Medical Training: a Comment on Comments

 Today is one of those lucky Fridays on which we have a piece to enjoy. The unusual bit about this article is that by writing about this topic I have deliberately broken the first rule of this blog. Know what it says? No author shall write about topical or trending issues. Just like shadow members of parliament claim to have been asked by their prospective constituents to contest for elections, I will also claim that some readers have asked me for my opinion on the issue of the withdrawals of final year students at the Kamuzu University of Health Sciences. 

On a normal day, I would not have taken up the challenge of drafting this article owing to the Richie Online philosophy of prioritizing fact-based opinions over trending issues. I was however sucked into the issue when I saw the quality of the debate on social media. A lot of people have strong opinions with no knowledge of what things are like at the medical school in question. The few who have an idea about what happens there are either not speaking out for one reason or the other or adding emotions to the debate and that is why I will just give some insights of what people need to understand before adding their voice to the debate.  

The practice of medicine is a perfect blend of science and art. To have a full understanding the body’s function, disease processes and how drugs work requires excellent understanding of science. However, to figure out the exact problem the patient in front of you has is a bit of an art. You must think about the hidden clues in what the person in front of you is saying to figure out what condition your patient has and why they are presenting with such at that time. With that in mind, the training of medical doctors and other professionals must be rigorous and foolproof. In motor vehicle mechanics terms, dealing with sick people can be likened to fixing a car while it is still running. As you can imagine, that would be particularly challenging.  

Medical training at KUHeS is aimed at equipping students with both theoretical and practical knowledge that enables the student to handle and treat a patient at the end of their training. The six-year course starts with the Foundation Year also popularly known as premed (premedical sciences). In this year, students study Language and Communication Skills, Biology, Mathematics, Physics, Chemistry and Computer Skills. Students who marginally fail to get the passing mark are allowed to sit for supplementary examinations but those who fail a certain number of subjects are withdrawn outright without the possibility of repeating the year. The logic behind this, as we were told, was that people who could not handle premedical sciences cannot handle basic medical sciences which are essential in medical training. I would agree with that reasoning.  

Then there are the basic medical sciences. These include anatomy, physiology, biochemistry, pathology, microbiology, and pharmacology. The study of these subjects happens in the two years following premedical and is divided into body systems. At KUHeS, the assessment of knowledge in these subjects is done through the integrated exam paper which combines questions from all the subjects.  

Year 3 to year 5 of MBBS comprises the combination of classroom and bedside learning. In this period, students are supposed to do ward work and demonstrate clinical skills as part of their training and this is reflected in their assessment which is divided into three parts: continuous assessment, written exam, and the clinical exam. Students must pass each of these components to pass a particular rotation or department. This means that if a student passed the continuous assessment and written examinations but failed the clinical exam, the result of the rotation is a failure. After passing all the end of rotation examinations, students are also subjected to an integrated examination at the end of the academic year. In the end of the year integrated assessment, students are examined on the material from all the departments they have been through in that particular year, and this comprises of a written and practical examination. If you are to think of it in football terms, the end of rotation examinations are qualifiers for the big tournament of end of year exams. A special type of the end of year exam is the infamous “FINALS” in which final year MBBS exams are examined on the content from year 3 to year 5. You may want to know the reasoning behind this. Patients are whole humans and general practitioners are expected to see a wide range of cases from convulsing children, adults with heart failure to women in labor. A chronically diabetic patient who has an accident and breaks a bone will need the doctor to consider all their needs and so will a psychiatric patient who gets pregnant and needs obstetric care.  

There is one interesting thing about the continuous assessment for the end of rotation: its content. In the first place, students are given logbooks to keep track of the procedures they have performed and observed and all the important cases they have seen in the department. There is also a list of graded bedside and classroom presentations that a student must do but what I found the most interesting was the subjective assessment. As part of the assessment comes in the form of subjective opinions from the senior lecturers and doctors in the department. The reasoning behind it? There are some things that written papers, logbooks and practical examinations cannot assess. Punctuality. Presentability. Attitude. Work ethic. Empathy towards patients. Teamwork. These attributes are observed by the seniors who are directly mentoring the student and if one is found lacking at this end they risk failing and repeating a department regardless of their performance in the other areas.  

There are specific rules that apply in the cases where one fails an exam. As I mentioned, the end of department examinations are like the qualification matches for the end of year exam and students who fail any block are not allowed to sit for the end of year exam. Once they have repeated and passed that department, they are allowed to sit for the end of year exam and then proceed to the next class (or graduate if in final year). Those who fail their final year exams are either allowed to re-sit for the exam or repeat the entire year. This repeating means that they must do all the rotations or departments all over again before having another go at the end of year exam, failure of which attracts a withdrawal.  

