Doctors stomp on private med students

The body that regulates doctors is refusing to acknowledge Sri Lanka’s only private medical school whose first batch of graduates are due out in May 2016

Thirty years ago, the government took over a private medical school by deploying the army in the guise of protecting it against Marxist insurgents, who with the government doctors’ union wanted it shut down.

Today, the first medical graduates to be qualified from Sri Lanka’s only non-government medical college may not be accredited or receive internships here, which are crucial for their being able to become doctors and practice medicine here or overseas, as a standoff between the doctors regulatory body and the owner of the private med school intensifies.

The Hippocratic Oath – taken by all doctors – says, “I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.” It does not distinguish between where the medical students hail from, be it Sri Lanka or Russia, or private or state medical college. Yet, that is exactly what is taking place in Sri Lanka.

From the outset, six years ago, when the South Asia Institute of Technology and Medicine (SAITM) welcomed its first batch of med students, the private med school has struggled for official recognition. In stages, the Ministry of Health and the University Grants Commission, the regulator of the country’s universities,  officially recognised the private med school, and its Bachelor of Medicine and Bachelor of Surgery degrees, a doctor’s basic qualification popularly referred to by the acronym MBBS. To the Sri Lanka Medical Council, however, the MBBS programme followed by SAITM med students will not qualify them to intern here. This means they cannot accredit themselves with the council and practice in Sri Lanka; and to do so is a criminal offence under the country’s laws.

Dr Neville Fernando, a surgeon, founded SAITM with a Rs3 billion investment (including a Rs2 billion teaching hospital with 850 beds) to offer degrees in IT, media, engineering, business, finance and of course medicine – because medicine was his passion. He had sold his family-owned Asha Central Hospital for Rs1.6 billion several years ago and divided the money among his children, but when the government invited the private sector to invest in higher education, he asked his children for the money he needed to set up a university.

“There are two groups opposing us,” he explains, “The medical council and the government doctors’ union (Government Medical Officers’ Association, popularly called the GMOA). They want to keep the profession to themselves because they can mint money with private practices. There is a shortage of doctors in the country, and these people want to keep the profession closed and all to themselves.” He questions, “If private education is unacceptable to them, how is not also private practice?”

The Sri Lanka Medical Council and GMOA comprise doctors educated by the free education system paid for by the people and employed at state-run hospitals where healthcare is mostly free. However, a majority of them have built lucrative private practices, which they are allowed to engage in outside official working hours.

Of the 15 state universities in Sri Lanka, only eight have medical faculties. Competition to get in is tough. Of the total number of students qualifying at the Advanced Level examination in science subjects (biology, chemistry and physics), less than a third will be allowed into the state university system

Private investment in higher education emerged in Sri Lanka during the last two decades. At first, these institutions prepared students to transfer to foreign universities for the final year, or two, to complete their degrees. In the last decade, these global universities accredited their local partners to teach and administer their university examinations, making it possible to graduate from a top university without leaving the country. Business, IT and Master’s degrees in business (MBAs) were the most popular qualifications here until SAITM introduced its medical degree six years ago.

Before SAITM, only state universities offered medical degrees at no cost to students under the free education system. Of the 15 state universities in Sri Lanka, only eight have medical faculties. Competition to get in is tough. Of the total number of students qualifying at the Advanced Level examination in science subjects (biology, chemistry and physics), less than a third will be allowed into the state university system. Demand for medical education is high, not least of which is because of its ‘status’, but also the lucrative private practice, perks and power that doctors can sometimes command.

As a result, over the years, parents who could afford to do so sent their children overseas to study medicine. An MBBS qualification takes two to three years longer than any other degree programme and is very expensive. To become a doctor, med students must also complete a year of internship at a hospital.  Private medical colleges can help bring down costs by offering foreign degree programmes here.

Three decades ago, Sri Lanka had a shortage of doctors, where for each doctor, there were 6,000 people in the population. Things have improved over the years, and today there is a doctor for every 1,100 persons in the country. But according to Fitch Rating Lanka, a credit rating firm, compared with the world average of 670 people per doctor, demand is growing for doctors and better medical care in Sri Lanka.

