Ensuring the standard of medical graduates in Malaysia.

In Malaysia, the Malaysian Medical Council (MMC) is assumed to be the body responsible for ensuring that medical graduates are of a sufficient standard to be safe, and competent medical practitioners. Under the Medical Act 1971, MMC is responsible for recognizing medical schools for the purpose of licensing the graduates to practice in Malaysia. This means that it should set standards and certify the achievement of the standards of Medical degree programmes awarded by all medical schools within and outside Malaysia. Unfortunately, this is akin to a final product inspection before approval and any pre-emptive remedial action prior to the finished product (ie. the process) is not possible. The teaching, training and curriculum is determined by the respective universities whereby the standards are loosely set by the Ministry of Education and since 2004, by the Ministry of Higher Education (MOHE). With the mushrooming of private medical colleges, the task of ensuring the standard was entrusted upon the National Accreditation Board (Lembaga Akreditasi Negara – LAN) which was set-up in 1996. LAN assured the quality by accrediting the basic medical programmes of private medical schools as governed by the LAN Act. This, unfortunately, gave rise to 2 sets of standards – the public medical schools as determined by MOHE and the private medical schools as determined by LAN. This anomaly was resolved when LAN was dissolved and replaced by the Malaysian Qualifying Agency (MQA) under the MQA Act 2007 which is now authorized to accredit both public and private medical schools thus ensuring a single, uniform standard. In the accreditation process of medical programmes, the MQA is advised by a Joint Technical Committee comprising of MMC, MOHE and the Public Services Department (PSD). The PSD is involved by virtue of the fact that all medical graduates must do their compulsory service in government hospitals or clinics for 3 years and PSD is the body that appoints them in government service. The Joint Technical Committee is also responsible for approval of medical programmes, constituting the evaluation panels, studying the report of the accrediting teams and submitting the recommendations on accreditation for approval by MQA, MMC and PSD. The Committee also conduct training courses for accreditors who can be from public or private universities, Ministry of Health and members of MMC to ensure that evaluating and accrediting teams sent out to the various medical schools are trained for the tasks. Accreditation of medical schools is done based on a set of criteria, standards and procedures which were first formulated in 1998. In 2000, the format of the accreditation guidelines was reviewed and the format of the World Federation for Medical Education (WFME) adopted. The WFME had developed ‘International Standards in Medical Education’ which specified basic and quality development standards that served as performance indicators for quality assurance in medical education. In 2006, a review was made of the Guidelines based on feedbacks and comments of those involved in the accreditation process. The new edition of the guidelines was adopted in 2007. The key changes include a ruling on continuous assessments whereby it should either be used as a pre-requisite for sitting for the final or professional examination or contribute not more that 40% to the final examination score. If used as a pre-requisite, the continuous assessment scores should not contribute to the final examination scores. Another one is the ruling on balance between medical and non-medical academic staff which should be 70 : 30 ratio as well as the ratio between full-time and part-time staff where full-time faculty should be more than 60%. Staff-student ratio is also stipulated for all the various teaching-learning activities such as tutorials-not exceeding 16 students per group; problem-based sessions – not exceeding 12 students per group; clinical teachings in skills lab setting – not exceeding 10 students per group and bed side clinical teaching-not exceeding 8 students per group. The overall staff : student ratio should be 1 : 4. Another new ruling is on the hospitals used with a ratio of 1 student to 5 beds. The hospitals recognized for this purpose much have the basic disciplines available ie. Medicine, Pediatrics, Surgery, O & G, Orthopedics, Radiology and Pathology. With the revised Guidelines for Accreditation, a rating scheme for accreditation was also adopted. The rating is based on the guidelines which sets out good practice in nine areas and the rating system uses a percentage scoring scale that indicates the degree of institutional and programme compliance to the standards for each area and criterion. Compliance is rated according to 5 Levels: Level 5 – Excellent, Level 4 – Good, Level 3 – Satisfactory, Level 2 - Less than satisfactory and Level 1 – Unsatisfactory. The accreditation period given to a particular medical school is then based on the overall rating points of the compliance obtained. As for the process of accreditation, before a particular medical course is started, a team is sent to evaluate the curriculum and consider the school’s plans and implementation details of at least the first two years of the programme. The team may go for a re-visit if there are areas of concern noted in the earlier visit to see if these concerns have been overcome. A pre-accreditation visit is carried out about 1 year before the formal accreditation visit to enable the school to know and rectify deficiencies before the formal accreditation survey, which is conducted when the first batch of students is in the final year. Thereafter, the accreditation survey is done every 1, 3 or 5 years depending on the length of accreditation duration given. Despite a structured and comprehensive accreditation system for the course and the medical school, it does not necessarily guarantee a very good medical graduate as the graduate’s own personal traits and behaviour would play a large bearing on the quality of the graduate. To assess this quality, a rating of medical graduates has been developed. The rating system is based on knowledge, basic procedural skills, interpersonal skills, personality/attitudes, discipline, continuing professional development and leadership qualities. From these, an overall score is obtained and rating is given as either A, B, C or D. This would be useful to assess the overall quality of medical graduates from any medical school and would provide important feedback to the medical schools to overcome deficiencies, if any. In conclusion, a quality assurance mechanism is in place in Malaysia to ensure quality medical education and medical graduates. This involves the key stakeholders such as the Malaysian Medical Council, Malaysian Qualifying Agency, Ministry of Higher Education, Ministry of Health and the Public Services Department. The standard set is similar to the World Federation for Medical Education and would also change and evolve over time in response to continuous improvement in quality. The introduction of ratings for medical schools and graduates will certainly spur medical schools to strive for improvement.