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.
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.
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.”