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A CRITIQUE OF MEDICAL EDUCATION IN KENYA

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A CRITIQUE OF MEDICAL EDUCATION IN KENYA

Part I: The Medical Schools

All people in all societies expect their doctors to be the best. The most qualified, the most ethical, the most intelligent, and most trustworthy people in the nation.
Yet in Kenya, leaders openly ridicule and belittle doctors as incompetent and untrustworthy. They use this as justification for their expensive trips abroad for treatment. They may say so because they have, through our money, access to highly trained doctors in highly advanced hospitals. But it is also clear that the rest of us, the Kenyan citizenry, don’t think too highly of our doctors. The ongoing litigation fever, open criticism of doctors, and the exodus to India by even the struggling masses paints a bleak picture of the relationship between the society and its healers.
Much of this dubious reputation may be unfounded. Yet there is always something worthy of consideration in every accusation. Something that may reveal underlying problems and open a portal to healing. The quality of a doctor, the determinant of competency, is medical education. In a society that has such a tenuous relationship with its doctors, an analysis of medical education should become the starting point towards a solution.

Who qualifies for medical education?
The best and brightest. That’s the universal standard.
Even before the training itself, we expect that those joining medical schools are the best and brightest kids. They are those flawless straight-A students we celebrate after every release of KCSE results. The ones carried shoulder-high, the ones chased by TV cameras, the ones who have done better than others can hope to.
In almost all countries, academic grades determine who enters medical school and who doesn’t. This has been the practice in Kenya. It is ironic, therefore, that these bright students have not become the great professionals we consider competent, those who can keep us from going to look for care elsewhere. As other nations have learned, academic grades are not a strong predictor of future professional performance.
This led the United Kingdom to start using the University Clinical Aptitude Test to assess whether applicants have the mental attitude necessary for clinical practice1. Elsewhere, there have been varying policies that incorporate social values into requirements for medical school entrance. Where this has been done, such as in South Africa, there is a certain degree of success2. Yet in Kenya, we continue to complain about our doctors while enrolling kids into medical schools right off high schools based purely on grades. And this, along with obliterating the waiting period between high school and medical school. This means that these students, all of whom are just teenagers, have experienced nothing at all outside the academic process. They have had no exposure whatsoever to the real society, to the sensitive forces that make social interactions stable. The only thing they understand is the competitive environment of classrooms. Many of them could not care less about being doctors. There is pressure from family, and they just happen to have the correct grades.
Medical education is a multifaceted process, as are the problems besetting it. Every country has a particular set of health care needs that inform medical training and the demands placed on doctors. No single international standard of training exist. Yet we all know that some countries are considered far better than others in medical training and the competencies of their doctors.

A look at the American Medical education
The US is considered by many to have the highest levels of excellence in medical education and the diagnostic and therapeutic aspects of healthcare. Any list of the world’s best medical schools and the world’s best hospitals is dominated by American institutions. The most impressive medical discoveries either originate from or are perfected in the US. It may seem obvious—the richest country, the best medical training, the best doctors, and the best hospitals.
But Americans have come a long way to achieve this. There was a time, in the previous century, when American medical education was so bad that it led some men to conspire to bring the entire system down. That was more than a century ago, and great minds at Hopkins, referred to as The Hopkins Circle, started what would forever change medical education in America. Thanks to their efforts, the US is now the world leader in medical education and medical research.

The Flexner Report3
The Hopkins Circle consisted of four men at Johns Hopkins. The concern was that America was full of substandard medical schools that were flooding their nation with poorly trained physicians. They already knew what should be done, but needed a thorough review of the system to buttress their recommendations. They commissioned one of their own, Abraham Flexner, to crisscross America and Europe and develop a model for the best medical education.
Flexner went on a mission. He interrogated the admission processes, laboratory facilities, the qualifications of lecturers, and the stake a medical school had in the teaching hospitals. Flexner reported that most medical schools had very poor admission standards, lacked the right laboratory facilities, and gave their students very little clinical exposure. So impactful was the Flexner Report that a third of medical schools in America were closed down. The majority of American medical schools were found to be defective and needed serious reforms in the wake of the report. All forms of for-profit medical training died. All the remaining medical schools had to conform to strict licensing requirements that were developed from the report.
The most significant finding was that the medical professors were unfit. They were doctors who were largely burdened with patient care and paid little attention to their training duties. Their mastery of science was lacking and they lacked a record of accomplishment in research. This is certainly not the kind of teacher you want for your doctor.

