Private Medical Schools: An Educationist’s Perspective
February 27, 2012, 12:00 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]
Introduction
The opening of a private medical school in Sri Lanka has created a great deal of interest, and a certain amount of anxiety, in the medical profession. Such a reaction is, perhaps, coloured by the earlier experience with such a venture several years ago. It is important to realise that there are several types of private medical schools in the world, and often useful discussion of this topic is hampered by misunderstanding and emotion. The writer of this article has no intention of entering into the current debate. However, because he has the education of the physician in Sri Lanka very much at heart, and has been associated with such education for over half a century, an attempt is made here to take an unbiased look at the issues from an educational, rather than an emotional or political, perspective. A definition of private medical education is attempted initially, followed by a summary of some significant events in history from which lessons can be drawn, and an overview of the pros and cons of this form of medical education. Finally, some suggestions are made in order to facilitate private medical schools to make a useful contribution to the training of the physician and, consequently, to the delivery of quality healthcare in the country.
Definition
Stated simply, a private medical school is one funded by a private party, while a public medical school is aided by government funding. The distinction is not that simple, however, as there are some private institutions which are partly funded by the government. Thus the Catholic University of Notre Dame in Fremantle, Western Australia has some Commonwealth Government subsidised places, while the Bond University on Queensland’s Gold Coast is "entirely free of government subsidy and influence". On the other hand, the Sharjah University of Health Sciences in the United Arab Emirates, while being a private university, is heavily subsidised by the authorities of that Emirate. Many US private medical schools are supported by Federal research grants.
Perhaps it is not correct, nor desirable, to state that private medical schools are "entirely free of government influence", as government-appointed bodies do and should have some control on the standard of education imparted at such schools. Nevertheless there are many instances of private medical schools which are totally autonomous. Private medical schools may, on the one hand, be profit-generating, benefitting a consortium or group of individuals, or, on the other, non-profit oriented, in which case they are created for the benefit of a particular social group.
Thus to place all private medical schools in the same basket is undesirable and only helps to thwart any sensible and non-emotive discussion on this contentious issue.
History of Private Medical Schools
Private medical schools are not a new phenomenon. Medical education has been in private hands for a long time, particular in the United States. Perhaps the oldest private medical school there was at Harvard University (1782), followed by Washington University in St Louis (1853) and Johns Hopkins (1894). At the turn of the century private medical schools increased at such a rate that grave concerns were held for the standards of medical education in North America. At that time Abraham Flexner classified medical schools into
1. the clinical type, native to France and Great Britain, where students learnt both basic and clinical sciences in an apprenticeship system. After a while a collection of such clinicians were loosely combined to form a medical faculty which was not part of a university;
2. the university type, where the medical school was part of a university and was taught the basic sciences by specialists in those sciences, and clinical sciences by faculty who, while part of a teaching hospital, taught medical students in the hospital; and
3. the proprietary type, rapidly developing in North America at the time, where medical schools were becoming trade schools. It was this type which caused grave concerns about the standards of medical education in North America and triggered the extensive study commissioned by the Carnegie Foundation from which emerged the oft-quoted Flexner Report. The latter resulted in a significant decline in the number of sub-standard private medical schools in North America. A closer scrutiny and rating of the quality of education imparted by medical schools through visits by the American Medical Association brought about two significant changes:
1. a dramatic reduction in the number of schools from 160 in 1890 to 85 in 1925
2. an increase in Class A schools from 66 in 1915 to 76 in 1925, with corresponding decreases in Classes B and C [A = rating of >70%; B = rating of 50-70%; C = rating of <50%].
The clinical type of medical school, common in Britain earlier, was exemplified by Oxford and Cambridge. The former was established in 1770 with the benefaction of John Radcliffe, founder of the Radcliffe Infirmary, by a private grant. Cambridge University, endowed by Henry VIII in 1540, established the first professorship of Physick for research only. In 1829 a comprehensive medical curriculum was instituted in relationship with Addenbrook Hospital, but it lost this collaboration subsequently, until 1948 when, with the creation of the National Health Service, clinical teaching moved forward. Our own medical school in Colombo was established in line with the British medical schools in association with a public hospital, and, as we are aware, gained university status only much later.
