Crisis in Medical Education
(An Imminent One In Healthcare Delivery)

By Philip S. Chua, M.D., FACS, FPCS

A Prelude

     I have been assigned the task of presenting this paper as a prelude to a discussion of a most delicate and essential dilemma confronting medical education and healthcare delivery in our country today. It is my hope that a thoughtful and candid evaluative deliberation of the national crisis, will allow all of us to help find ways to minimize, if not to solve, at least, the crisis in our own backyard. Click here

The alumni are concerned. And I am sure the administration and faculty as well. All this, because we all hold dear to heart our Alma Mater, its reputation and its future. I want to remind everyone present here today, that we are deliberating here as members of one family. We are family. And our common and mutual goal is nothing but the welfare, interest, and future of our medical school and the medical center, and the quality of our medical graduates. Needless to say, we all want our medical school and our graduates to be the best. We all want good medical care and healthcare delivery system for our country and our people.

The physical health of the nation and its citizenry largely depends on the quality of physicians, state of available technology and facilities, and the efficiency in the delivery of healthcare in the country, besides the habits and lifestyle of the people.

On top of our more than 6.3% inflation rate and national budget deficit of 3.407 trillion pesos, the Philippines is also facing another crisis of alarming proportion: the deteriorating quality of medical education, and the imminent healthcare dilemma.

Is There a Crisis?

Is there a crisis in medical education and an impending one in the delivery of healthcare in the Philippines? My answer to both is yes. It has been reported that the earliest and subtle warning signs of the tsunami earthquake-tidal wave phenomenon that recently devastated a great portion of the Far East were not heeded, leading to the demise of more than 150,000 people. We have more than subtle signs of a crisis in medical education and a looming one in healthcare delivery system in the Philippines. We cannot afford to close our eyes, stick our head in the sand and pretend they are not happening. We have to pay attention to the warning signs, no matter how subtle they may be.

Alarming Statistics

Only 51.4% passed the medical licensure board examination in August 2004; 51.94% in the examination given February 2004; 55.69% in August 2003; 57.23% in February 2003; 59.11% in August 2002; 66.03% in February 2002; and, 64.3% in August 2001. And this reflects the performance of all graduates from the various medical schools.

The long overdue clarion call was sounded by concerned physicians and medical educators in the country. Dr. Jose Ramirez, head of the Philippine Regulation Commission’s (PRC) Board of Medicine, recently spoke of this crisis of continued runaway decline in the passing rate in a forum on “Medical Education in the Philippines,” sponsored by the National Academy of Science and Technology.

The PRC board “worries that the quality of medical education in our country may have deteriorated in recent years, influenced by the unchecked proliferation of (fly-by-night) medical schools and of (their) pirating faculty members from established schools.” The PRC chief explains the decline to be partly a result of the “deterioration in the admission and screening of prospective medical student applicants.” Obviously, a number of these schools are less than discriminating in their admission in order to “get the maximum enrollees in for maximum financial profit,” since they are apparently, first and foremost, a money-making business venture, with the secondary objective of providing medical education.

Dissecting the Anatomy

Part of this unfortunate generic scenario is cost-cutting and skimping on facilities (audiovisual teaching aids, books, equipment), inadequate and/or poorly structured medical educational curriculum, the lack of competent fulltime and truly dedicated teachers, the lack of good hospital affiliation, and the commercial bottom-line philosophy of these inferior institutions that results in substandard quality of teaching.

In the 1950s, there were only 3 medical schools in the country. In the 60s, there were 7 medical schools (UP, UST, FEU, UE, MCU, CIM and SWU). The passing rates then were high up in the 80s and 90s.

Thoughtless and misguided actions by the Local Government Units (LGU) in the 1970s “encouraged the private sectors to finance medical schools in their localities to address the shortage of doctors in the rural areas,” since 40% of medical graduates migrated to America. Medical schools sprouted all over the country like the proverbial mushroom. This ill-conceived notion did not significantly alleviate the problem. The mal distribution of physicians and medical care was a bit improved when the United States closed its doors to foreign physicians in 1975 and the “saturation and congestion” of physicians in the big cities forced some to practice in the rural areas. But that effect was just a drop in the bucket. Most of our rural areas are still doctorless. Many new graduates who found the situation to be untenable for survival were forced to seek greener pastures outside of the Philippines, or outside of their profession.

In the meantime, the unabated replication of medical schools in the country has progressively led to substandard teaching, poor quality medical education, and the inferior graduates that these institutions are churning out as evidenced by the results of the medical board examinations. The lack of competent faculty members in the country prompted the new medical schools to pirate teachers from reputable medical schools.

There are 36 medical schools in the nation and 12 of them in the Metro Manila area alone. For a country the size of the Philippines with its 86.2 million population, it needs no more than ten medical schools to adequately serve the nation and its people.

Of these 36 schools only 19 (or 52%) have their own teaching hospital as required by law. How the others obtained the necessary governmental license to operate only highlights the flaws and inefficiencies in the entire Philippine educational system and its regulatory agencies.

If we had but ten medical schools in the country, these institutions would have more deserving applicants per school to select from, accept more qualified students, become more profitable to afford quality and dedicated teachers, superior facilities and teaching aids, a hospital of their own, and be able to optimize its ability to produce quality and world-class physicians. As it is today, the good schools are negatively impacted by the mediocre ones, who lure student applicants (thru various incentives) away from quality medical schools which can provide them superior medical education, and who pirate faculty members from good schools.

If the current deplorable situation continues, the Philippines will soon be notoriously known, and shamefully tagged internationally, as the mecca of medical diploma mills.

