! Hence it is more likely that there is a serious problem of mal-distribution rather than a dearth of doctors in the country!! If someone were to argue that PME should produce doctors for export then it becomes mandatory that they reach the standards of local graduates who have rightly and justifiably earned a reputation as being as good as any produced elsewhere in the world. If this does not happen the reputation of Sri Lankan doctors will be lost for good in the highly competitive contemporary medical service markets of the developed world.

If the government were to impose ‘no employment’ for all state graduates then the question would arise as to how the Ministry will choose graduates for state service. As there is so much nepotism, corruption, favouritism and political influence in giving post intern appointments it is very likely that plum jobs in the state sector will be grabbed by the undeserving, displacing those who deserve in the order of merit. As often happens some posts are never advertised but reserved for blue eyed boys who will often turn out to be PMGs!

Another point that I want to emphasise is the false notion that ‘more doctors means better health’. In fact more doctors joining the private sector may come to mean more unhealthy rivalry and cut throat competition leading to abuse, overuse or irrational use of drugs such as antibiotics, vitamins etc. Professionalism and ethics, now at a very low ebb, will then be confined to the dictionary only!

Targetting the SLMC:

Mr. EG , though having been a member of the UGC, a member of the Jayawardena University Council and also an acquaintance of Dr. H.H.R. Samarasinghe, former President of the SLMC, seems to be clueless about the functions and responsibilities of the SLMC. It is the statutory body that regulates the profession and is bound to act within the rules and regulations of the Medical Ordinance. It has no powers to ‘police’ doctors or act on its own but can inquire when complaints are presented with an affidavit. I was well informed that numerous attempts to amend the ordinance have been made but have been ignored by successive ministers of health.

Perhaps it is not too late even now for EG to contact Dr. H.H.R. Samarasinghe and get some first hand information about how the SLMC works!

The Public Health Services Regulatory Act(PHSRA) which was introduced with much fanfare was touted as the answer for most, if not all the ills in relation to specialists, patients and private health care services in this country. Specialists playing truant, seeing far too many patients during normal duty hours, charging unconscionable fees, not being punctual, etc. could be all remedied by implementing this much hyped PHSRA. But the Ministry is quite satisfied merely with collecting fees for annual registration and not giving anything back to the public or the profession in return. The GMOA has never defended errant doctors who have been caught by the Ministry’s Flying Squad, but has been highly critical of the Ministry when ‘top’ specialists who have been caught have been allowed to go scot free! Dr. SM too has placed on record the catalogue of events documented by the SLMC and placed as paid advertisements in the daily papers from the time of commencement of SAITM (Malabe Medical School). From this catalogue of events it is clear that SAITM has broken all rules but yet received favoured from the UGC and the Ministry of Higher Education, not to mention the appointment of its vice chancellor as a board member to the UGC-the height of conflict of interest!

Criticism of the GMOA:

Doctors all over the world have trade unions to look into grievances, injustices, unfair transfers, victimisation, etc. In most countries the state is receptive to demands of health care workers on justifiable grounds. In Sri Lanka it is the GMOA, urged on by its present day critics, who led the strike against the NCMC in the late eighties for trying to get hold of the Colombo Faculty MBBS degree for themselves.

The lethargy, indifference and insensitivity of the medical bureaucracy who have done nothing to prevent, respond sensibly to or de-fuse aggravating tensions are the main cause for belligerence of the trade unions in the state sector. Simultaneously there will be misrepresentation of facts in the state media with authorities hoping to wait for public agitation to build against the workers instead calling for negotiations or discussion.

It is also a fact that when the GMOA wins its demands other categories of workers such as doctors in the medical faculties also stand to benefit. Most of the shortcomings, deficiencies, shortages etc. in the state sector, as well as quality failure of drugs, devices etc. are brought to light by the GMOA (whereas the administrators are expected to cover up these deficiencies!) It is also public knowledge that new hospitals are opened up and equipped with beds, linen etc. borrowed for the occasion and returned after the ceremonial opening the following morning!

It is quite possible that SAITM may also benefit by unscrupulous activities of some well known administrators who have their children as students at the Malabe medical school. How will they recruit enough nurses for the 1000 odd bed hospital without ‘stealing’ from other private or state hospitals etc.?

What about the conflicts of interest when state faculty teachers engage in serving the EMS taking the ‘sabbatical’ for this purpose? Won’t their allegiance to the highly paid EMS make them ‘cheat’ by stealing notes, MCQs etc. from the state sector for the benefit of PMSs? What about the assessments of EMS students vis-a-vis the state graduates? Will they be assessed more leniently because they are being remunerated much better in the EMS in order to achieve the desired grades?

These are issues very embarrassing to talk about but which cannot be ignored when one considers the type of administrators who have ganged up to support the SAITM at whatever cost and with scant respect to rules and regulations as laid down by the SSMC, the final arbiter.

Dr. A. G. de Silva

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