Dissecting Private Medical Schools

The opening of a private medical school in Sri Lanka has created a great deal of interest and anxiety in the medical profession. Such a reaction is coloured by an earlier experience, but it is important to realise that there are several types of private medical schools in the world. The useful discussion of this topic is often hampered by misunderstanding and emotion. As I have been associated with medical education in Sri Lanka for over half a century, and have it very much at heart, I attempt here to take an unbiased look at the issues from an educational, rather than an emotional or political, perspective.

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, such as in the US, which are partly funded by the government.

In the centre of a controversy: The recently setup Private Medical College at Malabe (file pic)

It is neither 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 all schools. Nevertheless some private medical schools are totally autonomous. Private medical schools may be profit-generating or non-profit oriented, the latter usually targeted to a particular social group.

Private medical schools are not a new phenomenon. Medical education has been in private hands for a long time, particular in the US, as in Harvard (1782) and Johns Hopkins (1894).

At the turn of the 19th century they 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;
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 clinicians 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.

This 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 (rating 70% or more) from 66 in 1915 to 76 in 1925, with corresponding decreases in Classes B (50-69%) and C (less than 50%).
The clinical type was common in Britain earlier. Oxford University was established in 1770 and Cambridge University in 1540, but they both developed comprehensive medical curricula later in conjunction with established hospitals. Our own school in Colombo was established on similar lines in association with a public hospital, gaining university status much later.

Over the past two decades there has been a significant increase in the privatisation of medical education. This trend is evident globally. Table 1 (see below) is adapted from a recent review of the literature conducted by Shenaz Ilyas, a postgraduate student of mine.

The Philippines has the largest proportion (84%), most of them of recent origin, as there were only 10 medical schools in the country until the mid-1970s, of which five were government schools. 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%). Australia and the UK have only recently ventured into the field of private medical education, while in China, France, Greece, The Netherlands 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 train doctors of quality unless it has strong basic science and clinical departments, with the latter working either in collaboration or as part of a teaching hospital. In spite of the recent trend to move clinical education to community settings, there is no doubt that a hospital with staff committed to teaching is a sine qua non for any medical school. This has an important bearing for the establishment of private medical schools.
Many socio-economic, political, educational and technological forces operate, to varying degrees in different countries, to bring about the trend of privatisation of medical education.

1.The demand for places in medical school is universal but particularly acute in developing countries where government schools are inadequate to cope due to limitations of funds and resources. Private schools are a means of meeting such a demand.

2. Developed countries face a workforce shortage, particularly in unpopular regions. One solution is the creation of privately funded schools to counteract 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 to benefit from “medical exports” from developing countries to resource underserved areas within their borders, and developing countries set up medical schools to meet this demand, sometimes in collaboration with reputed medical schools in the former. 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.

3. Increased mobility across countries with improved communication has facilitated the migration of doctors. To meet the increased demand new schools are opened in many developing countries, which continue to lose their human resources in health to the more affluent countries. Consortia of countries, such as the European Economic Community, facilitate such migration. The development of international standards in medical education was partly triggered by the need to ensure minimum standards across countries in this era of globalization.

4.The term “medical tourism” refers to the increasing tendency for patients to seek cheaper options overseas, in the face of increasing costs of healthcare in many developed countries. India has been the leading country to cater to medical tourism, which may have led to the mushrooming of private medical schools to meet this lucrative demand.

5.In many countries medical schools are being established to cater to the needs of specific communities, such as minority, ethnic or disadvantaged groups. Some countries reserve seats for lower socio-economic and minority students, the US schools being a notable example of this practice.

6.Undoubtedly, a potent force that drives the opening of private medical schools is the potential for income generated from such schools. Large businesses have seen a lucrative source in the privatisation 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. 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 resulting from cuts in funding for higher education, many developed countries 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.

What are the pros and cons of private medical education?

In the face of difficulties faced by governments to meet the ever-expanding demands of increasing populations, privatization 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. However, there are hidden dangers.

With strong financial backing, private schools are likely to have up-to-date facilities and resources, which can reach the students without much red-tape, 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. Fundamentally, many private medical schools are set up as business ventures for profit, despite the stated intention of alleviating human suffering. If this “business mentality” pervades the institution, many disadvantages would accrue.

The main potential disadvantage, if monetary gain is the prime motive, is the poor quality of training, due to:

• poor quality and numbers of academic staff;
• a rapid turnover of academic staff;
• diminished staff incentives due to the short-term nature of contracts, despite comparably higher salaries
• dependence on visiting staff from other institutions, compromising continuity, relevance and integration of training, and faculty motivation
• inadequate hospital or other facilities for clinical training , the reasons for which deserve careful study.

Many private schools commence without providing for clinical training in the hope that, by the time students reach the clinical years, some arrangement would be made with neighbouring hospitals.

Even when such arrangements are made hospital staff pay scant attention to clinical training because of their practice commitments. Often such arrangements are quite expensive, eroding the profits of the school. An academic atmosphere may be lacking in the hospital, even though some hospital staff may relish the opportunity to teach.

A private medical school may have its own teaching hospital, share a teaching hospital with a public medical school, pay a high fee to a public hospital for using it as a teaching hospital or use one or more existing private hospitals for clinical teachig. The first is the most suitable model, as the school can develop its own identity and become a useful resource to the community, without being an encumbrance on any other training institution.

However, as private patients are generally averse to medical students learning from their illnesses, many private medical schools utilize public hospitals for clinical training. 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.

Another potential disadvantage is the laxity of student admission policy, often determined by paying capacity rather than academic merit, sometimes even at the expense of minimum standards. Some schools insist on minimum standards which are below those required for admission to state schools. This would compromise the quality of the product.

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. Prerequisite resources to meet these standards must be in place before the school is permitted to admit students. It should not be allowed to open its doors on promises that it will meet these requirements in the future.

Schools often agree to “put facilities in place” for clinical training, but find themselves in difficulty to do so when students are about to enter the clinical training phase. They then resort to interim measures until suitable facilities are found. Clinical training facilities must be available or agreed upon before students are admitted.

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

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), or an independent body (such as the Liaison Committee for Medical Education in the US).

Certification of competence, manifested by the granting of the degree, is an internal matter for the training institution, while licensure to practise is an external matter for an 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 find the assessment procedures do not meet minimum standards for safe practice. A curriculum may be deemed appropriate for practice in one country but not in another. These issues must 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? Pre-accreditation visits by a responsible and entrusted body, such as the SLMC, can ensure that adequate facilities are in place in any proposed medical school, public or private, before it is allowed to admit students. SLMC should develop its own guidelines and minimum standards, taking into account the realities of the country, for such pre-accreditation. If they are in place now, before new schools are ready to commence, then the SLMC can appoint an accreditation committee to judge each proposed school’s curriculum plan and resources against the standards before granting approval.

If a private school is opened jointly with a 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.

The advantages and disadvantages of privatisation must be considered carefully and steps taken to enhance the former while minimising the latter. Any venture which contributes to the development of healthcare in the community is 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.