Brain Shrink: The Crisis in Medical Education

Author: Paul Bisnar Blog: The Doctor is Out >> The Doctor is Out

For the past several years, the staggering results of the average passing percentage in physician licensure examinations dropped significantly. Based on Professional Regulatory Commission data, the 71% average passing percentage in physician licensure examination on 1997 still remains undisputed. Since then, the following successive average passing percentage results declined: 65% on 1998, 69% on 1999, 65% on 2000, 62% on 2001, 66.05% on February 2002, 59.11% on August 2002, 57.03% on February 2003, 55.56% on August 2003, 51.97% on February 2004, 51.4% on August 2004, 54.47% on February 2005, 51.46% on August 2005, and 54.29%. on February 2006. The 51.4% average passing percentage last August 2004 is the lowest so far among the results of August physician licensure examinations. Pushing the panic button is now long overdue. Brain drain of doctors is not the only serious crisis that our country experiencing, but also brain shrink, the crisis in medical education. The government and our leaders in medical education should look into this crisis seriously, because brain shrink has parallel deleterious effects as in brain drain to our health system. The quantity and quality of new doctors are in crisis. Flight-by-Night Medical Schools Last year, the former Chair of Philippine Regulatory Commission Board of Medicine, Dr. Jose Ramirez, spoke in a forum entitled "Medical Education in the Philippines" sponsored by the National Academy of Science and Technology. He pointed out the proliferation of "flight-by-night" medical schools. In the 1960s there are only 6 medical schools and the average passing percentage were as high up to 80 to 90%. To date, there are 33 medical schools distributed all over the Philippines, 10 of them are within Metro Manila, and majority had low average passing percentage board exam results. Some medical educators blame Commission on Higher Education (CHED) in this onus. They explained that the reason why many schools are not regulated because CHED does not want to interfere because they dont want responsibility. CHED is the leading agency that promotes quality education among medical schools. Dr. Philip S. Chua, former Chair of the Board of FEU-NRMF School of Medicine Alumni Foundation, commented CHED has obviously defaulted in its duties and obligations of strictly monitoring and controlling tertiary education. It is vested with all the powers needed, but apparently, politics, whatever kind it is, always gets in the way. To deny this is happening, to look the other way, and spare CHED this scathing criticism, is to do a great disservice to the medical profession and to our country and our people as a whole.

Relevance of NMAT The deterioration of admission and screening of prospective 1st year medical students is also a factor. Twice a year, April and December, the Center for Medical Measurement under the auspices of Commission on Higher

