2nd November 1997

Why not our children?

In a fresh controversy that threatens to divide the noble profession of medicine, certain parents of foreign medical graduates are contemplating filing action against the Sri Lanka Medical Council(SLMC) challenging the much debated Act 16 examination which was made compulsory for foreign medical graduates to gain entry to the profession.

In the early seventies, to prevent the brain drain as well as to deal with a severe shortage in the state health sector, consultant doctors were granted the privilege of being absorbed in the sector without fulfilling any other requirements. Today, according to many medical practitioners this is the provision which the foreign medical graduates use to justify their claims.

They allege that Sections 30 and 31 as amended, do not specifically say that foreign medical graduates should be evaluated before they commence internship, claiming that the uproar regarding the medical degree issue was created by the ill-considered decision made by the Sri Lanka Medical Council on April 10, 1997, making an overnight change in the rules applicable to granting internship. Foreign medical graduates allege that this amounted to the violation of the cardinal principal of natural justice.

In a counter argument, the SLMC states that the legal provisions which made the Act 16 examination compulsory have existed for the last thirty years, despite the lethargy displayed in implementation. It claims that the proposed examination is a simple oral examination which any medical student with basic knowledge could pass with relative ease.

Following a series of meetings with health sector professionals and concerned parties, Minister of Health and Indigenous Medicine Nimal Siripala de Silva ceremoniously announced that the exam is finally made compulsory for foreign graduates prior to commencing their internship.

However, as a result of the apparent divisions in opinions, the medical profession is facing the threat of being divided as local and foreign graduates , following the recent decision to strictly impose the above rule. This has also deviated attention from the real issue at hand, that the country's output of medical practitioners is totally inadequate to meet the demand, with a raging battle in the north-east and the Malaria epidemic plaguing the North Central Province.

Until the establishment of the Ceylon Medical College in 1905, medical degrees/ qualifications had to be obtained from abroad. This also provided for the supervision of the registration of medical practitioners. Local medical history indicates the registration of non-UK qualified doctors as being severely restricted.

Subsequently, the University of Ceylon took over the training of doctors, and the MBBs replaced the LMS. The most significant changes were implemented in 1955 when registration was confined to holders of MBBS (Ceylon), those registered under the UK Acts and holders of a qualifying Diploma under the UK Medical Acts. For the first two categories, it was required to obtain a certificate by the Medical Council.

In 1987, the Medical Ordinance was amended making it compulsory for medical graduates to have a provisional registration as medical practitioners to subsequently enable them to gain experience in a resident medical capacity in prescribed hospitals and institutions. This decision, the Medical Council quickly affirmed, was done in the best interests of the patients by ensuring that only competent persons entered the profession.

But to the Foreign Medical Graduates Parents' Association, (fmgda) the recent decision indicates the state medical graduates want to monopolise the state health sector, by creating a sort of Mafia where they try to prevent the absorption of foreign medical students.

The decision to make the Act 16 examination compulsory prior to gaining internship has brought to focus several issues which have plagued the medical profession for decades. In the wake of the decision, the health sector stands divided, each category judging the other.

A student who passes the Advanced Level examination has to wait for about two years to gain entry into university. His course of study involves another five and a half years, and another 1 1/2 years to finish the internship which adds up to eight years. In contrast, students seeking entry into foreign universities leave the country's shores promptly. The duration of their courses vary from 2-4 years. Some universities have no universally accepted standard of admitting students, enabling those even without the A/L qualification to enter them.

It was this the Medical Students' union took strong objection to.

Subsequently, the issue gathered momentum when the local graduates cried foul as foreign graduates entered the state sector. As Sanjeewa Tennakoon, a leading Student Union leader told The Sunday Times, it was totally unfair to absorb those who have failed to obtain minimum qualifications to enter the local medical faculties. Because they had the money they could purchase the degrees abroad and override the others in seniority once in the state health sector, he said

"They complete their studies at least two years ahead of us, but their knowledge is insufficient in certain areas. They have no knowledge of certain tropical diseases prevalent here. How can patients be entrusted to such people?"

He is quick to point out that they do not undervalue their medical counterparts' qualifications. Sanjeewa states that Act 16 is only a simple exam which has been existing for decades though not implemented. But the familiarisation course is only for three months which, he feels is totally inadequate. He then gave the example of a foreign graduate lady doctor who failed to prescribe the correct drug for Malaria, while serving in a hospital in Anuradhapura.

"We study parasitology and tropical diseases for a year to obtain our qualification. But many of the foreign universities only introduce tropical diseases, that also as terms only."

According to a doctor who wishes to remain anonymous, the responsibility of patient care finally lies with the house officer. "Those serving their internship are accepted as house officers, and they are to serve in difficult areas and war torn areas. This demands a higher level of competence and knowledge. They also can admit, discharge, give emergency treatment to patients. It is such a responsible job which is why they should evaluate the competence of foreign graduates, he said adding that the fuss was politically motivated because the well to do, influential people could afford to send their children abroad by spending several lakhs of rupees.

For decades, many foreign scholarships were awarded to Sri Lankan students, mostly from the USSR. Those who obtained the highest number of marks received these scholarships and went abroad for medical studies. These opportunities were made available as a gesture of friendship towards the Sri Lankan government. The Russian scholarship scheme came to a halt in 1990, and the Australian scheme, the following year. Currently, the Sri Lankan government receives scholarships from India, Pakistan, China and a few other states. Despite the existence of the legal provision, this paved an opening for foreign graduates to enter the state health sector without any assessment of their competence or knowledge.