With the government’s limited ability to set up medical schools or expand existing ones, the private sector must play a role. Fernando rose to the challenge and set up SAITM in 2009, but established doctors dogged his every move. First, the Medical Council said it cannot recognise SAITM because it was an unaccredited private med school. Then, when Fernando accredited the school with the Nizhny Novgorod State Medical Academy of Russia whose degree is recognised by the Council, it claimed that it only approves of the programme delivered in Russia and nowhere else. Fernando has spent the past seven years fire-fighting the Medical Council, and things have got nasty. SAITM’s first batch of doctors will graduate this May, but the Medical Council in a public notice said it will not allow them to intern or practice in Sri Lanka.

Because it is a self-regulatory body, objectivity and rationality can and does fall by the wayside at times. Even in a more mature economy like the UK, its self-regulatory body of doctors has been found to be overly strict on certain members they don’t like and lax on friends. Seeing the dangers of self-regulation, the UK doctors’ regulator now has half its members from outside the medical profession and it is answerable to the parliament.

SAITM is Sri Lanka’s only private medical college, but it is not the first. The first private medical college in Sri Lanka lived a short life and came to a violent end.

In 1980, the College of General Practitioners of Sri Lanka invested in a private medical college called North Colombo Medical College (NCMC) in Ragama. Its founders invested in the college because they felt the doctor-to-patient ratio was too low at the time, with one doctor for every 6,000 people. State universities were only turning out 240 doctors each year, and 40% of them were migrating in search for better opportunities overseas.

The doctor’s union and Marxist political party the Janatha Vimukthi Peramuna (People’s Liberation Front), popularly known as the JVP, opposed the NCMC on the grounds that education must remain free. The JVP threatened faculty members with death if monies collected from students were not returned and bombed the administrative office.

Amid mounting protests, the NCMC was able to gain affiliation with the University of Aberdeen, UK. Founded in 1495, the university has a rich tradition and produced several notable alumni like Patrick Manson who was the first to propose that malaria was caused by mosquitos and six Nobel laureates. But this was not enough to appease NCMC opponents about the new medical college’s credentials.

The doctors’ union forced the government to appoint a committee to look into the matter. In 1989, the army moved into occupy the buildings due to JVP threats. One morning, soldiers surrounded the building and just like that, the NCPC was taken over by the state. Its teaching hospital still functions as the Ragama Teaching Hospital. Many doctors who got their degrees from NCMC rose to the pinnacle in their chosen fields of speciality in the medical profession.

Fernando and his med students are leading a harassed existence. No sooner did Fernando welcome the first batch of med students in 2009, trouble started. He had advertised in local newspapers that the SAITM medical degree programme would be monitored by the Medical Council for quality standards. The Council reacted strongly, accusing Fernando of misinforming the public. It released newspaper notices of its own explaining that the Council had no jurisdiction over private medical colleges and did not evaluate or monitor quality standards of Fernando’s medical degree programme. This was a blow to the new university that was seeking to attract students to a field closely guarded by the profession where public expectations were high. Prospective students needed to be assured that the degree programme would not turn them into quacks and, most importantly, help them get jobs.

The Medical Council was established by the Medical Council Ordinance of 1924 as the regulator of the profession overseeing academic and professional standards, discipline and ethical practice by medical professionals, who must be registered with it to practice in Sri Lanka. Most countries have similar self-regulatory authorities for doctors. In the UK, all doctors must register with the General Medical Council. In the US, doctor registrations and regulation is handled by each state. Doctors in both countries are reviewed periodically to prove professional development and skills.

Fernando sought the council’s views on what needed to be done to get the Sri Lanka Medical Council’s stamp, only to be told that the existing laws were explicit – the council had no jurisdiction over local private med schools. A meeting in 2010 with council officials to sort out the problem went badly. Fernando argued that his college had the full backing of the government and demanded that the Medical Council withdraw its notices. He threatened to complain to the Ministry of Health if they did not comply.

The Council stood its ground. Fernando knew that without their approval his graduates will never be able to work in the country. Threatening legal action against the Medical Council, he walked out on them. He was angry and frustrated, but little did he realise his problems were only starting.

When he came up with the idea of setting up a private medical college, he had first gone to the regulator of the university system, the University Grants Commission (UGC), only to be told it did not have jurisdiction over private universities. He was directed to the country’s investment agency, the Board of Investment (BOI), instead.

The BOI approved Fernando’s investment application for a private university, which was named South Asia Institute of Technology and Management (also SAITM). In his application, Fernando had specifically stated that he would offer degrees in health sciences, which covers the gamut in the medical profession, from doctors’ MBBS, dentistry, psychiatry and nursing. The approval came with a condition, that before enrolling medical students, the private medical college should affiliate itself with a recognised foreign medical degree-awarding institute.