The trigger to this article is the social media debate about what is going on at our medical school as rumor has it that there are increased incidences of withdrawals of students in their final year. While some have jumped to the defense of the school and pointed out that medical degrees do not need to be handed out like doughnuts, others have bemoaned the strict and prohibitive nature of the assessments in medical school. From the other narratives that are circulating, some students feel targeted for withdrawal by lecturers in some departments and others have argued that it is wrong to assume that someone can be withdrawn on academic grounds just because of a lecturer’s sheer emotion. I will not comment on the specifics because these things work on a case-by-case basis. I will, however, point out some of the issues that I have with the arguments people are putting out when debating the issue in question. 

Firstly, I would like to address the issue of withdrawing a student in their final year. To be fair, by the time a medical student reaches their final year, they have absorbed a lot of material and been rigorously tested through all sorts of examinations. In the case where somebody has finally managed to pass all the rotations of the final year and qualify for the infamous “finals,” chances are that they will manage to get the passing mark. There are a few cases in which people have failed to do so for one reason or the other, but students make it on the second attempt. There are some peculiar cases, however in which students failed the repeat final exams and ended up being withdrawn, raising eyebrows from other students, and interested parties and leading into suspicions of foul play on the systems and lecturer’s part. On the one hand, one would wonder how one would fail the exam having passed through all the rotations of final year twice and on the other hand you would wonder if the assessment system can be manipulated to target a student. I would say that both situations are technically possible so we should not rule them out when looking at the matter. 

Then there is the issue of lecturers failing students who would have otherwise passed. I have a problem with the way that people have jumped to the defense of the lecturers because we know that our tertiary institutions have lecturers who make a name out of boasting about the number of students that fail their course. It may not be all lecturers, but there are some bad apples that may deliberately fail students for the fun of it. For some, it may be that the lecturers themselves have challenges with teaching and providing formative and summative assessments to students. This may be because the lecturers themselves are doctors whose training is in providing clinical care with little or no training in education. While most have done an excellent job of training other doctors, there may be others who have challenges with calibrating their expectations on what a student should be able to achieve at a particular level of their training. To answer the question of whether a lecturer or set of lecturers can fail a student who deserves to pass, I would give a yes. It is technically possible and cases of such have happened. You may even have examples from your own institution and medical schools are not immune to this owing to the complexity of the nature of assessments.  

The other problem I have had with the arguments surrounding this issue is that people have taken this issue as an opportunity to vent about all the problems that we have with medical education in Malawi. I must confess that it took me a bit of time to separate the issue of the withdrawal of senior medical students owing to my own traumatic experiences as a medical student. The debate about the withdrawal of medical students has led to the resurfacing of issues to do with the hostile teaching methods and intimidation employed by other lecturers, favoritism and sex for grades and other issues. While some of these may be linked with assessment, it might be worthwhile to address them independent of the issue at hand.  

There is a transcript of a student that was allegedly withdrawn circulating on social media, and it has some people wondering why the student was withdrawn after consistently performing well. The question one must ask is whether rules were followed in the making of the decision to withdraw the student because there are clear rules surrounding that. Some have argued that the student in question should head to the courts instead of the social media. While I know some people who have won court cases and returned to college after being withdrawn, such cases take a lot of time, resources, and patience which a lot of people do not have. At the end of the day, you are not guaranteed that your outcomes will be good if you seek the intervention of the courts although I will say that it is one avenue that one can explore. 

There is one question of what alternatives we have for students who fail their examinations in senior years of medical school after amassing huge volumes of medical knowledge. Others have suggested an alternative degree that such students can graduate with to allow them to have a starting point and to participate in other areas of medicine outside of clinical practice like medical education. Alternatively, some have suggested the option of transferring the prior grades and completing medical training in other schools outside the country. Plausible, but not manageable by all.  

At the end of the day, we all agree that there is a problem of some sort in our midst. There will be all sorts of opinions and suggestions as to what can be done and some of the solutions will be radical. All I can suggest is that we debate this critical issue with objectivity. Then are others that are suggesting a change in the “system.” As we think of the best system for ensuring fairness in the assessment of medical students, we should not forget about the importance of ensuring that standards are maintained and the quality of medical doctors coming out of our medical school is not compromised.  We should also realize that this is the best system we have had for years and that even the best systems can be manipulated for personal interests. The challenge here is that of balancing fairness and quality and I think it is fair to say people will always have something to say about whatever system we put in place for this.

To medical students who may happen to be reading this, your training is not easy and will require that you give it your best in every way. You need to demonstrate that you can handle the scientific, artistic, and the ethical demands of being a doctor. There may be issues along the way, but you need to soldier on because your training has never been easy and will never be.  

Let me end it right there.