April 11, 2016
Medical education and the safety of patients are two inseparable things. They are two sides of a coin. Major schools of medicine in the world are using this guideline, referring to the World Federation for Medical Education.
This is why it is difficult to establish a school of medicine. It needs to involve the medical profession from the start and not just be an administrative decision, as there is the matter of patients’ safety that should not be seen as “a matter to be taken care of later”.
So strict is the assessment of medical education and graduates that often times foreign medical graduates cannot work as doctors in the United States. Why? Because the person’s competence is doubted, as the number of medical schools and the ratio between the number of medical schools and the number of medical students per school in the origin country is outside of the normal ratio. Medical education must abide by the universal conventions as all of the graduates must be approved and accepted as competent doctors in handling sick people wherever they may be in the world.
The quality and competence of a doctor will be directly assessed in relation to his or her origin country and school of medicine. Universal values are applied here: The opening of a new school of medicine must begin with the opening of a medical study program supported by an existing school of medicine with an “A” accreditation. After the new medical study program produces one batch of graduates, it can be recommended to obtain an operational license as a new school of medicine. The opening of new schools follows the rule of one school for every 4 million citizens, a permanent lecturer for every 10 students in the academic educational level (to obtain a Bachelor’s degree) and one lecturer for every five students in clinical education (in the hospital) to obtain a professional title.
In the clinical level of education, every student must obtain the amount of variation of cases enough to obtain competence as mandated by the state’s and the profession’s competence standards through the Medical Council. In the clinical level, in order to reach the necessary amount and variation of cases, medical students must face many risks, including the risk of catching a sickness.
Upon graduation from the competence exam, new doctors must participate in a year-long internship. Afterwards, they may choose the next step of their careers and must obtain a registration letter (STR) from the state – issued by the Medical Council – to be able to provide legal medical services.
Universally, this is a doctor who is responsible and has the authority to conduct primary health care. Generally they develop the ability of public health education, sickness prevention measures, early diagnosis and treatment. The STRs are renewed after certain time periods (in Indonesia, this is every five years) to ensure an updated competence and the safety of patients. This is a summary of the series of quality control maintenance processes that all doctors must undergo universally.
Indonesian medical education
In Southeast Asia, Indonesia was the first country to have a medical education in the form of the Javanese School of Doctors in 1849. This long experience should have made Indonesia a regional role model. Is it truly so?
With a population of 240 million, then Indonesia should only have 60 schools of medicine under the universal ration. In reality, currently the country has 83 schools of medicine with another eight recently opened. Up to March 2016, 110,906 doctors have obtained STRs from the 69 schools of medicine who have graduated students. With a universal ratio of one doctor for every 2,500 people, Indonesia needs only 96,000 doctors. If every school of medicine graduates an average of 200 doctors per year, Indonesia will have 83,000 more doctors in 2021, clearly an excess even after calculating the shrinkage.
This fact may affect the medical ethics and professionalism that need to be upheld. Many students undergoing medical studies may also receive poor training in the amount and variation of cases necessary to fulfill the competence requirement. Despite the large number of hospitals, the availability of clinical doctors is not adequate to fulfill the ratio and provide equal-quality education.
Currently, out of the 69 schools of medicine that have graduates, only 16 have the “A” accreditation, with the rest accredited “B” and “C”. Accreditation levels for medical education should only be “accredited” and “unaccredited”, considering the multiple factors contributing to schools not obtaining accreditation, such as the quality of the student acceptance selection process, the number of students received, the availability of permanent biomedical and clinical lecturers, the availability of learning facilities including dry and wet laboratories, computers, skills laboratories including forensics, libraries and healthcare facilities like hospitals and public health centers (puskesmas) with an adequate amount of variation of cases.
Student acceptance selections, apart from a strict academic selection, must be complemented by a motivational exam so that an accepted student is really one with the character of a doctor (candidate). The values of honesty, patience, empathy, altruism that are known as soft skills must be stronger than mere intellectual values. This will affect the attitude of a doctor, when he or she has to take a stance and make a risky decision, but still prioritizing and respecting the feelings, psyches and autonomies of patients.
Patients’ safety depends mostly on the doctors’ soft skills, above their high academic knowledge and skills. Role modeling has a very special place. Therefore, medical education must not be massive.
Patients’ safety above everything
Hippocrates, who lived in the pre-Christian era, said that: “In the world of medicines, there is sickness, the sick and the doctor. The doctor’s task is to help the sick.” The sentences show that the soul of the doctor is to help and this must be deliberately established since the beginning of medical education.
Therefore, for Indonesia with such huge area and population, doctors must be seen as a strategic human resource. Academic acceptance selections must be highly strict and follow universality rules, the number of schools of medicine must be in line with the professionalism of medical education as is adhered to globally and the education must be state-funded to avoid it becoming an education “to obtain income”. Afterwards, the state can place doctors for up to their first two years after internships to fill public health centers as primary care physicians and afterwards facilitate their next career steps. Such assurances will provide doctors with the comfort and safety to serve the nation with a certainty of primary health care, medical professionalism and global recognition of the quality of medical education and the general public with certainty of health services.
Pulmonology and Respirational Medicine Department, School of Medicine, University Indonesia; Persahabatan Hospital, Jakarta.