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(Based on the Presidential Address, Ceylon College of Physicians, 2004)

by Professor Janaka de Silva

During consultations with a physician - a need for ‘kindness’

Our patients bitterly complain, both in public and in private, that many of us, modern physicians, are lacking in correct attitudes and good communication skills. How much patients value these qualities in a doctor was highlighted, albeit indirectly, in a recent survey of more than 200 surgical patients, where the attribute most sought of the surgeon was not, as we doctors would expect, 'surgical competence and skill', but 'kindness'. We should not dismiss our patients' concerns regarding us, as biased, semiliterate or hysterical. Because if we are unable to realize or ignore how we are perceived, then we cannot address the concerns and interests of the society we serve.

Studies on the correlation between performance at the Sri Lankan 'A'level examination and performance in Medical School have yielded conflicting results. Basnayake and Amarasinghe in 1987, in Peradeniya, reported that the overall performance at the second MB (the first examination in medical school), fell far short of expectations, with only 40-50% of students passing the examination at the first attempt over a five-year period between 1981 and 1985.

Performance was only weakly associated with the A'level aggregate mark, but the 'A'level mark taken in conjunction with the AL attempt appeared to predict performance at the examination better. In the same year, Udupihilla and colleagues, found that all poor achievers at the second MB examination were poor in comprehending English, leading to non-use of textbooks and the inability to write notes at lectures. Senanayake and Weerasinghe in 1996, again in Peradeniya, also observed a poor correlation between the A'level aggregate mark and performance at the second MB, and the correlation got even worse for subsequent examinations, becoming weakest at the final MBBS.

They, however, found that the number of attempts at the AL had a bearing on academic performance in Medical School, with students who entered Medical School at the first or second attempts faring significantly better than those entering at the third AL attempt.

Weak marks

The same study also found that correlation between performance at examinations within the Medical Faculty was high. More recently, de Silva and others, in Ragama, found that the A'level aggregate mark, which is the single measure of academic performance used for admission to Medical Schools in Sri Lanka, was a very weak predictor of performance in Medical School.

They also found that female gender, and students who obtained at least a 'B' grade in Zoology were more likely than others to pass all undergraduate medical examinations at the first attempt, and that those who obtained at least a 'B' grade in Physics performed better at the second MB examination.

Similar studies have been done in the United Kingdom. A recent review reported that previous academic performance is a good, but not perfect, predictor of achievement during undergraduate training in British Medical Schools. A Meta-analysis of 62 papers, found that previous academic performance (A'levels or other Medical School admission tests) was a moderate predictor of undergraduate academic performance, and had a small predictive value for postgraduate performance.

Analysis

Analysis of academic predictors of success in the Nottingham undergraduate medical course found that achieving a high grade in A'level Biology predicted success at the final examination, highlighting, like the Ragama study, the importance of individual A'level subject marks as predictors of subsequent undergraduate performance.

A recent 20 year follow up study of 511 doctors who attended a Medical School in London, showed that a good performance at the British A'level examination predicted both better undergraduate performance and obtaining postgraduate qualifications, like the MRCP, early.

The British A'level accounts for 23% of the variance in performance in undergraduate medical training, while our A'level accounts for 5%. Only 50% to 60% of students in our Medical Schools pass any examination at the first attempt, compared to more than 90% to 95% in British and Australian Medical Schools. About 10% of our students fall behind their year, whereas this is a very rare occurrence in the UK. Poor English language skills are likely to contribute to this situation, because our medical students are in the unenviable position of having to study Medicine in English after having had all their secondary education in either Sinhalese or Tamil.

Because performance at the British A'level seems to predict subsequent undergraduate performance at Medical Schools in the UK, and this does not appear to be the case in Sri Lanka, it is interesting to compare the two entry systems.

British system
Sri Lankan system

3 A'level subjects 3 A'level subjects (was 4) Only Chemistry compulsory Biology, Physics, Chemistry Practical examination None dmissions on merit-based system Only 0% on merit Most enter at first A/L attempt Only 5% at first attempt (15% at third attempt) Good grades in all subjects required Weighted average (Z score) Interview/aptitude test None It, therefore, seems that the problem we have, lies not only in the A'level examination itself, but also in the way in which we use the results of this examination to decide entry into Medical School.

While it is felt that many of our graduates who qualify MBBS have adequate knowledge and psychomotor skills, such as, in clinical examination and performing procedures, it is also generally agreed that they have deficient attitudes, communication skills, English profiency, analytical skills and self-learning ability.

This shouldn't be all that's surprising when one considers that they come into Medical Schools, having had all their secondary education in their mother tongue, in an examination oriented, didactic teaching based, murderously competitive secondary education system, and often get more of the same at our Medical Schools.

