Continuum of Medical Education

Medical education is a continuous stepwise process that includes preclinical training, clinical training and assessments. Assessment too can be considered as a system including selection, continuous assessment, qualifying examinations and licensing exams.  Purpose and focus differ in each assessment. At each step, different competencies are assessed and certified. Therefore each step of the process of medical education becomes pre-requisite for the next step. All these components have to be considered together when certifying a fully qualified medical graduate.

Further, it is not possible for one examination to assess all the competencies expected from a medical graduate. Each steps assumes that previous steps of the process have been successfully completed.  Therefore the performance in any one of the components (e.g. licensing examination) cannot compensate the inadequacies of other components in training and assessment. This calls for a foolproof system that ensures each step is carried out properly.

The objective of this series of articles is to discuss the importance of getting each of these steps right.

Firstly, it is important to understand the steps and phases of medical education process.

Main phases of basic medical education are,

1.     Undergraduate Medical Education

2.     Internship

3.     Continuous Professional Development/Life long learning

The aspirant physician will have to overcome three main hurdles during this process. They are;

1.     Selection

2.     Qualifying

3.     Registration to practice

Selection for Medical education

Gaining admission to a Medical school in Sri Lanka is highly competitive. Some of the students who fail to gain admission to a Sri Lankan state medical school may enter an overseas medical school.

The selection of students for admission to a government medical faculty for a given academic year is based on the rank order of Z-scores obtained by the candidates at the G.C.E. Advanced Level Examination (A/L examination) held in the related year, and released by the Commissioner General of Examinations. Cut off marks, applied by the University Grants Commission, vary from year to year depending on factors such as performance of students in the given year, total number of places offered by universities and the population of each district, etc.

There is a perception that GCE A/L is a poor selection test for medical school entry.

In almost all leading medical schools worldwide, performance at the GCE A/L or equivalent examinations is the main criteria for student selection. The entry criteria for top medical schools are almost universally straight ‘As’, highest GPA scores or their equivalent.

Other methods such as letters of recommendation and interviews are now proven to be of questionable reliability and poor predictive validity. Aptitude assessments and methods such as Multiple Mini Interviews (MMI), when they are used, are additional criteria and do not compensate for poor academic performance. Even in aptitude tests such as MCAT, the biology sub component has shown the best predictive validity.

Large-scale research worldwide has proven that Advanced Level examination performance is the best predictor of future academic performance at undergraduate and postgraduate levels and in Continuous Professional Development. As shown by extensive research conducted in the UK and supported by many research studies worldwide, performance during high school, undergraduate and postgraduate education is mainly determined by core-intellectual capacity, which is essentially like a “core-academic backbone”. GCE A/L and similar examinations can measure this capacity reasonably accurately.

There are three broad reasons why this is so and why the A/L should have predictive validity for medical school performance:

1.     Cognitive ability

2.     Substantive content - GCE. A/L provide students with a broad array of facts, ideas and theories relevant to future medical students. E.g. human biology, molecular biology, cell biology and genetics.

3.     Motivation, commitment and personality - achieving high grades at the GCE A/L requires not only intellectual ability, but also motivation, commitment and personality traits that are also beneficial at medical school and for lifelong learning.

Although the minimum A/L criterion set by the UGC for entry to medical courses is three passes at the A/Ls, in actual fact, all students entering local medical faculties have earned much higher grades. The University Grants Commission (UGC) criteria of 3S as minimum grades for entry into medical faculties are outdated and not realistic or suitable anymore. It is similar to the fact that what you could do with Rs. 100, 30 years ago, cannot be done with Rs. 100 now. The current baseline performance of those who are selected to follow medicine is far higher than that, particularly due to grade inflation. With such grade inflation, the rational and logical measure should be to make the bar higher. How the UK responded was to increase the bar as 3A grades minimum. Therefore, requesting high achievement at GCE A/L examinations is a sound approach to select medical students.

In contrast, the A/L performance of overseas medical graduates is highly variable. In 2009 SLMC analysed the A/L results of 227 Sri Lankan students who were admitted to overseas medical schools. The results are as follows:

       i.         Only O/L subjects – 6 students

     ii.         Non bioscience A/L subjects - 12 students

    iii.         Only one subject at bioscience A/L - 1 students

    iv.         Only two subjects at bioscience A/L - 8 students

     v.         Three simple passes at bioscience A/L - 10 students

    vi.         Two simple passes and one C, B or A - 31 students

  vii.         One simple pass and two C, B or A - 51 students

 viii.         Three C, B or A - 108 students

This analysis based on a small sample collected within a limited time period only gives us an idea about the proportions. The actual numbers from categories I to vi may be much higher. This is a serious concern.

In 2009, SLMC declared that any Sri Lankan student who seeks entry medical faculties overseas, should have three passes in biology, chemistry and physics/mathematics with at least two being grades C, B or A. These criteria were incorporated to SLMC standards and criteria for accreditation of medical schools. During the 2017 revision of minimum standards, SLMC recommended 3 B s or equivalent as the minimum entry criteria.  Unfortunately, none of these recommendations are yet to be approved by the parliament.

Undergraduate Medical Education

Keeping in line with current global trends, medical education in Sri Lanka has undergone a renaissance since early 1990s’. Most of the Sri Lankan medical schools now follow more student-centred, integrated and community oriented curricula. Many Medical schools have thorough and rigorous student assessment systems where students need to succeed up to 40 examinations, each having several components.

Extensive clinical training, which is essential to fulfill the competencies required by a doctor, is provided in all state medical faculties. In the Faculty of Medicine Colombo clinical training is over 140 weeks covering over 4000 hours of full time work. Most of the medical schools follow more integrated, community oriented curricula in line with current trends in medical education.

There are concerns regarding the quality and standards of some recently established Faculties of Medicine. The main concerns are related to infrastructure and availability of staff. However, even those Faculties have access to extensive clinical training facilities and the degree programmes are subjected to the approval by SLMC.

In 2009, South Asian Institute of Management (SAITM) (Later South Asian Institute of Medicine) initiated a BOI project to start a medical school in Malabe. Since its inception, SAITM has been in the center of controversies. In 2018, the government decided to absorb the SAITM students to the Faculty of Medicine at KDU.

The quality and standards of overseas medical schools where Sri Lankan students enter vary widely. The range is from excellent to completely unacceptable. This is reflected by the wide variation in the knowledge and skills of those returning with foreign medical degrees. Those who have qualified from certain medical schools pass the ERPM examination easily. Others are weak in their knowledge base, problem solving skills and even more so in their clinical skills. In many medical schools overseas, they do not receive the hands on clinical experience that they should receive, particularly in subjects such as Obstetrics and Gynaecology and in Pediatrics. These are serious concerns.

What is the reason for this variability?

In the past SLMC recognized registrable foreign medical degrees based on the WHO list. However, according to WHO itself “a listing in the World Directory confirms that the medical school exists, but it does not denote recognition, accreditation or endorsement by the World Directory, WFME, FAIMER or any of the sponsoring organisations unless expressly stated”. Further, the recognition process was only a desk exercise without a site visit.

The situation changed with the introduction of the concept of minimum standards in medical education by WFME in early 2000. Defined Minimum Standards in Medical Education in Sri Lanka have been in existence from 2006. In 2009, SLMC revised Minimum Standards to be in line with the WFME guidelines. Since then, formalized recognition process of medical schools by SLMC was based on these criteria.