COMMENT: Collaborate to meet the needs of clinical education
TEACHING on patients is the most important part of training medical students.
In the Guidelines For The Accreditation Of Malaysian Undergraduate Medical Education Programmes adopted by the Malaysian Medical Council on April 12, 2011, the Malaysian Qualifications Agency demands that "clinical education or experience with patients should be broad-based and must be equivalent to at least 120 clinical weeks of which 70 to 75 per cent of duration must be on real patients".
More than half of the usual five-year training in medical schools, directly or indirectly, involves contact with patients.
However, opportunities for medical students to perform and practise physical examination on patients have been increasingly decreasing.
Many reasons could have resulted in the fewer chances for students, including the change in clinical practice, reduced length of hospital stay by patients, increased number of students and ward closures, noted Malcolm Dean in his article published in The Lancet (no. 338, pages 874-875) in 1991.
I C McManus and others, in 1998, highlighted the magnitude of this problem in the United Kingdom (Clinical Experience Of UK Medical Students, The Lancet, no. 351, pages 802-803).
Although this issue has been a global concern for many years, however, in Malaysia it has become apparent only in recent years.
The following are some of the reasons in the context of local medical schools:
Provision of ambulatory care
This type of care has become popular internationally as it is more convenient for patients and saves huge costs of hospitalisation. Following international trends along with acquiring increased facilities for ambulatory care and development of necessary infrastructure in the country, many local patients, who used to be treated in hospitals, are now being looked after in community or outpatient clinics.
This has resulted in the reduction of the number of inpatients suitable for medical students to examine and for the sake of patients' safety, the students are not encouraged to practise their physical examination skills on the very sick. Generally, only stable patients are selected to demonstrate physical findings to students.
Meeting the needs of the future
To achieve its target of one medical doctor to 600 people by the year 2020 (Annual Report 2009, Ministry of Health, Malaysia, page 29), the Malaysian Ministries of Health and Higher Education have allowed a number of private medical schools to operate and have encouraged the public medical schools to admit a growing number of students.
To provide clinical training to the growing number of students, the public and private medical schools have to share patients in public hospitals. This has resulted in a lower student to patient ratio in these teaching hospitals.
The following are some suggestions to cope with this situation without compromising the standards of training and also avoid unnecessary discomfort to patients:
Coordinate and collaborate
Medical schools should be encouraged to collaborate among themselves for clinical teaching of students. This partnership can be achieved as follows:
l Coordinate teaching timetables, so that overlap of training can be avoided.
l Combine teaching sessions, so that more students can share the same patients. This will also address the shortage of clinical teachers.
l Develop patient banks: create lists of patients who are willing to offer themselves for teaching sessions. These patients can be called as and when required.
l Monitor the rotation of students between hospital wards and clinics.
l Share information about the positive signs in patients.
l Plan evening rounds so that teaching can be held by on-call doctors.
Use private hospitals
There are a number of well-equipped private hospitals in Malaysia which are frequented by a large number of patients. Medical schools should collaborate with these hospitals to organise teaching sessions. The consultants and specialists in private hospitals can provide much needed help in the training of medical students.
Use public and private clinics
Medical schools should be encouraged to intensify the existing use of public health clinics for training of their students. Moreover, general practitioners can be trained to teach medical students in their own clinics.
Home visit programmes in the community run by both non-governmental organisations and Health Ministry can provide another opportunity to train medical students.
Use special institutions
Additional clinical experiences can be provided in institutions by offering special care such as shelters for the elderly, handicapped and challenged, orphanages, drug rehabilitation centres, hospice and prisons.
Inpatients, especially those who are relatively more stable or are admitted for elective procedures, can be counselled to cooperate for physical examination by students so that more numbers can gain clinical experience.
These suggestions address the issue in the short term. In the long term, each medical school should have its own teaching hospital.