Fernando chose Russia’s Nizhny Novgorod State Medical Academy and an agreement was signed setting up his medical college as an extension of Nizhny. The name of the university was changed to South Asia Institute of Technology and Medicine. Later, the Medical Council and doctors’ union would accuse Fernando of misleading the BOI.

On paper, Fernando’s choice of foreign partner seemed good. The Medical Council recognises the standards and medical degree offered by Nizhny Novgorod State Medical Academy. But this only opened a can of worms. The Council is mandated to maintain a list of foreign medical degrees that meet its standards. It recognizes a foreign university after a process of evaluation that includes an on-site visit. At present, it recognizes over 200 medical colleges worldwide, from Armenia, Russia, Bangladesh, Nepal, Nigeria, India and China. Students that are awarded MBBS degrees from these universities are then allowed to sit for an exam before they can practice in Sri Lanka. If they studied in a foreign language, they need to spend four months familiarising themselves with English terms. Nizhny Novgorod trained doctors in English.

While the Medical Council recognised the MBBS degree awarded by Nizhny Novgorod, it refused to recognise SAITM because it was located within the country. “The Sri Lanka Medical Council has recognized the degree awarded by Nizhny Novgorod State Academy of Medicine of Russia Federation for the course of study conducted in Russia for a six year period. Therefore, the Sri Lanka Medical Council (SLMC) does not recognized any other programme conducted in Sri Lanka or elsewhere by the Nizhny Novgorod State Academy of medicine of Russia Federation,” the council claimed in its 2010 annual report.

Fernando found this absurd and continued to recruit med students. After all, the regulator of the university system recognised his degree. It was just the professional body standing in the way now. He invited the medical Council to visit the campus in a bid to finding an impasse.

Meanwhile, the regulator wrote to the BOI asking for particulars of Fernando’s application. In response to a direct question from the regulator whether Fernando indicated if he was investing in a medical college, the BOI said ‘No’, but said health sciences was listed as one of the degree programmes. The doctor’s union then used this to falsely accuse Fernando of misleading the BOI and thus cast the med school in a sinister light. Recalling this episode, a visibly disgusted but amused Fernando said, “This is the calibre of doctors we are dealing with, they don’t even understand the term health sciences”.

The Medical Council, doctors’ union, state med students and Marxist JVP politicians upped the ante on their demands for the closure of SAITM. This forced the government to appoint a committee to investigate the legitimacy of the private med school. Meanwhile, the Ministry of Health issued a gazette notification in August 2011 that helped Fernando’s cause, but also complicated matters further. The government used the gazette notification to say it recognised the private medical college as a medical degree-awarding institute subject to certain conditions which were to “provide a commitment, which is continued and uninterrupted”, to make available “the facilities to be put in place relating to the conduct of clinical training by the faculty either at its own teaching hospitals or an agreement with any other teaching hospitals; improving clinical exposure for the students”.

Two years after establishment, SAITM now had 200 med students.

For Fernando, investing in a private medical college was proving to be a risky business in Sri Lanka when various ministries and agencies operate in silos with overlapping jurisdiction. Matters become worse where there was no clarity on laws and regulations. Despite being recognised by the Health Ministry and UGC, the Medical Council also opposed the private medical college on the grounds that it did not have its own teaching hospital. So, in 2012, Fernando signed agreements with three state hospitals at Homagama, Thalangama and Avissawella, all three around forty minutes to an hour away from downtown Colombo, for clinical trials as the Health Ministry had wanted.

The doctors’ union threatened strike action against the move, a popular manoeuvre of the union. (In 2015, they threatened to put patient lives at risk to strike because the government stopped issuing duty free vehicle import permits to doctors.) Fernando says he did not want to risk lives, so he backed down. His students were sent to private hospitals instead. But the union continued to harangue him on the grounds that none of these were teaching hospitals.

Fernando had already begun work on SAITM’s own teaching hospital funded by a Rs2 billion Bank of Ceylon loan. When the doctors’ union found out about this, they tried to sabotage the loan. “They tried to block the loan thinking it was a grant. Nothing comes free. I have to payback Rs50 million each month,” Fernando says. The hospital would be completed by 2013.