Education (CHED) subject pre-med students to National Medical Admission Test (NMAT) as a requirement to enter medical schools. CHED let each medical school to determine its own passing percentile cut-off (see Table 1). Due to decreasing enrollment of medical students (see Table 2) and the decrease in number of NMAT applicants (see Table 3), majority of medical schools are force to lower their NMAT percentile cut-off to accommodate dwindling medical student enrollees in order to sustain their daily operational cost. According to Dr. Policarpio B. Joves Jr., Assistant Dean of FEU-NRMF Institute of Medicine, their cut-off grade in NMAT is 40. Due to aforementioned reasons, they are forced to lower the passing grade down to 15 as recommended by the Council of Deans of Philippine Medical Schools. However, some medical schools dont recognize the recommended NMAT cut-off grade by the Council of Deans. Some of these schools had no reference NMAT cut-off grade and they rely more on the applicant pre-med transcript of record as basis for admission. Other medical schools with reference NMAT cut-off grade tolerate NMAT flunkers to enroll provided they pass it before they graduated. Thus, a student can take NMAT as many as he wants until he reach the passing mark. Some medical schools such as University of the Philippines and University of Santo Tomasare strict and dont accept applicants who fail to meet their required NMAT cut-off grade. According to Dr. Fernando Sanchez, Executive Director of Association of Philippine Medical Colleges (APMC), due to dwindling number of medical students, many medical schools are forced to accept unqualified and lesser intelligent applicants, hence, affects the poor performance in the medical board examinations. Dr. Georgina T. Paredes, Dean of UERMMC College of Medicine, and Dr. Policarpio B. Joves Jr., Assistant Dean of FEU-NRMF Institute of Medicine, expressed the same opinion. A not well circulated thesis entitled Correlation of Admission Criteria and Performance of FEU-NRMF Medical Students (1994) by Dr. Rogelia Bongat from the National Teachers TrainingCenter for Health Professionals, University of the Philippines, showed that NMAT grades of medical students didnt reflect its true academic performance in the real world, so to speak. Her study should encourage policy makers to review again the relevance and importance of NMAT as a requirement for entering medical school. Problem Based Learning (PBL) Two schools of thought differ in opinion regarding the relevance of PBL to brain shrink. Critics blames PBL as a culprit of brain shrink but staunch supporters of PBL repel their accusation. There are now 17 medical schools adopting PBL. These include UERMMC, Saint Louis University, Angeles University Foundation, Cebu Institute of Medicine, West Visayas State University, Mindanao State University, Ateneo de Zamboanga, and others to name a few. Queen's University at Kingston, Canada, Faculty of Medicine defined PBL as an educational format that is centered around the discussion and learning that emanates from a clinically based problem. It is a method that encourages independent learning and gives students practice in tackling puzzling situations and defining their own gaps in understanding in the context of relevant clinical problems, hopefully making it more likely that they will be able to recall the material later in the clinical setting. It is a way of learning which encourages a deeper understanding of the material rather than superficial coverage. Its main objectives are to develop an ability to identify relevant health problems that warrant further discussion or self-study within the context of a clinical scenario presented as a "patient problem; to develop an appreciation for the interrelated nature of the physical, biological and behavioral mechanisms that must be considered with each health problem during the process of generating a management plan; and, to develop the knowledge base necessary to define and manage the health problems of patients, including the physical, emotional and social aspects, within the context of effective health care provision within society.

UERMMC College Medicine is one of the PBL pioneers. It shifted its traditional educational format to PBL on 1998. On 2003, the first batch of its PBL product took the physician licensure examination with disappointing passing percentage result. Dr. Paredes, Dean of UERMMC College of Medicine, admitted that since 2003 and the succeeding board examinations, the results were not good as expected compared to the batches who were educated on traditional curriculum. She gave logical insights why is this so. First, she said that the PBL training of medical students in UERMMC-CM don't jibe with the type of questions given by the board of medical examiners. The type of questions in physician licensure examination remains traditional in which questions are departmentalized into 12 different subjects as stated in Medical Act of 1959. Second, the reference passing grade of physician licensure examination is now criterium based and not norm based. Norm based was adopted until year 2000. The Medicine Board of Examiners sets the passing grade of the examinees irregardless of its diverse grade results. On the other side of the coin, Dr. Sanchez from APMC and a staunch supporter of PBL cited that previous and recent top-notchers of physician licensure examinations are PBL product. Likewise, Dean Paredes claimed that 90% of their students who took the problem based oriented US Medical Licensure Examinations passed. Dr. Sanchez pointed out that brain shrink is multifactor in causes and PBL is not one of them. However, Dr. Ramirez observed otherwise. He speculated that introduction of PBL curriculum in some medical schools could have caused the increase in flunking rate. He said that PBL is a philosophy introduced some 20 years ago in England(it) gives the students independent study time. Unfortunately, frequently what s happening is that the students do not use their time to study. However, he admitted that I do not find PBL curriculum intrinsically wrong since the problem of the growing flunkers in the medical licensure exams could also be attributed to poor teaching strategy of some schools. Dr. Joves stated that FEU-NRMF remains traditional in curriculum since its conception. Since then, the performance of their graduates in physician licensure examination remains satisfactory. Last August 2005 board examination, sixty-one percent (61%) of their graduates passed. However, he admitted that 61% is low compared to the results of board examinations many years ago. He view that their brain shrink is also multifactor in causes. Board Exam According to Dr. Sanchez, there is an existing mutual agreement between the different Deans of medical schools and the examiners of the Board of Medicine. The medicine board examiners agreed to be transparent in their type of questions. Different medical schools gave blueprint guidelines to the board of medicine of what type of relevant questions to be included in their crafted licensure examination. However, Dr. Sanchez and other medical educators were disappointed because despite of their mutual agreement, they were not given a chance to monitor the type of questions given by the examiners in the licensure examination. They felt that the blueprint guidelines they suggested to the board of examination were not followed. Worse, some educators observed that there are questions in board examinations that are appropriate for medical specialist and not to newly graduate medical doctors. Dr. Sanchez emphasized that medicine board examiners are secretive in the crafting of the board examination. He said that board of medicine didnt want to validate their questions with the deans. He suggested that they should be transparent in order for them to monitor and ensure the relevance of the physician licensure examination. The Faculty The lack of full time faculty members is now a problem. Medical doctors prefer to be clinician rather than to teach in a medical school because it is more lucrative and cost-effective. The salary of a medical faculty is meager in comparison to clinical practice.

