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.
Basic
training?
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.
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