Medical curricula

The newer medical curricula specifically address some of these issues. Reducing the information load, placing more emphasis on teaching, communication skills, giving more weightage to in-course assessments - where attitudes can be better tested - and encouraging a self-learning culture, are significant differences between the new and the old, traditional curricula.

Two of our Medical Faculties, first Colombo and then Kelaniya, have followed this new philosophy in Medical Education and revised their curricula. However, attitudes and communication skills cannot be improved just by changing the curriculum. Students learn most of these attributes by observing their teachers. Teachers need to be aware of this, and guard against becoming bad examples.

This is the reason why I only partly agree with the idea, 'just pick the right students and the rest is easy'. Teachers also have a big role to play in fashioning good doctors; they have the influence to 'make or break'. Teaching should, therefore, be undertaken only by those with a genuine interest and ability.

Studies

Several studies in the UK and USA, have compared integrated and problem-based methods of learning, with the more traditional methods of Medical Education.

In brief, students who learn medicine in an integrated problem-based manner seem to enjoy the learning experience more, perform better at undergraduate clinical examinations, and probably cope better with internship and the junior doctor years, while those who follow traditional curricula appear to be better in the basic sciences and at passing specialist postgraduate examinations.

In Sri Lanka, such comparisons may be premature at present, and have to be made when there are larger graduate sub-populations to analyze. What we need to do for now is to examine our students' experiences at Medical School, take their opinions seriously, find out what more we could have offered them, and use this information to fine tune our academic programmes.

One would consider a post MD Senior Registrar, just months before board certification as a specialist physician, as the nearly finished product of both our undergraduate and postgraduate Medical Education systems. These then are the ones who rose to the top, and a good many of them are of excellent quality.

But that is not enough. After State spending amounting to many millions of rupees, the public demands that all or at least nearly all of them be of a high standard. Our postgraduates have a sound knowledge of medicine and good clinical skills, but, as reported by foreign examiners at our MD examination and foreign trainers, they seem to still lack proper attitudes, communication skills, analytical skills, and an interest in research.

Development countries

In developed countries, attitudes and communication skills are considered so important that they are given pride of place in postgraduate medical training programmes. In the UK, for example, they are a major component of the Specialist Registrar training programme and are specifically tested in the new MRCP 'PACES' examination that has completely replaced the clinicals.

Of the Sri Lankan candidates who have recently failed the MRCP, the majority have failed at these stations, confirming, at least to my mind, the low place we accord these important attributes in our training programmes. We have, however, come a long way. The theory papers and vivas are now structured and lend themselves to objective marking, and there is continuous training of the trainers themselves.

Are there solutions to these problems? Probably.

We are likely to get students better suited for the undergraduate medical course if their secondary education in the science subjects is in English. We should also gradually increase the proportion of students we admit to our Medical faculties on merit, to 80% from the present 40%, or to as much as possible within our social context.

Because the total A'Level aggregate has been repeatedly shown to correlate so poorly with subsequent performance in Medical School, there is little point in only increasing the proportion of students who enter Medical Faculties on merit.

The increased intake on merit should be combined with having the mark obtained standardised for the number of attempts (for example, 65 marks in a subject obtained by a student at the first AL attempt should be considered equal to 70 marks obtained by another student at the third attempt) so that many more students will enter medical schools at the first AL attempt; making entry to Medical Schools based on good grades in all subjects, rather than based on a single score; insisting on a minimum grade in the General English test, for example a 'C'; and if possible including some skills testing, and administering an appropriate aptitude test. This last suggestion will be difficult. As an alternative we could introduce some form of career guidance, ideally after the O'Level examination.

This should make it easier for students to make informed choices on the courses of study they wish to follow and thus become better motivated to follow them, rather than choosing a course of study just because their parents want them to.

Once they come into Medical School, curricula should be geared to rectifying identified deficiencies such as those in communication skills, self-learning abilities and analytical skills, and teacher behavior must reflect the changes that we desire in our students.

Changes

Changes in our postgraduate training programme should include giving more weightage to continuous on-the-job assessments - which would make the training less examination oriented, encouraging research - at least audit, modifying the MD examination to reflect these changes, and having a mechanism for continuously training the trainers. The Board of Study in Medicine of the Postgraduate Institute of Medicine, has gone a long way towards addressing these issues.

There is a small nucleus of young, competent, motivated, academically aggressive physicians in this country, who can compete internationally. The future of Medicine in Sri Lanka depends on increasing their numbers.

This will require many changes in how we, at present, train our medical students and postgraduates.

We should not fear change. For those who believe that change could lead to a worse crisis than we have at present, and let's not kid ourselves, we do have a crisis of public confidence in our physicians, let me end by quoting an old Chinese saying: 'Every crisis carries danger, but no matter how dangerous the situation, at the heart of each crisis also lies a tremendous opportunity'.

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