Over the past two decades there has been a significant increase in the privatization of medical education. This trend is evident globally. The following figures (Table 1) are taken from a recent review of the literature on this trend conducted as an assignment by a postgraduate student of mine, Shenaz Ilyas and published subsequently in 2010.
No private schools in China, France, Canada, Greece, Netherlands
* 1975 figures; # 2005 figures ; GCC = Gulf Cooperation Council
Table 1. Proportions of private medical schools in selected countries
The Philippines has the largest proportion of private medical schools: 32 out of 38 (84%). Most of them have been of recent origin – there were in all only 10 medical schools in the country until the mid-1970s, of which 5 were government schools. In Malaysia, the total number of medical schools has increased from 8 (of which only 1 was private) in 2005 to 26 (of which 15 (58%) are private) in 2010. Many of the latter schools offer training in collaboration with overseas universities. India tops the list with the largest number of private medical schools: 137 out of 271 (51%), with the US in second place: 62 out of 131 (47%). In the Middle East, out of a total of 32 medical schools in the Gulf Cooperation Council (GCC) countries, 12 (38%) are private (4 in Yemen, 3 in the UAE, 2 in Bahrain and 1 each in Saudi Arabia, Qatar and Oman). Of the 79 medical schools in Japan 29 are private (37%). Australia and the UK have only very recently ventured into the field of private medical education, the former with 2 private schools (Bond and Notre Dame) out of 17 (12%) and the latter with 1 (University of Buckingham) out of 44 (2%). In China, France and Canada all medical schools are public.
A lesson to be learnt from history is that no medical school worth its salt can survive and live up to the standards of an institution for the training of doctors unless it has both strong basic science and clinical departments, with the latter working either in collaboration or as part of a teaching hospital. In more recent years, however, with the increasing costs of healthcare and shorter duration of hospital stays in tertiary care hospitals, the locus of clinical training has moved significantly from the hospital to ambulatory, general practice and community settings. In spite of this move there is no doubt that a hospital, whose professional staff have commitment to teaching, is a sine qua non for any medical school. This has an important bearing for the establishment of private medical schools.
Forces bringing about the trend of privatization of medical education
Many socio-economic, political, educational and technological forces operate to bring about the trend of privatisation of medical education, and these operate to varying degrees in different countries and contexts.
1. Demand for admission: The demand for places in medical school is universal but particularly acute in developing countries where government schools are inadequate to cope with increasing admission due to limitations of funds and resources. Private schools are a means of meeting such demand.
2. Workforce shortages: Developed countries face a workforce shortage, particularly in certain sectors of the public domain. While many strategies have been used to meet this shortage, one way out seems to be the creation of privately funded schools in the face of the diminishing academic dollar. Funding cuts in higher education have been a well-known phenomenon in the short-sighted policies of many governments, and the public sector has stepped in to fill the void so created.
Developed countries also aim at benefitting from "medical exports" from developing countries, particularly to resource unpopular, underserved areas and communities within their borders. This stimulates the latter to set up medical schools to meet this demand. It also creates an impetus for twinning programmes between medical schools in developed and developing countries. Such programmes enable the latter to receive the imprimatur of the more recognized school, while facilitating the recruitment of medical personnel to the developed country. This practice has recently been frowned upon by accrediting bodies, such as the General Medical Council in the UK, which insist that minimum standards be met in the less recognised school before granting accreditation. It has been reported that such bodies have even threatened to withdraw recognition from the established school if it continues to give its imprimatur to a twin which is sub-standard.
3. Globalization: Increased mobility across countries with improved communication between them has facilitated the migration of medical professionals. To meet the increased demand new medical schools are being opened in many developing countries, which continue to lose their human resources in health to the more affluent developed countries. The formation of consortia of countries, such as the European Economic Community, has facilitated such migration. The development of international standards in medical education has to some extent been triggered by the need to ensure minimum standards across countries in this era of globalization.