Meanwhile, the government committee on the private medical college completed their inquiry in early 2012.

The committee appointed to inquire into the legitimacy of SAITM included two senior officials from the Ministry of Health, a doctor and a lawyer; an academic from the Post Graduate Institute of Medicine; and a former Director of the World Health Organisation. It echoed the Medical Council’s complaint that Fernando’s application to the BOI was flawed as it did not mention that SAITM would award degrees in medicine. It is unclear whether the committee realised that this was a moot point since the BOI had already confirmed that SAITM had said it would offer degrees in health sciences.

What was important about the committee report was the recommendation to the medical council that it should monitor SAITM and evaluate its programme, which the council had refused to do until then

The committee also pointed out that the BOI had wanted Fernando to get approval from the Ministry of Health and partner a foreign medical college before enrolling students. The committee claimed Fernando had not done both of these. This claim was another moot point given the August 2011 gazette recognising SAITM as a medical degree-awarding institute, subject to satisfying specific conditions and the agreement with Nizhny Novgorod State Medical Academy of Russia whose degree the doctors’ regulator recognised.

What was important about the committee report was the recommendation to the medical council that it should monitor SAITM and evaluate its programme, which the council had refused to do until then. “It is desirable to commence the process as soon as possible since students have already been admitted after the gazette notification and it is necessary to monitor the academic and administrative conditions,” the report said.

The ball was now in the Medical Council’s court. Fernando’s private med school already had official recognition and was close to being recognised by the profession. But the regulator still maintained that, unless the parliament changed the laws, it had no jurisdiction over the private med school. Fernando persisted.

In 2012, Sri Lanka’s celebrated physician, Dr Carlo Fonseka, president of the Medical Council, in a public statement said the council would indeed monitor SAITM and its teaching hospital. But he could not guarantee the outcome, and there was also the matter of med students who had been enrolled before the Health Ministry officially approved SAITM in 2011. Fonseka suggested, “Why not send the students to Russia instead. It will make no difference if the course they are following here is the same as in Russia.” If the same logic applied, the course would be valid here too.

With the teaching hospital finally complete in 2013, Fernando invited the Medical Council to visit the campus and teaching hospital. The delegation that conducted the inspection had a bad report to give. It said the private teaching hospital did not provide adequate clinical exposure in terms of the “number of case mix and that exposure to trauma in surgery, common surgical emergencies, obstetrics and gynaecology, as well as exposure to emergencies in adult medicine and paediatric were lacking”. Fernando argued that his med students got clinical practice at private hospitals such as Nawaloka Hospital, Asiri Hospital, Oasis Hospital and Ninewells Hospital, so they were exposed to a good mix of cases.

In a press statement, Fernando again pressed his point that the regulator was duty bound to register his med school because the higher education regulator and Health Ministry had done so. He accused the doctor’s regulator of double standards. “They (the regulator) register foreign universities without proper guidelines, while imposing all the regulations on us,” he said. Instead, the Medical Council advised the government to suspend the med school’s MBBS programme, leaving 800 med students helpless. Now desperate, Fernando once again turned to government hospitals.

The doctors’ union opposed this move, and were joined by vocal state med students and threatened strike action. Fernando could not back down like the first time.

A group of private med students filed a petition before the Supreme Court that their fundamental rights were being violated. The court ruled in their favour. The doctors’ union claimed in the media that allowing private medical students to train at government facilities was akin to misappropriating public property, a criminal offence, not mentioning that state universities and government facilities were paid for by all Sri Lankan citizens even though only enjoyed by a few.

The court did not agree with the union, and in December 2015, it instructed the Health Ministry to allow SAITM med students to undergo forensic medicine, psychiatric medicine, public health and community medicine training at the Avissawella Base Hospital and the Kaduwela MOH. Each student was required to pay Rs50,000.

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The South Asia Institute of Technology and Medicine at Malabe

The doctors’ union says it will not cooperate with private medical students visiting public hospitals. University student unions, who need no excuse to do so, took to the streets decrying what they claim is a threat to free education and free healthcare.

“As far as we are concerned, the court had settled the matter. It is over. If the GMOA (doctors’ union) interferes, they will be in contempt of court,” Fernando says.

Through all these hurdles, Fernando will see his first batch of MBBS-qualified doctors pass out this May. He had found ways to satisfy the doctors regulator’s requirements at every turn. To him, the clinical training issue was the last major obstacle. But he was wrong.

