Private Medical Schools:
An Educationist’s Perspective

February 29, 2012, 8:29 pm , The Island.


Raja C. Bandaranayake

[The text of the Inaugural Lecture of the Forum for Sri Lankan Medical Educationists, delivered on 9 January 2012, at the Postgraduate Institute of Medicine]

Continued from yesterday

The relationship between the private medical school and the teaching hospital may take one of several different forms:

1. The private medical school has its own teaching hospital. This is the model used by most established schools.

2. The private medical school shares a teaching hospital with a public medical school. This model usually affects both schools adversely.

3. The private medical school pays a fee to a public hospital for using it as a teaching hospital. Usually the fee is very high fee, eroding the school’s income.

4. The private medical school uses one or more existing private hospitals for clinical teaching.

 The most suitable model is the first one, as the school can develop its own identity and become a useful resource to the community, without being an encumbrance to any other training institution. However, private patients are generally averse to allowing medical students to learn from their illnesses. Thus many private medical schools utilize public hospitals for a significant part or all of their clinical training. I am of the firm opinion that, if a hospital, public or private, is designated a teaching hospital, carrying with it all the benefits of a teaching hospital, a condition of patient admission to that hospital should be their consent to be used for teaching purposes.

Another potential disadvantage is the laxity of student admission policy adopted by some private medical schools. Often admission is dependent on paying capacity than on academic merit, sometimes even at the expense of ignoring minimum standards. Some schools insist on minimum standards but these are often below those required for admission to state schools. This would naturally compromise the quality of the product.

Private medical schools sometimes pose a threat to public medical schools by attracting academic staff from the latter with higher salaries and/or better working conditions. Another strategy is for faculty to work part-time in each institution. I have seen both these practices occur, often to the detriment of an already established public school.

Private medical schools, because they are expensive, result in a diminution in socio-economic diversity in their student populations. Combined with the fact that patients admitted to private hospitals usually lack that diversity, such bias will affect the graduates’ ability to deal with lower socio-economic patient groups and minority groups.

Unless rural medicine is a stated goal, private medical schools tend to be established in urban areas, in order to attract the wealthier sectors of the community. Rather than correct the mal-distribution of doctors, such schools tend to contribute to it. In some countries permission is granted to open new schools only if they are located in under-served areas.

Guidelines for the establishment of private medical schools

The key to ensuring that any private medical school contributes effectively to healthcare in the community in which its graduates serve is to enforce a system of monitoring which guarantees that minimum standards are met.  In order to meet these standards prerequisite resources must be in place before the school is permitted to admit students. It is not enough if the school is allowed to open its doors on promises that it will meet these requirements in the future. Schools often may agree to "put facilities in place", particularly for the conduct of clinical training, but often find themselves in difficulty to do so effectively when students are due to enter the clinical training phase. They then have to resort to interim measures until suitable facilities are available. Irrespective of whether the school intends to have its own teaching hospital, or to use the facilities already available in the public or private sector, the facilities must be available and/or agreement must be reached before students are admitted. If clinical skills are to be taught in the early phases of the curriculum the facility of a clinical skills laboratory must be available before students are admitted. The nature of the curriculum plan will determine the resource requirements for the school to implement the different phases of the curriculum.

Even more important are human resource requirements. No school should be allowed to open its doors to students if it is to depend on academic staff of an existing school for the implementation of the teaching program. As pointed out above, this could lead to lower standards in both schools.

Minimum academic requirements should be insisted upon in the system of student admission to the new school, commensurate with existing requirements in the country. Allowances should not be made based on socio-economic status, influence or paying capacity of the candidate.

The task of ensuring that the minimum criteria for a medical school are met is the responsibility of the independent body granting licensure to the graduates of the school to practise in the society which the school is to serve. In most instances this is a medical council (such as the Medical Council of India, the General Medical Council in the UK or the Australian Medical Council in Australia), or other specially appointed body (such as the Liaison Committee for Medical Education in the US) which is not affiliated to any particular medical school or university in the country. It must be recognised that certification of competence, manifested by the granting of the degree, is an internal matter, which is the responsibility of the training institution, while licensure to practise in a given country or society is an external matter, which is the responsibility of the independent licensing body. These are clearly distinct functions. For example, a school may deem its products competent based on internal assessment, but the licensing body may not find the assessment procedures used meet minimum standards for safe practice. On the other hand, the curriculum may be deemed appropriate for practice in one country but not in another. These are issues which have to be dealt with by the licensing body, which in Sri Lanka is the Sri Lanka Medical Council (SLMC).

What then can the SLMC do in this regard? The practice of undertaking pre-accreditation visits by a responsible and entrusted body, such as the SLMC, can go a long way to ensuring that adequate facilities are in place in any proposed medical school, public or private, before it is allowed to admit students. I would suggest that SLMC develops its own set of guidelines for such pre-accreditation, as well a set of standards representing the minimum essential requirements before a new school can commence training. These guidelines and standards can take into account the socio-economic realities in Sri Lanka better than standards developed elsewhere by other bodies. If such a set of guidelines and standards are in place now, before new schools are ready to commence, then the SLMC can be entrusted with the task of appointing an accreditation committee which can judge each proposed school’s plans and resources against the standards before approval is granted. In doing so, the Council must judge the resources available in relation to the intended curriculum plan.

If a private school is opened jointly with an existing school in another country, SLMC must ensure that the standards of the latter are at least on par with the minimum standards expected of a medical school in Sri Lanka before such a joint venture is accredited for licensure in Sri Lanka.

The Council should be particularly wary of prestigious schools using their prestige to encourage sub-standard schools to be opened in Sri Lanka, and ensure that adequate standards are met before such schools are allowed to admit students.

Conclusion

 I have attempted to take a dispassionate and educational view of the vexed question of privatisation of medical education. The history of the trend of privatisation and the forces which contributed to its development point to important lessons for Sri Lanka as it grapples with this issue. The advantages and disadvantages of privatisation must be considered carefully and steps taken to enhance the former while minimising the latter. I see any venture which contributes to the development of healthcare in the community as a positive one. However it could be fraught with dangers if adequate safeguards are not taken to maintain the high standards of healthcare which this country is noted for. I have outlined some steps which could be taken by an independent body, such as the SLMC, to avert these dangers. We must be constantly vigilant to prevent the "trade school mentality" of the pre-Flexnerian era from permeating our medical schools, which until now have been held in high esteem internationally.