In Dr. Melflor Atienza recently presented study entitled Filling the Gaps in the Practice of Internal Medicine in the Philippines to the Philippine College of Physicians, she revealed that only 18% of internist are in teaching. Most of them are in clinical practice. She also enumerated the problems of faculty that should be address such as inadequate facilities for instruction, non-regular appointment as faculty, low salary, lack of faculty development programs, lack of competence or confidence in teaching, and lack of incentives to teach. Likewise, Lack of faculty members led to pirating of faculty members from the old schools and the emergence of so-called flying doctors. Both still exist today and are bad for medical education Dr. Sanchez lamented. Due to economic uncertainty, numerous faculty members are enticed and subsequently joined the nursing bandwagon. They can earn their annual teaching salary in First-World countries as a nurse for just a matter of few months. All of these factors eventually demoralize faculty members but also medical students alike. The lack of role model and dedication of faculty members due to the effects of aforementioned factors affect the quality of medical students. Increase Commercialization of Health Education Some National Government Organization observes there is rampant high cost of health education in private colleges and universities that cater large number of students for profit irregardless of the quality of their applicants. Tuition fee in medical school ranges from P55,000 to P85,000 for a semester in Metro Manila. They refuted the claims of school owners that high cost of health education guarantees quality education. Dr. Chua likewise agreed that the commercial bottom-line philosophy of these inferior institutions results in substandard quality of teaching". However, further concrete studies are needed to support this factor. The Medical Students The nursing craze which started as early as year 2000 halted numerous medical students to pursue medicine. Medical students are enticed to shift to nursing because it is an easier course and more lucrative than medicine. Moreover, the tuition fee of nursing course is not far from medicine and it is shorter to finish. For them, witnessing thousands of medical specialists shifting to nursing is demoralizing. They are just starting to dream to become a doctor, but they can now see the true color and bleak future of their chosen profession. According to Dr. Joves, wrong values imparted by faculty members to medical students are part of the problem. He recounted that faculty interviewers are quickly to deny 1st year medical student applicants to enter medicine when their true motive is to serve humanity. Those applicants who answered that they want to be a doctor for prestige and profit are eventually accepted. Interviewers view those students who want to serve humanity are shallow and clich, while those students who want to be a doctor for prestige and profit are sincere and honest. What a paradox! Naturally, the compounding aforementioned factors translate into brain shrink. The Solutions Here are some recommendations to treat brain shrink:

1. CHED should have the political will to review the quality of flight-by-night schools and vigilantly monitor the quality of medical schools. 2. Review the relevance and possibly reform NMAT as a gauging mechanism of medical students entering medical school. 3. The Board of Medicine should validate their questions with the different Deans to ensure its quality and relevance in Physician Licensure Examination. 4. Amended Medical Act of 1959 should be again scrutinized and possibly once again amended to make it relevant with the current trends in medical education. 5. Incentives and development programs for faculty members. 6. Make tuition fee of private medical schools reachable to the mass population. 7. Improve the academic curriculum of medical schools and inclusion of Health Social Science subject. 8. Government should subsidize the cost of medical education to those cannot afford but qualified applicant. 9. Possibly reduce the length of medical education. 10. Reorient value formation to medical students. Brain shrink is a dangerous threat to our health system. It is imperative that national government, medical organizations, health educators and policy makers, politicians, NGOs, and media should join hands and participate in managing this crisis. We need brain gain not brain shrink.