Wednesday, November 2, 2016
Cambodia - Building a medical system without a foundation?
Among Cambodia’s 11 registered medical schools, many lack basic resources for hands-on training – including cadavers. As a result, instructors, doctors and students worry about the future of the profession in a country already distrustful of its health care system
In 2014, the University of Health Sciences (UHS) – Cambodia’s leading public medical institution – was forced to stop using human cadavers for its medical training and substitute the corpses with live pigs.
The Kingdom has no law on the donation of corpses to science, and police feared the cadavers might have been murder victims.
The university only had four cadavers at the time, and they had begun to decay, says Dr Nhem Aklinn, the head of the UHS simulation lab. The formaldehyde they were using to preserve them was toxic, causing health problems among students and professors. The odor wasn’t helping, either.
So now, just once or twice a year, the Kingdom’s advanced medical students administer anaesthesia, perform surgery and try to control the bleeding on the pigs. If they wake up, the medical students have “done well” – although their long-term prognosis is unknown, Aklinn says. But for now, the pigs will have to do the trick.
It’s a gruesome illustration of the problems with Cambodia’s medical-training standards. Students and experts tell Post Weekend that it’s time the government take a closer look.
The UHS medical simulation lab has mannequins, but no cadavers. Athena Zelandonii
A lack of human resources
Under the Khmer Rouge regime, doctors were killed, hospitals shuttered and medicines banned. Cambodia began to rebuild its medical infrastructure in the 1990s.
But from the selection process for medical school to the curriculum itself, and from the qualifications of university faculty to the regulation of licensed doctors, Cambodia’s beleaguered health care system continues to struggle. And many don’t trust most of the country’s doctors, with those who can afford it, Prime Minister Hun Sen among them, choosing to seek medical care abroad.
“[Those measures] are 100 percent in question,” says Cambodian-American doctor Mengly Quach, a critic of the country’s health care. Without proper training, he says, “[the doctors] are kind of being licenced to kill”.
There are 11 medical schools nationwide – two public and nine private, according to Ministry of Education spokesman Ros Salin, and around 20,000 medical students in the Kingdom. Seven of the private schools have been founded in the past five years.
The private institutions tend to have more resources. The private school Post Weekend visited this week has its own teaching hospital and a few cadavers, though not enough to train all of its future doctors.
It is common practice to use animals for advanced medical training, but there is sometimes no substitute for human cadavers. Some pig tissue and organs are similar to those of humans: on a recent morning in the UHS lab, advanced surgical students practised coronary bypass surgery on pig hearts.
But experimenting with pigs can sometimes reach a dead end. “It would be better if we had fresh cadavers for training, Aklinn says. “When [the students] learn how to repair a knee joint, it’s difficult to learn without real cadavers.”
Mam Bunsocheat, the vice dean of the faculty of medicine at UHS, says that establishing a cadaver or organ donation law in Cambodia would be “controversial”, given Buddhist belief in reincarnation.
Advanced surgical students practice a coronary bypass on a pig’s heart. Athena Zelandonii
People are concerned about what could happen to them, or their relatives, in the next life. “Cambodians [believe] that if you… cut a body part, during reincarnation, [the person] will be missing a body part,” he explains.
UHS has mannequins in its simulation labs, and the school recently purchased a 3-D, digital human cadaver designed in the United States that cost about $150,000 to assist with training. (Instructors, in turn, still need to receive their own training on the 3-D cadaver.) The cadaver can turn 360 degrees, and students can cut into its tissue with a virtual knife.
But there’s not even enough space in its simulation labs for the 250 new students accepted to UHS each year.
Shrouded in criticism
The Ministry of Health has faced recent criticism over physicians’ ethics and qualifications. In August, Dr Beat Richner – the head of the Kantha Bopha foundation – issued an open letter requesting that the government develop an exam for doctors who work in private clinics, as well as to close the private practices of those who fail to pass that exam.
The letter was prompted by the hospitalisation of 447 severely ill children over the course of one weekend, with 146 of the most severe cases transferred to Kantha Bopha’s hospitals. Most of the kids were misdiagnosed, or had been treated incorrectly, Richner said.
Currently, there is no licencing exam for medical professionals in private or public practice. Physicians are required only to register with the Medical Council of Cambodia – the sector’s independent governing body – with a valid medical diploma and criminal clearance.
In July, there were 4,990 doctors registered with the council, up from just 2,472 in 2015. But trust remains a problem. “We all agree that the trust [of doctors] is quantitatively low,” says Chheng Kannarath, the council’s deputy secretary-general.
Kannarath says that the sharp increase in registration could be attributed to increasing awareness of regulations among doctors; the council has been conducting professional development workshops in the provinces.
UHS lab manager Nhem Aklinn says it lacks resources and funding. Athena Zelandonii
But – at least for now – the council can’t do much, even with registered doctors. Its complaint system is limited by a lack of resources for investigations. “So far, no doctor has been officially disciplined by the council,” Kannarath says. “But there are cases under investigation.”