Earlier this decade, I sat on the task forces of two complementary projects by world bodies to develop international standards: the World Federation for Medical Education (WFME) International Standards for Undergraduate Medical Education, and the Institute for International Medical Education (IIME) Global Minimal Essential Requirements. While we agreed in both groups that there was a core in both process and content of medical education that was common to all countries, we were acutely aware that societal needs in health, and resources for training human resources to meet those needs, varied across countries to such an extent that a certain degree of flexibility had to be incorporated in the standards. This was achieved by the WFME, for example, in the manner in which standards were developed at "basic" and "quality" levels, with exhortations to all countries to satisfy the former but aspire to the latter.
4. Medical Tourism: A new term, "medical tourism", has been coined to identify the increasing tendency for patients to seek cheaper options overseas, in the face of increasing costs of healthcare in certain more developed countries. India has been the leading country to cater to medical tourism, one force which may have led to the mushrooming of private medical schools in this country to meet this lucrative demand. Singapore is another destination of choice for medical tourists, because of the high standards of medical care in that country. Nevertheless, as far as I am aware, there are no private medical schools in Singapore, though there are several in neighbouring Malaysia.
5. Targeted clientele: In many countries medical schools are being established to cater to the needs of specific communities, such as minority, ethnic or disadvantaged groups. Some of these are public while others are private. In Australia, for example, James Cook Medical School in Townsville, Queensland targeted students from rural Australia and the neighbouring Pacific Islands which lacked a system of undergraduate medical education of their own, other than the Fiji School of Medicine. In India some private medical schools were opened to cater to the needs of different caste and ethnic groups. Some countries reserve seats for lower socio-economic and minority students, the US schools being a notable example of this practice for a long time. Political expediency may be one factor which drives governments to resort to this practice. The Bond University Medical School in the Gold Coast in Australia, a recently established private medical school, has been free of government subsidy and influence but is actively seeking support for scholarships to indigenous and East Timorese students.
6. Income-driven forces: Undoubtedly, a potent force that drives the opening of private medical schools is the potential for income generated from such schools. Many are the examples of large businesses which have seen a lucrative source in the privatization of medical education. Unfortunately many have under-estimated the cost of instituting and maintaining a medical school of high quality. As a result they either run at a loss or lower their standards, even though intentions might have been good initially. Sometimes, they expand into other health-related ventures to compensate for the loss in revenue occasioned by a quality medical school. Charging tuition fees is a two-edged sword: higher fees can be afforded by a minority of the population, while lower fees cut down on profits. Something has to give, and often it is the quality of the product.
In the search for the much wanted academic dollar, many developed countries whose funding for higher education has been drastically cut, have resorted to an aggressive search for income from other countries through such means as attracting international students for medical education, and opening of private medical schools in partnership. Prestigious schools have created departments of International Medical Education partly, at least, for this purpose. Others have opened branches in other countries at considerable expense to the latter, and lent their prestigious name to encourage students to attend, even before minimal requirements, such as adequate staff, have been addressed. As a result the standards of the curriculum in the earlier years of operation are in jeopardy. Some established private medical schools have set up branches in neighbouring countries without adequate facilities initially. Such practices do not contribute to the quality of training in the host country.
The Pros and Cons of Privatization of Medical Education
Advantages
In the face of difficulties faced by governments to meet the ever-expanding demands of increasing populations, privatization of medical education has the potential to contribute to increasing the access of healthcare to all sections of society, if it is implemented with the benefits of the community in mind. It has been found that the geographical distribution of medical schools does not mirror the regional population. For example, the Caribbean, with a total population of less than 40 million, had 54 operating medical schools in 2007, while of the 57 African nations, 16 did not have a single medical school. These workers also found a strong relationship between the number of medical schools and physician density. Naturally, if the medical workforce increases, the doctor to patient ratio would do likewise, assuming the population remains constant. Any medical school, whether public or private, has the potential to improve the health of the community in which it is located. However, there are hidden dangers.