Fernando is playing by the book, he says. For a high risk Rs2.8 billion investment to work and deliver good returns, you can’t afford to be reckless. For his med school to be a success, the public must have trust in the doctors produced there, this is why official approval is so important.

The academic staff and students of the private medical college are required to be screened by the University Grants Commission. “I have no control over who I recruit to the faculty or who enrols as a student,” Fernando says.

The campus and teaching hospital (the Dr Neville Fernando Sri Lanka-Russia Friendship Teaching Hospital) are held by a family trust. Fernando says he has given the University Grants Commission, the regulator of the state university system, a 51% equity stake. “My family will manage the trust and control the board. If there is a dispute among the children at any given time in the future, the campus and hospital will pass on to government management,” he says.

Fernando believes the Medical Council overstepped its boundaries when the UGC and Ministry of Health had given his medical school official recognition. “We have filed a case against the council as they have exceeded their mandate,” he says.

The feud with the professional regulator became personal in 2015. The battle was fought in the media and it was nasty.

The doctors’ regulator chief Carlo Fonseka publicly claimed Fernando’s teaching hospital was responsible for the death of Ven Maduluwawe Sobitha Thera, a Buddhist monk who successfully campaigned for a change in government in January 2015 by uniting political and civil organisations behind a slogan of good governance. The monk had been treated at the med school’s teaching hospital a few weeks before he passed away in a hospital in Singapore. Fonseka charged that the private teaching hospital had been negligent and caused a bacterial infection that led to the monk’s demise. The incidence of negligence of medical council-accredited doctors in government and private hospitals is surely much greater; should state medical faculties be shut down then?

Fernando said he would sue Fonseka for Rs500 million for hurting the reputation of his teaching hospital. Fernando said the monk had been airlifted from his teaching hospital to a private hospital in October 2015. He was admitted for rehabilitation and not treatment. “He was in good health when he left the hospital,” Fernando says, claiming he had a close relationship with the monk for nearly three decades. Sobitha Thera had visited his teaching hospital several times, the last was to rest under the care of his personal physician. “There was no treatment or surgery of any kind,” Fernando says.

It was after this spat between these two doctors that the medical council issued the January 2016 warning to private med students that they will not be able practice medicine in Sri Lanka. Fernando wants to continue the fight. He says his each of his 800+ students will petition the Supreme Court until their grievances are dealt with.

People also fail to realise that quality matters to a private long-term venture like SAITM. If its doctors consistently make life-threatening mistakes, public trust will be lost and the med school will not get any more students. This will result in the investor losing a lot of money

Fernando has already invested Rs2.8 billion in the project, and after seven years, he is not certain whether it will survive simply because his own profession is blocking him. If the private med school is falling short of standards, surely it is not beyond the profession to fix them? Besides, its faculty comprises lecturers from state medical faculties who have retired or are on sabbatical, so any shortfall in the education provided by SAITM must also hold true for state medical graduates. Says Fernando, “To criticize my faculty is to criticize their own lecturers,” with many of them mentors and colleagues of the Medical Council and GMOA members.

People also fail to realise that quality matters to a private long-term venture like SAITM. If its doctors consistently make life-threatening mistakes, public trust will be lost and the med school will not get any more students. This will result in the investor losing a lot of money. This is something state medical schools don’t have to worry about because they are sponsored by the state and it is their graduates that regulate the profession.

The problem, in a nutshell, is best articulated by the committee appointed to investigate the problem in 2011. Ironically, it came in the form of a recommendation: “any future application for a private medical college must be evaluated by a joint committee comprising representatives from the Ministry of Health, the BOI, the medical regulator and the UGC, consulting the government doctors’ union and related professional bodies”. This is not good enough.

Fernando took this merry-go-round for seven years and he is still riding it, and for all it’s worth, his first batch of doctors will be unemployed this May. Instead, this committee should formulate clear policy and processes before investors get here. The doctors’ union may be vocal, but why consult them when they are not a professional body but a trade union, whose members the Medical Council should discipline when they bring health services to a standstill with their strikes.

The Hippocratic Oath, which goes beyond professional conduct, is clear on this – doctors should not play god. The Medical Council here is playing god with the lives of private med grads and the future of medicine in the country. If Fernando’s venture is allowed to fail, no investor may be willing to step in to fill the void again.