Celebrating the Golden Jubilee of Carlo Fonseka, a Medical Educator


Sunday Island (SI): Congratulations! We understand that you are celebrating your golden jubilee as a medical educator.

CF: I am celebrating nothing. It is a fact that I joined the Physiology Department of the Faculty of Medicine, University of Ceylon in 1962.This means that 50 years have passed since I became a medical teacher.

SI: Given your excellent academic record in the Colombo Medical Faculty, why did you choose to specialize in Physiology instead of becoming a surgeon or physician?

CF: People with much better and much worse academic records than mine have become surgeons and physicians. It is not so much a matter of academic record as of personal interest. If "the proper study of mankind is Man", it seemed to me that physiology, that is to say, the scientific study of how the human body works to keep itself alive and to move about and to have its being, should be the basis of all humanistic studies. Prof. Elsley Koch who taught us Physiology when we started our medical studies greatly inspired me by his erudition and by his personal kindness to me. He focused our attention on the aphorism that "the physiology of today is the medicine of tomorrow". Remember, the Nobel Prize for Medicine is awarded either for medicine or physiology. What continues to fascinate me in physiology is, above all, how the human brain works. For me the human brain is the greatest mystery under the sun. It is the organ with which we think, we think!

SI: When it comes to practical medical education aren’t practising surgeons and physicians better equipped than a mere physiologist to decide on how to train medical students to become doctors?

CF: Of course, they are very important in the training of doctors, but medical education itself has become a specialty and involves much more than imparting practical skills to medical students at the bedside. It is in fact a very cerebral activity. In our country where most surgeons and physicians are so busy working from 8 am to 4 pm in government hospitals and from 4 pm onwards in private hospitals, many of them hardly have any time left to think through the problems of medical education.

SI: As you see it, what are the real issues in medical education?

CF: They are the same issues as in any form of modern education in any discipline. They can be reduced to three: (1) What to teach? (Objectives) (2) How to teach it? (Curriculum) (3) How to find out whether the students have learnt it? (Assessment). The subject of medical education has become rather complicated during recent decades. Fortunately, I had the opportunity of taking intensive courses on medical education in Chicago in 1973 organized by Prof. George Miller; and at the University of Cambridge in 1998.

SI: Given the new developments in medical education, what do you regard as the burning issue in medical education in Sri Lanka at this time?

CF: Without a doubt it is the problem of assessment i.e. how to find out whether those who are licensed to practise medicine are equipped at least with the minimum levels of knowledge, skills and attitudes required to function as safe, effective doctors of acceptable quality. What to teach them has been well defined by experts. As to the question of how to teach it, experience and research have shown that there are many acceptable ways of doing it. The real challenge is how to find out whether medical students have learnt what they should know to perform as competent doctors.

SI: Who set the standards of assessment in Sri Lanka?

CF: According to the Medical Ordinance published in 1928 and amended from time to time thereafter, the Sri Lanka Medical Council (SLMC) is empowered with the maintenance of standards of education relating to courses of study and examinations which entitle a person to obtain registration to practise medicine.

SI: Is it the SLMC which laid down the standards of medical education in our medical faculties?

CF: In the days of the Ceylon Medical College, it was the Ceylon Medical College Council (equivalent to the present SLMC) that laid down standards. However, after the University of Ceylon was founded on the 1st of July 1942 by the absorption of the Ceylon Medical College and The University College, the business of laying down standards became the concern of the Faculty of Medicine, University of Ceylon. The old Ceylon Medical College Council deals with the educational matters of pharmacists, medical laboratory technicians and such important allied health categories. Later on, as new faculties of medicine were established, they became responsible for defining objectives, designing curricula and teaching and examining medical students. To this day the SLMC plays no role at all in conducting the professional examinations leading to the award of the MBBS Degrees of the eight medical faculties in the country. The examinations are conducted mainly by the professors of the medical faculties with the help of consultants in state hospitals. (Some of these consultants may be in the SLMC). The role of the SLMC has been just to register the list of names of those who have fulfilled the academic and other requirements necessary to practise medicine, forwarded to it by the university authorities.