Many countries depend on expatriate doctors. Unfortunately the migration of physicians is such that the flow is, generally, from the more to the less needy countries. Countries in the Arabian Gulf Region depend heavily on expatriate doctors. While the governments of these countries have been actively opening new medical schools, the products of these schools are unable to meet the demand. As a result, these countries have become a haven for doctors from developing countries, particularly the Indian sub-continent, to earn the much valued dollar. Over the past decade a number of private medical schools have been operating in these countries, and more continue to be opened. The demand for expatriate doctors is likely to diminish when the products of these medical schools are available. The problem, however, is that, in pursuance of the income on which these schools largely depend, places are made available to overseas students as well. In some of these schools foreign students outnumber local students. It is likely that such students would not remain in the country for long after graduation, returning either to their home countries or looking for opportunities to further their postgraduate education, which is poorly developed in many of the countries in the Region.
Another advantage of private medical schools is that they create a competitive environment with public schools and with each other. If the standards attained by the private school are high, and they develop a good reputation for medical education, other schools would aspire to reach those standards. For example, in one state school I visited in North America I often heard expressions of hope that they would become the "Harvard of the North", meaning that they would like to emulate the curriculum developments that had taken place in Harvard Medical School, which was considered a prestigious school in the US. As alternatives become available for students, faculty and the community, the monopoly exerted by state schools will be diminished.
If the private school has a strong financial backing, it is likely to have up-to-date facilities and resources. These can reach the students without much red-tape and delay, as is often evident in state schools. The private school has the opportunity to be freed of the burden of the bureaucratic machinery of the government, and can use this freedom either to the advantage of the students or of the investors. I know of some schools which opt for the former in spite of a potential loss of revenue. Thus whether this freedom is seen as an advantage or a disadvantage depends very much on the motives of the founders of the private school.
Disadvantages
Fundamentally, many private medical schools are set up as business ventures with the chief purpose of making money. Rarely does the noble cause of alleviating the suffering of the masses enter into the equation, though such laudable intentions have often been proclaimed by such institutions. If this "business mentality" pervades the setting up and the running of the institution, then many disadvantages would accrue from the privatization of medical education. Balancing profit with quality in healthcare is a tightrope act which many entrepreneurs are incapable of or do not care to face.
It will be obvious from what I have just said that the main disadvantage of private medical schools is the poor quality of training provided to the students if monetary gain takes precedence over alleviating affliction through education. I have seen many instances of this in different countries.
There are many reasons for the poor quality of training provided in some private medical schools:
* The poor quality and numbers of academic staff
* A rapid turnover of academic staff
* Diminished staff incentives due to the short-term nature of contracts and uncertainties about tenure, even though they may be lured to private schools by the offer of comparably higher salaries
* Dependence on visiting staff from other institutions or countries, compromising
o continuity of training
o relevance of training
o integration of training
o motivation of in-house staff
* Inadequate hospital or other facilities for clinical training due to the following:
o Many private schools start admitting students without making prior provision for their clinical training in the hope that, by the time students reach the clinical years, some arrangement would be made with neighbouring hospitals.
o Even when such arrangements are made hospital staff pay scant attention to clinical training because of their practice commitments
o Often such arrangements with hospitals independent of the medical school are quite expensive, and erode the profits of the school.
o An academic atmosphere may be lacking in the hospital, even though some hospital staff may relish the opportunity to be involved in teaching.
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.
(To be continued tomorrow)
University students today said they were in the midst of discussions with fisheries, teachers and labour unions who had vowed to unite in their take trade union action in protest against the increasing cost of living and people’s suppression.
Universities in the country will be inactive for a second time this month from Wednesday as non-academic university staff will go on strike again since the government had not come forward for discussions to address their demands for higher wages and benefits, university non-academics said today.
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