The Full-Time Medical Professor
It is not any wonder that the most important and controversial prescription was that all medical schools should have full-time medical professors. They were to dedicate their entire lives to research and training. They were to be not just clinicians but scientists as well. They were to be paid a full-time salary to ensure that they would not be tempted to take time away from their core duties of teaching and research. This gave rise to the physician-scientist who dominates the halls of medical academia in the west.
But these professors needed to be supplied with the right students. The report recommended that admission to medical schools should be only for students who have gone through university training before. This is the standard upheld a century later.

Why is this so important?
Undergraduate training is largely a trial phase for most people. Most enter the university as teenagers lacking a concrete conception of their passions, still experimenting, unsure. Many discover their true passions during their university years, often digressing to other professions altogether. After someone has experienced four years of undergraduate training, it is highly unlikely that they would mistakenly apply for medical school. Besides the grounding in science, applicants to medical schools have matured sufficiently to handle the rigors of medical training from the start.

Kenyan perspective
That was more than a century ago. Yet in Kenya today, medical schools admit students straight out of high school. They lack basic lab facilities for scientific training; their libraries are filled with old, out-dated books fit for archives; and they have very little control over how their teaching hospitals are run.

The medical professor
The Kenyan situation is exactly as it was before Flexner, a century ago. The professor in medical schools is a poorly paid doctor who spends half his time threatening to go on strike, and the other half practicing in several hospitals to earn a living. If they attend teaching sessions at all, they are late, tired, distracted, and grumpy. They have little time to read, no time at all for research, and are content to teach with materials from other countries, nearly all American.
Why did Flexner insist on the medical professor as a clinician-scientist and demand that they participate in serious research and the generation of new knowledge?
Because only a person involved in the generation of knowledge can be a teacher at all. The one who has to use other people’s knowledge, who has no interest or capacity to conduct research and generate new knowledge, must be feared tremendously if this is the person who will produce competent doctors for the society. How do the research accomplishments of our medical professors measure against international standards? How many hours of actual teaching to professors dedicate to their students?

Admission requirements
The situation becomes hopeless if this distracted professor is supplied with an even worse medical student out of which a doctor must be produced. Picture that situation. A teenage mind, unsure of itself and of life, transitions from high school to medical school without pause. Those high school grades may be impressive, but they are not the right yardstick for the rigors of medical training. There is absolutely no scientific grounding in our high school education. Teenagers coming out of high school have not learnt how to learn yet. They only know how to memorize facts and formulas, a hopeless strategy in medical training. And adolescence being what adolescence is, decisions on what to do with life cannot stand in the face of the stresses that going through medical training impose. Couple this with the pressure from family and peers, and you get exactly the wrong applicants into medical schools. If the requirement for undergraduate training before medical school seems absurd, if Kenyans cannot accept such a demand, they should also stop complaining about the quality of their doctors. You cannot keep standards low from the beginning then place lofty expectations at the end.

The medical schools
It is doubtful that any medical school in Kenya would survive Flexner’s rigorous assessment. No more needs to be said about the state of medical schools.

Way forward
The wise learn from their neighbor’s mistakes. Everything in the Flexner Report, and everything from the outcome of its implementation should serve as lessons as Kenya expands its training for doctors. If the doctors we have today are deemed incompetent (rightly or otherwise), it is because the training system gave them no chance. The quality of doctors is the direct result of medical training.
We want more doctors. But what we really need is more highly trained doctors. The training and deployment of adequate supply of health workers that comprise an optimal mix of skills must entail scaling-up the capacity and staffing of training institutions, and investing in infrastructure. We should not simply open more medical schools and admit more students. We should strengthen existing training infrastructure. There should be admission standards based on sound foundations and propped by legislation so that any medical school flouting admission requirements will lose its license.
The most recently established medical schools are private, some in for-profit universities. Yet Flexner recommended a century ago that for-profit medical schools are inherently flawed. They could not be salvaged because a for-profit model is incompatible with the moral and economic underpinnings of medical training. The serious investment in equipment, research facilities, competitive salaries for professors, and the ability to attract competitive research grants are not decisions that can be made by a board of directors worried about the bottom line.
Medical schools not only need to be established with the right capacity for training but should also be audited annually. They should be assessed continually for compliance with admission standards, staffing with the right full-time physician-scientists, and participation in the kind of medical research that can hold up against international standards. Those that fail should be struck off and required to meet the standards before their training licenses are renewed. There should exist a regulatory framework that upholds accepted standards of education and practice.