SI: But didn’t the SLMC play a role in conducting the so called Act 16 Examination for medical graduates who had qualified abroad?

CF: Yes. From 1965 up to 1998, the SLMC played a role, not in conducting the examinations, but in organizing the clinical and oral examinations which were conducted by the teachers in the medical faculties.

SI: What happened after 1998?

CF: When more and more medical graduates with foreign qualifications (FMGs) came to sit the Act 16 Examination, the extra burden of examining them became too heavy for the teachers of the medical faculties to bear. They had to give priority to their own faculty students. When it became clear that some of the FMGs did not perform well in these clinical and oral examinations, at the request of the Peradeniya Medical Faculty, it was decided to hold a "Screening Test" in the form of a Multiple Choice Question (MCQ) paper. Only those who scored at least 40% in this MCQ paper were allowed to proceed to the clinical/oral examination.

SI: Many FMGs who had studied in countries such as Russia and China have told us that the written MCQ paper was a formidable challenge to them because they had been trained in countries where very little English was spoken. Is it true to say that their difficulty was not because they did not know enough practical medicine, but because of their imperfect understanding of English?

CF: English must have been a major part of the problem. After 1970 students entering our own medical faculties had had their school education in Sinhala and Tamil. They also had great difficulty in coping with medical education through the English language during their early years in the medical faculties. I remember that in the 1970s when we introduced MCQs into our examination system in the Colombo Medical Faculty we used to provide them with Sinhala and Tamil translations of the MCQ papers. It was hard work, but we did it. I am glad to say that our students did not take us to Courts alleging unfairness and victimization.

SI: When did trouble begin with the FMGs?

CF: In 1999 the SLMC assumed responsibility for setting the MCQ papers. The minimum pass level (MPL) was fixed at 40% and those who passed the MCQ paper were eligible to take the clinical and oral parts of the examination conducted by the medical faculties. Then in 2005 the SLMC decided not only to prescribe but also to conduct the Act 16 Examination, which came to be called the Examination for Registration to Practice Medicine (ERPM). In the "New Format" of the ERPM the minimum pass level was raised to 50% and the number of questions was doubled by introducing the Single Best Answer (SBA) type of questions.

SI: On what basis was the minimum pass level raised from 40% to 50% and various other changes of the ERPM effected?

CF: I really don’t know. Until I became its President, I was never a member of the SLMC. When I was Dean of the Medical Faculty, Kelaniya from 1991 to 1997, I could have represented the Faculty in the SLMC. I didn’t bother do so because so far as I was concerned, the main role of the SLMC was just to register the list of duly qualified medical graduates the medical faculties forwarded to the Registrar. The fact is that although the SLMC was supposed to lay down standards of medical education, everybody in the business knew that the high- achieving academics in the medical faculties were better qualified and better trained than most members of the SLMC, to define the standards in medical education. It is only because most Deans of the Medical Faculties represented their Faculties in the SLMC that there were at least a few specialists trained in medical education in the SLMC. The others in the SLMC included eight members elected by medical practitioners (the vast majority of whom are members of the GMOA) and four nominees of the Minister of Health. Nobody expects most of them to understand the logic of fixing such things as the MPL.

SI: How did the University Grants Commission (UGC) get involved in the ERPM?

CF: In 2009 some 54 FMGs alleged in the Supreme Court that the SLMC had "victimized" them in the conduct of the ERPM. On 30 March 2009 Mr. Shibly Aziz appearing for the SLMC, submitted that the SLMC "having taken note of the grievances of the petitioners, is now agreeable to have the ERPM conducted entirely through the UGC". Accordingly, the Supreme Court directed the UGC to conduct the ERPM.

Coontinued on next week

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