In March this year, it was reported that the Dambulla Base Hospital authorities were forcefully inserting intrauterine devices (IUD) into patients who had just given birth. Until patients agreed to the procedure, the hospital refused to discharged them or to issue birth certificates to the newly born babies. It was the patients’ understanding that inserting the contraceptive had been made compulsory by the FPA. The Hospital Director, Dr. Charles Nugawela assured a special investigations as directed by the Health Services Director Dr. Jayasundera Bandara. The Western Province Health Services Director Dr. Shanthi Samarasinghe too assured an inquiry. She claimed, she also learnt of this only after it was exposed by the media.
Since then, the issue had got distracted over nonessentials, and a gross violation of fundamental rights had became a “misunderstanding” because of the doctor’s “over exuberance”. Her failure to discuss the need or benefits of early contraception with the patient and partner, or explain the risks, which though rare are still possible and the affront to the patient’s dignity where she had been treated no better than a cow never surfaced. When this was inserted without the patient’s consent in the first place, would she be obliged to have it removed when she desires so, was never questioned. Shortly, the whole incident was euthanized, without revealing the status or the outcome of the investigation.
This case is interesting because it erupts when all the forces – from the undergraduate to the senior doctor – had joined to protest over the private medical faculty at the South Asian Institute of Technology and Medicine. They insist that the SAITM medical graduates should not be given the registration from the Sri Lanka Medical Council that is prerequisite for them to continue with their internship. Without this registration, they cannot treat patients.
There are many arguments against the SAITM medical faculty. One argument is, a profit oriented degree course would take shortcuts to maximize profits, resulting in an “epidemic of unqualified doctors who would endanger the patients’ lives”. Hence, powerful trade unions as the Government Medical Organization Association has resorted to actions that has paradoxically affected the very patient GMOA et el are trying to save from SAITM doctors.
In this context, the silence over the Dambulla debacle is indeed curious. If SAITM should not be allowed on the question of ethics, can this doctor – whose identity had been shielded – be allowed to continue to practice medicine?
The Dambulla case is not an isolated incident. Time before, a mastectomy was done on the wrong breast. Her trauma was thus doubled by this error as she lost both her healthy and her diseased breasts. Again, there is no visible sign of an investigation to determine the cause for the error and the disciplinary action taken against the doctor. Likewise, there are many cases of malpractice. The dengue epidemic for 2016 and 2017 has reached unprecedented levels. Yet, the efforts by the medical associations to educate the layperson on the basics of this deadly virus is abysmal.
Whilst worrying over the quality of doctors SAITM produces to ignore the malpractices and inefficiencies of registered doctors is indeed contradictory of both the SLMC and the GMOA observes Professor JAP Jayasinghe.
A graduate of University of Peradeniya with a doctorate from University of London, Professor Jayasinghe had worked in the Peradeniya, Ruhuna, Kelaniya and Sri Jayewardenepura Universities as well as universities in East Asia, Europe, UAE and the USA. Currently he is attached to the School of Medicine & Dentistry, University of Aberdeen, Scotland.
He had dealt with the SLMC in many occasions. Also, as a professor in a British University he has dealt with both Medical and Dental Councils (GMC and GDC) in the UK. In particular, he was involved in the establishment of a medical course and a dental school in the UK where the curricula to suite UK standards was prepared. This involved long term dealings with both UK councils. It is with this experience he compares the functioning of these two councils.
“It is interesting,” he states, “to examine how the issue of private medical education in Sri Lanka developed into chaos, street fights, political exploitations and finally boomeranged to some of those initiated the dispute. Originally it was SAITM graduates not having minimum standard and then it became the illegality of the SAITM. Some factions are fighting against any form of private medical education and finally the issue appeared to be against the Chairman of SAITM and his family.”
Among the arguments for and against private medical education in Sri Lanka, there are many falsehoods and deceptions purported on recognising a medical degree, he notes.
“First of all, a graduate should have a recognized medical degree. In Sri Lanka, the degree recognizing body is the University Grants Commission. If the UGC has recognized the SAITM degree, all those who passed the MBBS final examination are medical graduates.
“Examinations are quality assurance processes within the university to ensure that the candidates possess all the graduate attributes which includes knowledge, skills and attitudes relevant to the course. All universities also employ external quality assurance processes which involve external examiner participation in assessments. This is to ensure the quality of the degree is equal to other universities awarding the same degree.
“The external examiner’s role is to certify that the degree they examined is equal to the degree of their own institute. If this is not the case, they put down deficiencies in their report for the medical school to take necessary action. SAITM too adapted this procedure and their degree has been certified to have the same standard as the government medical schools by the external examiners.