At the same time, several agencies commenced sending students abroad, making them pay handsome amounts for their education. It soon became the trend that many who failed to gain entry to the national university system but could afford to pay for it, began going abroad.

As a result, the agencies sending students abroad also grew in number, making it a profitable business,

As the controversy rages on, the Medical Faculty Students Union claim that the decision to make the Act 16 examination compulsory was largely supported by eminent scholars and leading medical practitioners who realised that the non-implementation of the said provision was misused by some who had no competence as doctors.

The FMGPA has made representations to President Kumaratunge that the decision made by the SLMC was unfair, especially considering the fact those who returned to Sri Lanka until April were given internship training without the compulsory completion of the Act 16 exam prior to commencing training.

According to Lalindra Kuruppu, Secretary of the Foreign Medical Graduates Association , they were given written assurances without any ambiguity that there is an Act 16 examination which could be completed before, during or after the internship.

He further states that it is unjust to make this exam a qualifying exam as they have obtained degrees approved by the SLMC and the World Health Organisation. Further, the FMGA allege that the decision taken on 10th April 1997 was not conveyed to them, destroying their ability to consider other options such as completing their internship in the country of study.

FMGPA however has reportedly made several serious allegations against the present universities and the conduct of the students. A direct attack on the local graduates has been launched, alleging that the local campuses did not have a conducive atmosphere for their children to enter for studies. As one parent said, "We did not want our children to be part of any terrorist organisation in the country. When we sent our children abroad, the tax payers were not made to pay for their education".

According to the Secretary of the Association D.C.Rajapakse, their children were sent abroad during the height of JVP insurgency when nobody dared enter a local university. "They went when there was no way out. This problem regarding internship is a creation of interested parties, and a violation of the basis on which we sent our children abroad. Yet our plea fell on deaf ears," he said.

Countering the above argument, Sanjeewa Tennakoon, the Secretary of the Medical Students Union says that the majority of the foreign medical graduates have failed to score the relevant marks to enter local universities.

He claims that the Sri Lanka Medical College for the last seven years has not been closed even for an hour, and there have been no reports of misconduct on the part of the government medical faculties despite the JVP insurgency which received tremendous support and participation from certain faculties elsewhere.

"If we are to counter their wild allegations which is a direct insult to the local universities in general, we will have to publish a newspaper for that purpose" he said.

Substantiating this argument is Dr. Nanda Amarasekara who states that while all local graduates satisfy the minimum entry criteria of the UGC to enter the six medical faculties in the country, most of the students leaving for higher studies abroad do not meet these criteria In fact no one can vouch for their suitability for a medical course abroad , as neither the UGC nor the Ministries of Health and Education are aware of the their criteria for selection in to the foreign medical universities, he said.

Dr.Amarasekara in a strongly worded letter to the President of the SLMC states that in a group of 447 students who were given appointments in the state sector in April 1996, only three were scholars on UGC approved scholarships, while over 100 were private candidates or those who had been selected on dubious entry criteria, a reason why he says, foreign medical graduates should not be given automatic registration of the SLMC. Further, he stresses that only those with minimum entry criteria into our medical faculties should be considered for granting scholarships to medical schools abroad, and that there should be a central register of them maintained by the UGU and open to the public.

Adding credence to the above argument Prof. H.J. de Silva, a consultant physician has suggested that the Act 16 examination should be brought on par with the final MBBS exam conducted by the medical faculties in the country. Similarly, the Sri Lanka Medical Association has proposed the thorough revision of the Act 16 exam, and that the MCQ ( multiple choice question) component be included to make it a real test of medical knowledge.

At present, the final year students have to face five written tests, five practicals, five multiple choice questions (MCQ) and three vivas before seeking internship. They also have to show prowess in patient handling by dealing with five patients covering five aspects of their study before seeking temporary registration as interns. In contrast, the foreign medical graduates only do the viva lasting for about twenty minutes.

The fact remains that following the disintegration of the USSR, the newly formed states like Estonia and Lithuania also started enrolling students at their smaller universities. Locally qualified doctors argue that the standards of these universities cannot be the same as the former USSR institutions which maintained high standards.

According to a spokesman from the FMGPA, the local graduates besides wanting to create a Mafia for themselves, also fear that they will have to share the state sector employment.

"Our children do not need these jobs. But they naturally want to be absorbed into the profession. They can do private practice. They ask only for the right to do internship on their own right without passing the Act 16 examination. These degrees are accepted both by the SLMC and the WHO, so why evaluate again?

"Despite the criticism that the majority of the foreign graduates are substandard, and have failed to enter the local universities, there are many students who excelled in their studies at school level, and went abroad during the insurgency. You cannot expect them to waste the best years of their lives awaiting university entry," the spokesman said.

The crux of the matter is that the output of the local medical faculties is insufficient to meet the present demand. Patient handling at various levels demands far more doctors. In Sri Lanka, the ratio is a doctor per 2000 persons or more. With serious epidemics constantly affecting civilian life and a debilitating war which devours many young lives while rendering others disabled, we need a more co- ordinated health sector. This demands that whether foreign or locally graduated, they should have a particular foundation or competence to deal with the ground situation.

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