CHED Has Defaulted

It is obvious that the Commission on Higher Education (CHED) should take a great part of the blame for the deterioration of medical education in the country. 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.

PBL: Not a Factor

Problem-based learning (or PBL) has somehow been tangentially mentioned as a possible factor in the low passing average. There is really nothing intrinsically wrong with PBL. If problem-based learning, which is working well in great medical schools like Harvard and others, is not working for our students, perhaps our students are not serious, smart, mature and responsible enough to survive without spoon feeding. At any rate, to dwell on this insignificant issue is only to divert our attention from the real causes of the crisis at hand.

An Imminent Crisis in Healthcare

To digress a bit, I would like to touch on the imminent dilemma in healthcare delivery in the Philippines. It is obvious that inferior medical graduates leads to poorer quality physicians. This situation only aggravates the country’s rapidly diminishing medical manpower resources. Over the past several decades, physicians and nurses found themselves in a quandary, a dilemma posed by our failing system and deteriorating economy. With the survival of their family and themselves at stake, the Filipino physicians and nurses found no choice but to seek a greener pasture abroad. This exodus continues to cause the Philippines not brain drain anymore but brain hemorrhage of alarming proportion. More than 250,000 (quarter of a million) Filipinos are applying for passports every year, the majority of those, physicians and nurses leaving for employment overseas. More than 10,000 of our physicians have pursued nursing education. More are expected. Almost 4,000 physicians have migrated to the United States between 1996 and 2002, an average attrition of about 700 a year. Between 1994 and 2003, 84,843 registered nurses left for abroad, an average of about 9,500 annually. If this hemorrhage continues, the healthcare delivery in the country will be devastated, and the health of our people placed in extreme jeopardy.

A British study predicts a full blown crisis in healthcare delivery in the Philippines by year 2008, for lack of competent physicians and nurses to take care of ailing Filipinos. Hospitals in Negros and other cities in the country find no choice but to close doors for lack of medical-nursing manpower. And this is only the beginning.

A Government Obligation

The recent anti-exodus pact signed by around 6000 specialists in internal medicine at the recently concluded 16th mid-year convention of the Philippine College of Physicians in Bacolod is a welcome and laudable band-aid on the large and gaping wound in our system. We need more than a unilateral covenant like this. The onus is on our national government. If only we had less corruption in the government, perhaps our country would be solvent enough to address this financially-related dilemma, and greatly minimize the escape of these physicians and nurses seeking a greener pasture elsewhere. After all, if given a choice, if a good one is available, these physicians and nurses would rather stay right here, at home, with their families and friends. Most of them leave with a heavy heart, compelled by the harsh reality at home. Only our government, perhaps joint venturing with the private business sectors, can pre-empt and prevent this imminent crisis in healthcare delivery in the Philippines.

The Ugly Realities

In summary, the complex multi-factorial etiologies of this national crisis in medical education, in general, would include these ten: (1) Over abundance of medical schools in the country, many of which provide substandard medical education; (2) Admission of poor quality of students; (3) Lack of competent fulltime faculty, aggravated by piracy of teachers; (4) Unattractive salary for fulltime faculty members, discouraging many qualified ones from teaching; (5) Inadequate facilities and clinical exposure; (6) Dereliction of duties on the part of the Commission on Higher Education and other governmental agencies; (7) The apparent “personalization” and seeming lack of fairness on the part of the members of the board examiners, who still utilize an antiquated system of examination; (8) The indifference and ineffectiveness of medical associations, association of medical colleges, specialty societies and the like, to provide effective leadership and challenge what is going on; (9) the harsh financial realities confronting medical schools in the country today; and, to a major extent (10) The dirty politics and rampant corruption in our government, with the resultant rapidly deteriorating economy of the country. All these are the leading causes of the crisis before us today.

Capping the ceiling at 36 is not even the answer. Since the present system and agencies appear to be impotent in curbing the explosive growth of medical schools in the country and in strictly implementing quality control among these schools, perhaps President Gloria Arroyo needs to create an oversight commission, composed of renowned and respected Filipino medical educators in the academe and in the clinical arena, specifically tasked to scrutinize under the microscope the Commission on Higher Education, the Board of Medical Examiners, and all other governmental agencies involved, and replace their membership, if needed, and correct whatever deficiencies these agencies have. And, obviously, all the existing 36 medical schools should be strictly re-evaluated, to weed out and close the non-compliant and substandard ones - those which fall short of the established criteria and requirements for a good medical school in the country.

To allow these 36 medical schools to continue business as usual, without strictly mandating quality control, is to place in jeopardy and harm’s way, not only the good reputation of the Philippines and its medical force, here and abroad, but the very health and well-being of our nation and our people as a whole.

Soul Searching

This is the anatomy of this dreaded national disease. Some of the 10 factors I have listed above may also be at play, and applicable, to our own Alma Mater. The goal of this forum is not to point fingers or assign blames, but to analyze, as objectively as we can, the crisis at hand as it applies to our own school, and seek ways to improve ourselves to the best of our limited abilities.

I am under no illusion that the answers to these complex problems are simple and easy. Far from it, because it is a glaring fact that the major factor in all this is the political cancer of corruption which have permeated into the very core of every agency in the government, including even those involved in medical education and healthcare delivery in this country. The same malignancy that dragged our national economy a few decades ago, from the top in Asia, just below Japan, spiraling all the way down second to the bottom, just above Bangladesh today.

As always, realities will, sooner or later, prevail. But reality check should inspire us and not dampen our resolve. What is important, though, is for us not to be derelict in our duties, and to come together as a family, to give our best shot. After all, whether we like it or not, this is our family, THIS is our Alma Mater. And, ladies and gentlemen, THIS is our country.
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