“The graduates however cannot practice medicine or dentistry just after graduation, unless they don’t wish to practice medicine. Instead, they may work in the medical industry, as lecturers in non-clinical departments (Anatomy, Physiology etc) of a medical faculty, be medical administrators or as medical researchers.
“Those who wish to practice medicine or dentistry need to be registered with a professional body which will ensure the ‘standard of practicing doctors’ in the country. In Sri Lanka, it is the SLMC and in UK it is the GMC. In order for a medical council to register medical graduates they have to make sure that those graduates have acquired the right level of knowledge, skills and attitudes required to employ them as intern doctors.
“This is determined by laying down the expected standard for an intern doctor and then using that as tool to measure the standard of each medical course they examine. The GMC, since 1991 adopted laid down the attributes of a medical graduate that will qualify to become an intern doctor. This was compiled into a document called ‘Tomorrow’s Doctors’.
“The essence, ‘Tomorrow’s Doctors’ laid down the knowledge, skills and attitude’s a medical graduate should possess instead of specifying the infrastructure a medical school should have, what subjects medical schools should teach or how the students should be taught. When GMC inspects medical schools they check against this document and sample various aspects of the course and assessments to determine the achievements of the graduates. Since they use the same tool to measure all the medical schools, they can easily compare the quality of medical graduates coming from different universities.
“As a response, most UK medical schools adopted what is known as an ‘Outcome Based Curriculum’. This means the curricula were directed towards achieving graduate attributes laid down by the GMC.
“Keeping with the rapidly advancing medical field, the GMC amended this document a number of times in the past two decades. The most updated graduate attributes are laid down in the document, ‘Outcome for Graduates’, published in July 2015. All these publications can be downloaded from the GMC website.
He regrets to note compared to the GMC, the conduct of the SLMC is sadly lacking. It is unfortunate that key players like the SLMC in the SAITM controversy had contributed to the dispute instead of helping to resolve it. Though SAITM is made to be the scapegoat, the actual culprit is the SLMC.
Professor Jayasinghe identifies a number of areas has failed Sri Lanka’s medical education.
1. Outdated, Unfulfilled Regulations
The SLMC is still operating on a Medical Ordinance established in 1950s. While other South Asian countries’ medical schools have moved with time, Sri Lanka is trying to regulate medical professionals with over 60 years old, grossly outdated set of regulations.
Despite following this outdated Ordinance for decades, the SLMC has not been able to satisfactorily fulfill its requirements to lay down the minimum standard for medical education.
“Since all government medical schools and the SAITM produce doctors, the SLMC should use the same tool to measure all of them. But where is the document detailing the attributes a graduate must possess? If you use a different gauges to measure the widths of a series of pots how do you know which one is bigger? This is exactly what SLMC appears to be doing.”
2. Confused of its Role
The GMC describes the specific attributes a medical graduate must possess from the degree course in terms of knowledge, attitude and skill. These can be easily proven.
Conversely, the SLMC focuses on all aspects of a university starting from buildings, administration, finances, staff at every level, student selection and etcetera, ending with toilet facilities. Though they describe a whole curriculum for a medical school, the crucial aspects of developing appropriate attitudes, ethics, professionalism and patient safety measures on the whole is woefully lacking. This perhaps explains the attitude and behavior of undergraduates and trade union doctors that are unbecoming to the profession.
The SLMC prescribed curricular contents are broad, sometimes vague, unattainable during undergraduate years and most importantly impossible to measure objectively. For example according to the SLMC regulations graduates must possess “creativity, resourcefulness and adaptability”. It would be interesting to know how SLMC measures these achievements.
Further, such a rigidly prescribed curriculum hinders the incorporation of advancements in pedagogy and technology to medical schools. As an example the SLMC has specified the number of microscopes for students in laboratories. In the west few medical schools use microscopes for teaching now. There are virtual microscopes using computer software which are far more superior and efficient than traditional microscopes. It will be impossible for a Sri Lankan medical school to acquire such latest technology as it would violate SLMC regulations.
3. Failure to Monitor Registrants
The role of a medical council is not only to lay down minimum standard for a new graduate, but also to regulate the registrants throughout their life as medical practitioners. It is important that registrants update their knowledge and skills through continuous professional development and de-register those who failed to meet prescribed targets. Those who fail to regularly update their knowledge cast greater risk to patients and become no better than medical quacks.
4. Conflict of Interest
The main problem hindering SLMC from developing the medical education in Sri Lanka are its members whose membership to other associations creates a conflict of interests. Thus they are unable to make pertinent decisions.