National assessment
A further requirement should be a nationwide test for medical school graduates before they are allowed to proceed to our hospitals. This means that graduates from different medical schools are weighted against a national standard. It should be robust enough to identify deficiencies in scientific knowledge and clinical skills that would jeopardize patients. It should also be set and administered independently of medical schools. This way, it will be a filter not only of unfit graduates but also of unsuitable medical schools.

Role of the Ministry of Health
Desirable competencies must be identified and aligned with population health priorities and any identified skills gaps. Afya House should take the lead in everything in medical education from the beginning to the end. It ought to develop policies for basic medical training and supervise the training itself. There is the example set in Iran, where health care is under the Ministry of Health and Medical Education. The Iranians must have seen something that should be obvious to Kenyans: That trying to control all the different players in medical training across different ministries with different priorities and standards is a nightmare. The responsibility of any MOH in any country is huge and daunting. Yet it gets worse when the MOH has to deal with whatever caliber of professionals it is handed by the education sector.
Afya House is the only office with a vantage view if Kenya’s health workforce needs. It is the central authority of prevalence of diseases in Kenya, demographic patterns, population trends, workforce gaps, and the capacity to use all these data to project future needs. If any utility for this information exists, none can be greater than planning the future of Kenya’s health workforce landscape.

Impractical 
How practical is this reference to American systems? Before dismissing this proposition as inconceivable and preposterous, let us all ask ourselves what alternatives exist if we are to get the quality of doctors we need for the future. If we cannot meet the cost of reviewing our medical training system, how shall we sustain the expense of going abroad for treatment? How can Kenya prevent its own from seeking health care elsewhere as well as gain a reputation as a medical tourism destination?
The very future of health care is riding on the present decisions regarding medical education. Even as MOH seems detached from this matter, there must be a department responsible for human resources. How strong is it? How is it constituted? How much influence does it have over the grand scheme of MOH operations? And as health reforms shape up, is it possible to convince Afya House that, first, it is impossible to reform health care without the necessary quality and numbers of the health workforce, and second, that only a thorough review of medical education will deliver the right workforce quality.
It is likely that everyone agrees medical education needs to be reviewed. But how will it be done? The Flexner Review offers a good example. However, even more, instructive and hopeful is the outcome of its implementation. The taskforce developing strategies for strengthening the health care workforce for UHC, for Kenya’s future, should undertake a thorough review of medical education in the country. It should crisscross the nation to develop an informed work plan on what deficiencies exist and how they can best be repaired. That may sound unacceptable, but everyone should be scared if the strategies for the health workforce are to be developed by a taskforce sitting in a cozy office, or a luxurious hotel room, brainstorming about the future of our doctors.

Next in this series:

Part II: Do medical internships serve the need for competent doctors?

Part III: The tragic tale of specialty training in Kenya

Part IV: A critique of continuing medical education and licensing for doctors

 

Bibliography

  1. Patterson F, Knight A, Dowell J, Nicholson S, Cousans F, Cleland J. How effective are selection methods in medical education? A systematic review. Med Educ. 2016; 50(1):36–60.
  2. Sikakana CNT. Supporting student-doctors from under-resourced educational backgrounds: an academic development programme. Med Educ. 2010. September;44(9):917–25.
  3. Thomas P. Duffy. The Flexner Report – 100 years later. Yale Journal of Biology and Medicine 84 (2011), 269-276.

Notes on Flexner Report

The citation in this article is a review of the Flexner Report. The Flexner report itself is an impressive volume whose actual titled “Medical Education in the United States and Canada”. The interested reader may refer to the original report or the numerous reviews available online.

 

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