Unlicenced practitioners still proliferate. After a 2014 HIV outbreak in Battambang’s Roka village caused by an unlicenced doctor using tainted needles, the government shuttered 1,368 unlicenced providers. But early this year, ministry estimates suggested that another 1,700 unlicensed clinics were still operating.
According to a 2014 report by the World Health Organization, Cambodia had a total of 18,596 health professionals in public clinics, with general medical practitioners accounting for about 2,000 of them. The number of health professionals is projected to swell to 31,978 by 2020.
Medical schools need more rigorous selection processes, says Quach, the Cambodian-American doctor. And the faculty, training and curriculum need to be reconsidered. Students often train unsupervised, Quach says.
That’s even if there is equipment available. Students Post Weekend spoke to say they often don’t receive hands-on training until their last few years of school, and there is usually not enough equipment in the simulation lab for all of the students.
Students also complain of the theory-heavy lectures they sit through.“We have more than 100 students per class,” says Phang Veng An, a second-year medical student at UHS. “We don’t have a lot of interaction between the students and the teachers.”
Older lecturers teach in French, while younger ones speak English. And Khmer is still used in the classroom. “Teachers don’t even understand what they are teaching,” An says.
At UHS, Bunsocheat and Aklinn both acknowledge that training hours and space are limited, often by funding. Advanced students only spend two hours in the lab per week, they say. And those are only the 180 students participating in an international pilot program each year.
Prior to the pilot program, no students received hands-on training until their fourth, fifth and sixth year, when they are sent to an outside hospital to train with “real patients.”
The simulation lab’s virtual cadaver cost around $150,000. Athena Zelandonii
Pou Vichet, a UHS medical student, says: “It’s a bit too late.”
“If we don’t even know how to take blood pressure or give injections, how will we be able to carry on our duties?” he asks. “We need to know what doctors do at a hospital. It’s not easy if you don’t see it.”
Dr Chap Modich, a doctor at Mercy Medical Center Cambodia, a private hospital, says they select two or three residents per year. Most of the time, hospital staff need to provide refreshers on the basics: anatomy and how to take down a patient’s medical history.
“Mostly, they don’t have any hands-on experience,” he says. “When students go to the hospitals, no doctor can monitor to make sure they’re doing the right thing.”
And those studying in public hospitals don’t have “enough equipment,” says Sopha Chum, executive director of the Health and Development Alliance, which seeks to improve access to quality care.
Private medical school students tend to fare better, Chum says, based on his observation. Classes are smaller, and the curriculum is malleable. “At the public school, it is difficult to update the curriculum,” he says.
The International University (IU) – a private institution – is a step ahead of other Cambodian medical schools, says Dr Ojano, its president.
Two hundred students are admitted annually to the medical faculty, its “most popular”, and IU – which has it’s own teaching hospital – recently passed the first step in an accreditation process for ASEAN medical schools.
“It’s not easy to run a hospital, but we can,” Ojano says. “It’s important to teach the medical students.”
But even IU has room for improvement. Their simulation labs reach all medical students, but the school only has eight cadavers – and they aren’t cutting it, says Vouch Phisith, IU’s deputy director for international affairs.
Without an established donation law, the bodies could also be ethically loaded. In 2012, the school requested special permission from the national and municipal police to use cadavers. The school routinely borrows bodies of the relatives of poor families and then returns them, along with the funds to cover their funerals.On Wednesday morning, at least one of the cadavers seen by Post Weekend looked fresh.
Building a solution
UHS student Veng An says “there are a lot of things to improve” at his medical school. The budget for public medical institutions is overseen by the Ministry of Health’s budget, according to the Education Ministry’s Salin. Officials at the Ministry of Health did not respond to repeated requests for comment for this story.
But Bunsocheat said the university had this year seen improvements in training, and there are hopes for a physical solution on the horizon.
“Our dream is to have our own university teaching hospital,” says Dr Sansothy Neth, another administrator at UHS. “We plan to review our curriculum and add more practice [time] for students.”
Neth says the government has purchased land to build the hospital, though he couldn’t confirm where, and officials are currently studying other models.
“We are also trying to find partners for funding,” he adds.
(Bunsocheat points out that if the training hospital were up and running, Cambodia could import cadavers.)
UHS has received some French support in medical training since 1996.
Julien Aron is a technical expert who advises the international pilot program, where students are able to get simulated clinical practice. He hopes the new, active methodology will bring about change. “There are still some old methods of teaching,” he says. “But UHS is willing to open the lab to all students in a year.”
But whether or not the introduction of simulation practice will help improve the quality of doctors in Cambodia remains to be seen. Vanna Chetra, 23, going into his sixth year of medical school, say he’s seen a difference from his earlier years, when he only learned from “books and lectures.” During a recent morning, he was doing clinical training with younger medical students.
“We are fighting hard to show [people] that we can do this – that we can do better,” he says.