My friend needed urgent medical attention in a rural area. He was rushed to a nearby private medical facility, and all that was ringing in my head was.’ will he get a qualified medical person to give the initial high-quality of healthcare needed to allow transfer to a higher’?
The question of the quality of doctors that are emerging from medical schools is a trending topic currently. To evaluate doctor training the true North question would be whether, when the older doctors retire, there would doctors with the adequate training and experience to deliver the highest quality ofhealthcare. Medicine being an apprenticeship, it is assumed the older the doctor is in practice, the more experienced they are. This forms the basis of the so-called (and I dare add – dreaded) major ward rounds, where the consultant doctor leads the evaluation of patients admitted for care in hospitals.
Their quality of education and training of doctors begins from the selection criterion used to determine who is admitted to a medical school. Normally the first criterion is a high intellectual capacity. Medical school training is generally rigorous requiring prolonged reading, cramming and understanding of the subject matter. It is thus important that those admitted to medical school be subjected to some form of testing on their academic ability. In Kenya the entry criterion to medical school is generally a high passmark overall, and in the relevant subject blend that includes a minimum mark in biology. Thus those who study go to study medicine outside Kenya and had not met the minimum criterion to join a Kenyan medical school at the time of their exam are not elligible to be registered by KMPDC. Previously this was possible but following concerns and feedback from the profession a minimum criterion for registration was set at the Council. This is based on the KCSE marks or equivalent in other education systems.
It was interesting to note that in Zambia it was possible to repeat individual subjects that one may not have performed as well as was needed, and later group the individual subjects into one certificate to meet the minimum cluster to qualify for medical school. This, in my view, may not be a good measure of the ability of the student to take up medicine because medical training requires one to be performing highly in many subjects simultaneously. Because of its demanding academic nature, medicine has a higher drop-off rate than other fields of training.
Another key component that affects the quality of medical training is the number of medical students being trained at any one time vis-à-vis the infrastructure and personnel. How is this possible? Traditionally African universities undertaking medical training did not have their own university hospitals. Many were also reliant on direct government funding to run. These universities used nearby government hospitals as their training grounds during the clinical yeaars of medicine. Many had a memorandum of understanding (MOU) with those nearby government hospital to accommodate their students. With decreased government funding of government universities and with an increase in private universities training medicine, universities have increased the number of medical students they have admitted on commercial grounds. KMPDC in Kenya was seen as a stumbling block to this process because it is charged with registering doctors as well as indexing medical students. Through joint inspections, KMPDC gives recommendations of the number of medical students that can be trained to the highest standards and these numbers are usually at variance with the numbers that the universities admit for commercial purposes. The number of students taken currently are way higher than the infrastructure and personnel that the university can train to high quality and also way above the capacity that the hospitals have for quality training. The student to patient ratio is too high.
A big challenge that some African countries are facing is the exclusion of the medical councils from the decision-making of the quality of training that they medical schools are giving. The problem stems from a lack of University hospitals attached to the medical school. The universities thus continue increasing the number of medical students admitted so as to raise revenue, without a corresponding increase in staffing and infrastructure. Moreover the bed capacity of the hospitals that the universities have negotiated to use for clinical year training do not increase their bed capacity. For medical education in Kenya, The Commission of University Education (CUE) does not consider the input of the medical Council. This was as a result of change in the CUE act that stated that the input of the medical council MAY be considered instead of SHOULD be taken up. Because of this, the medical council’s input is ignored. This has led to the universities over enrolling medical students for the purposes of school fees. Medicine training fees are the highest because of the intensity of the training and the length of time it takes. The university of Nairobi is a case in point. The enrollment of more than 500 medicals students into first year instead of the 150 that would be recommended by the Medical Council is a case of dilution of the standards of medical training. The medical associations are pushing to have a change in the University Act to make the input of the KMPDC mandatory. This push is spearheaded by Dr. James Nyikal, the current Member of Parliament for Seme who is a past Chairman of Kenya Medical Association, a past member of KMPDB council, a past Director of Medical Services, lecturer at the University. He knows the importance of quality medical education.
In my recent visit to Zambia, I heard that they are suffering similar challenges. There is a proliferation of private medical schools and there doesn’t seem to be a control of the quality of training as the country faces similar challenges to Kenya. The people mandated with the university education does not take the Zambia medical association input, and the entry criterion into medical school is also not very stringent and not well firmed up.
The problem of medical in internship seems to be affecting the whole of Africa and beyond. In Kenya, the doctors went on industrial action to protest the maltreatment of medical interns. There were delays in budgeting and deployment of medical intense by government by the Ministry of Health. There was even a suggestion to underpay the medical interns. In Uganda, the fight is the same. The doctors there are even underpaid. In Zambia, there was even the dangerous suggestion that the medical interns should work for free. I advised the executive of Zambia Medical Association to completely reject that suggestion as it would lead to serious inequity in who gets trained as a medical doctor.
Medical internship is the most important induction into the practice of medicine for medical doctors and therefore any challenges that may dilute the quality of medical internship must be resisted. Medical interns are fully qualified doctors who are working under supervision and apprenticeship of their senior colleagues. Medical interns provide the much needed healthcare. The only difference is that they are under supervision for a period of one year. On completion of medical internship the doctors are licenced to work on their own.
it is that important and paramount on the medical profession to protect the medical intern from the political expediency. For the medical profession, Politicians will come and go. The impact of their policies will affect the medical profession for ever even after they have left. The doctors will be there when the politicians have long gone and they will be the ones to take care of the negative consequences of bad political decisions made on the medical profession. Ideas like free internship or poorly paid internship must be rejected with the full force of the profession. Professionals must come together as coalitions of national medical associations and reject any policies that will lead to the detriment of the medical profession. The first policy to reject is an unsupported internship.
In Zambia, it was interesting to hear the minister of health make proposals on health care financing that were very similar to the proposals that have been pushed in Kenya. In typical political style he asked “is there anyone here who cannot pay 500 kwacha to Health scheme?“ In Kenya that debate started about two years ago when the debate on the social health insurance was taking route. Kenya have gone ahead and enacted four laws that are set to guide healthcare financing. Where is the content of the bills or the methodology of health care financing is not the theme of this article, it is important to note that politicians seem to sit in one place agree on something and push it to the populace. The challenge for the medical profession is to behave like politicians. We need to address the challenges that face our population together.
The challenges that face that made the call profession are the same. Different countries are a different pieces of these challenges and there are answers to all these challenges if the medical doctors put their heads together. These forms are bigger need for national medical associations to have regular meetings, and make resolutions on important matters of health to push as agendas in the respective countries.
Medical doctors face the same challenges wherever they are. Many of the challenges are political in nature. It is this time for the doctors to forge a common agenda and a common approach to the common challenges, facing the medical profession. It is time for the doctors to push in policies that are beneficial to the population and to themselves. It is time that we take the agenda, and direct politicians on what to do with the healthcare that we are the experts, and not the politicians pushing their agendas on us. That way will ensure that we have protected the medical profession from the political expediences that the medical profession has faced.
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