A hospital-based specialist medical education system must be realized immediately (Kompas, 30/12/2022) given that the university-based education system is considered unable to meet the need for, or the even distribution of, specialist doctors across the country. This narrative was raised by several media outlets at the end of 2022 in relation to the health minister's statement about the plan to reform the national education for specialist doctors.
There is a strong impression that there is a dichotomy between hospital- and university-based education. However, this narrative is not appropriate when used to describe the complexities of specialist medical education in Indonesia. Hospitals are not only complementary to universities providing specialist medical education, and vice versa – the two education systems are interrelated.
Education model
Specialist medical education is inseparable from hospitals. The difference between hospital and university-based education is the managing institution. It cannot be said that one is better than the other because both have a coordinated contribution to implementing education. The government only needs to manage the characteristics of each model so they are centered on the needs of the health system and the situation of higher education in Indonesia.
The educational model is called university-based when the process of admission, the implementation of the learning program and student evaluation are carried out by higher education institutions, in cooperation with one or more hospitals to fulfill the students’ competencies.
The scope of this competence fulfillment is broad because medical schools have the flexibility to work with various educational institutions. In addition, while giving a guarantee of the quality of education and graduates, this model is said to have advantages because supervision is provided by both higher education and health authorities, the potential of shared human resources, more secure financing, facilities and infrastructure as well as strong academic and research support from the scientific community.
Hospital-based education abroad is known as a community-based model managed by a hospital whose capacity is recognized by the medical education collegium.
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This education model focuses on fulfilling health-service competencies with a limited academic and research portion. Clinical coverage focuses on the treatment of diseases within the setting of a hospital work area or health service network. Their loyalty being demanded, medical students are educated by hospital staff who automatically become the teaching staff.
The number of students per hospital is limited, adjusted to the capacity of the hospital. The facilities and funding are fully provided by the hospital. Quality assurance is carried out by hospitals and collegium, which also issue competency certificates for graduates.
Hospital-based specialist medical education is vocational in nature, with the students being prepared to serve within the working area of a hospital. Meanwhile, university-based education places more emphasis on a balance between work competence and academic performance and researching skills to encourage graduates to be able to innovate.
Review on education system
Brazil, Italy, Japan, Canada, Malaysia, Singapore and China adopt university-based specialist medical education, while the United States, Australia, the United Kingdom, the Philippines, Germany and New Zealand implement hospital-based education.
Given the well-performing healthcare practices in these countries, it can be said that the two educational models have produced competent graduates to run health services. So, which is the right education model to deal with the needs of specialist doctors in Indonesia?
Law No. 13/2013 on medical education mandates that Indonesia adheres to university-based education. However, the implementation of this model is considered unable to fully come up against the challenges in the production of specialist doctors because of the necessity for students to meet academic and research competencies, medical schools falling short of meeting the standardization and requirements needed to open specialist study programs and the quota-based limited intake from universities.
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This model is believed to involve too many stakeholders with overlapping policy complexities, which has the potential to pose bureaucratic obstacles to the acceleration of the program to produce specialist doctors.
The hospital-based specialist medical education model seems able to answer the increasing needs of graduates in Indonesia, given its emphasis on fulfilling service competencies. Is this model really independent of the university? The fact is the collegium structure in Indonesia consists of lecturers representing different universities. They have the knowledge and expertise in carrying out university-based specialist medical education.
The hospital-based education model requires long-term investment in order for hospitals to become learning spaces that meet the standards as a self-sustained education provider. This is a tough challenge considering that the majority of hospitals in Indonesia were originally designed purely for healthcare services. With this long-established mindset, individually and organizationally, to solely provide health care, it is difficult for hospitals to accommodate the presence of educational and research activities in a short time.
To become a self-sustained education provider, a hospital will need to increase its educational expenditure, which remains an obstacle for many teaching hospitals. In addition, standardization and regulations need to be in place on the national or regional level so that hospitals are able to carry out the educational process independently. Without adjustments to the standards and regulations, the management of specialist medical education will lose a quality control mechanism, which subsequently will affect the programs to produce qualified medical specialists.
Integrated architecture
It is time for university-based specialist medical education to be integrated with several elements of hospital-based education. Through this integration model, medical specialist education will optimize the quota input from universities based on learning assignments.
This model is in line with the health minister's plan to increase the number of scholarship recipients to 2,500 specialist medical students this year (Kompas, 2022), and to optimize the educationa process so the output can immediately meet the needs of the seven basic specialist programs in the regions.
The educational process of this integration model can be promulgated in regions through the Academic Health System (AHS) concept. The government needs to calculate the need for specialist doctors per region to be assigned with the production of graduates at the designated medical schools. This should be done through a consortium collaborating with local hospitals as educational vehicles.
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This model opens up opportunities to expand the educational network between medical schools and hospitals. It supports the additional establishment of specialist medical education centers in Indonesia, which will also increase the student quota, monitor the educational process optimally, cater to the needs of doctors and create a sense of belonging among local stakeholders who will then be willing to contribute to solving health problems in the community.
The government needs to regulate the spread of healthcare centers to guarantee an even distribution of specialist doctors. Mandatory service for graduates are still relevant considering that the government subsidy is quite significant compared with the paid tuition fees. Compensation for specialist medical education students, as mandated in the 2013 Medical Education Law, is deserved considering the mandatory healthcare services they will have carried out as doctors during their specialist education.
Increasing specialist medical education programs requires coordinated cooperation among stakeholders. This education not only focuses on accelerated quantity, but also the quality of education and graduates with students and graduates being stimulated to develop academic knowledge, clinical competence and healthcare service innovation for the future.
Ova Emilia, First medical education professor in Indonesia and chancellor of Gadjah Mada University
This article was translated by Musthofid.
