Medical education in our country faced two man-made disasters in recent times. The North Colombo Private Medical School issue and the more recent South Asian Institute of Technology and Medicine (SAITM) disaster.
One of the most quoted phrases of the German philosopher and political theorist, popularly known as the ‘father of communism’, Karl Marx, is that “history repeats itself, first as a tragedy, second as a farce”. Marx’s words seem to be a good fit for many occasions and the current attempts to restart fee levying 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.
Pvt. medical schools
The 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 from many socialist elements in the Island, and especially the State university student bodies. Their slogan was to 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.
History repeated in 2008 and as Marx said, this ended up in tragedy. The SAITM was established in 2008 by Dr. Neville Fernando. The University Grants Commission (UGC), in 2013, granted the SAITM 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, with students not attending lectures and exams. Exams were delayed by over a year and as a result, even the running of hospitals was affected. The GMOA strikes disrupted patient care in hospitals island-wide. Following a fast unto death campaign performed by the parents of State medical students, on 8 November, 2017, the Government decided to abolish the SAITM. So, was this not a tragedy in the real sense? If this is repeated, it will be a farce. Farce is defined by some as a foolish show, a mockery, a ridiculous sham.
The latest addition to this is an attempt to enrol fee levying students to the already established Kotelawala Defence University (KDU) medical course. In the future, the KDU will have two sets of students, non-fee levying and fee levying, with visible differences between the two student factions that may create un-envisaged additional conflicts. Maybe, some feel that due to it being a military institute, firm control measures can be instituted to prevent any unrest. A totally private medical school is also planned in the outskirts of Colombo at the National School of Business Management (NSBM) campus using the Homagama Base Hospital, and a few more private medical schools are being planned by interested parties. The Homagama Hospital is currently used for clinical training of Sri Jayewardenepura medical students as the Colombo South Teaching Hospital’s (Kalubowila) patient numbers and wards are not sufficient for a batch of around 200 students. Already, the GMOA and the Association of Medical Specialists have shown their concern for this act as it would affect the proper training of future doctors. Students are agitated and protesting against this move. These protests are likely to escalate, disrupting the medical education in the faculties and eventually even other university students will join these protests.
The current status
Bachelor of Medicine, Bachelor of Surgery (MBBS) courses in our medical faculties are all very similar and run on similar curricula approved and monitored by the UGC and the Sri Lanka Medical Council. The MBBS course is quite different from most other courses as it deals with living human beings. The major difference is that of clinical training. More than 50% of the course involves training in hospitals in the last three years out of the total of five years. The Government has taken a decision to increase the numbers taken for medical courses and also to start fee levying privately run medical schools.
First, let us consider the training in State medical schools and why new admissions cannot be increased freely. Clinical training in the last three years involves working in hospitals on all days of the week, some Sundays and some nights. From the days when 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. 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 improved to suit the increase.
Colombo, Peradeniya, Ruhuna, Jaffna, Jayewardenepura, Rajarata and Eastern are well established Medical Faculties. Of them, Rajarata and Eastern are still understaffed and don’t have professors in most of the departments. 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, they have no hospital wards under them. Universities need to attract young and bright lecturers but the opposite is the truth, as there is no suitable background for them to join these Faculties and hence, many are leaving the country for overseas jobs. In the criteria needed to qualify to be selected as a lecturer in a medical faculty, one basic requirement is first or second class honours at the final exam.
Clinical training
Most days of the week, students spend the mornings in the hospital and in the afternoons attend lectures and tutorials in the faculty and return to the hospital for seeing patients in the evenings and some nights. For this, the hospital and the faculty have to be close to each other. Hostel facilities are another important issue as students in a faculty are from all parts of the Island. There have been requests from the authorities to increase the intake of students to Colombo and Ruhuna 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 online, 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 into an operating theatre is limited due to risks of infection. 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.
New pvt. medical faculties
In Sri Lanka, becoming a doctor is still the number one choice. Therefore, there is a bigger demand than that can be catered for. So, the parents who can afford, seek entry into overseas medical schools, paying exorbitant fees. They are studying medicine in China, Russia, Eastern Europe, the United Kingdom (UK), Malaysia, Australia and India to name some. 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 for private medical schools? Clinical teachers have to be selected from high achievers. Would parents 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. 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. Starting a private medical school or two will not help to earn adequate United States Dollars and to prevent Dollars being sent to overseas medical schools that would help to save our bankrupt economy. The recent exodus of doctors started due to the situation in the country and it will improve one day and then the local graduates will stay back, and the demand from countries like the UK will drop, causing an overproduction of medical graduates. When junior doctors and even consultants report for work in hospitals, the on-call facilities provided are in very dire conditions. They repair the toilets and get basic amenities using their own money. There is much that can be done to retain our doctors in the country. The 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 as our planners are very slow-paced and have no proper vision.
(The writer is an Emeritus Professor of Medicine at the University of Sri Jayewardenepura)
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The views and opinions expressed in this article are those of the author, and do not necessarily reflect those of this publication