There have been recent exchanges regarding the entry requirements to the medical school at the University of Malta. While the entry requirements to most if not all courses at university are the minimum required, conforming with normative standards, those for the medical course have been quite stringent. Notwithstanding the high grades required however there is no numerus clausus, whereby even the number of students who enter is limited to what used to be called the ‘clinical bed / student ratio’. Last year we had an entry of over 100 students to the first year. They all got the entry grades. Minister John Dalli has expressed his opinion that the medical course should come in line with other courses; and I would add with EU standards. But ‘standards’ here are not dictated by any directive; rather by standards I mean that one should look to our neighbouring countries and not be too shortsighted.

There are a number of issues to evaluate in deciding how many and how students are to enter the medical school. While it is probably true that better grades do not mean better doctors, nor better medical students at that, it is also true that one should see that students have an aptitude for the health care profession characterwise. But this has always been a worldwide problem to evaluate and one has to keep one’s feet on the ground, especially in a small country like ours where it is easy to be accused of nepotism and unfairness. If one has to have faith in the system, the entry requirements must be objective and rigorous – that is, if challenged, one should be able to justify. There is no better system than having the results of Advanced levels. Alternatively one can have a university assessment of one’s own, but this would be in its own turn defeating our purpose.

Yet having an open number (a numero aperto, as it were) has problems of its own. So lowering entry requirements does not necessarily translate into opening the doors wide to allow an unlimited number of students into the course. We have seen that with EU regulations, students can simply pack and leave the country as soon as they qualify. Gone are the days when you had to work two years of housemanship, rotating between departments, before you are given the licence to work. One can do this, with freedom of movement, anywhere in Europe. This means that we pay with our taxes for this. But is this not what happens all over the EU, one may ask? True, but in the EU they do not dish out stipends as we do and perhaps we can consider making students choose between receiving a stipend and working for two years in the local hospital and not receiving a stipend, but being allowed to leave after the course. This will in turn however still create a different standard with other courses, where students are given a stipend and not bound to work with the government afterwards.

One has to keep in mind however that the EU does not bind us to making our own standards, and it has been the experience of many neighbouring EU states that special conditions were made on the medical course. In Italy it used to be the case that the course was open to all. This led to many unemployed doctors. They now have a closed number in all medical schools and therefore the taxpayer does not pay for the education of many professionals without due consideration to the needs of the country. As long as one does not move against the principle of freedom of movement, one can bind people to work in exchange for financial help.

It is a myth that we think there are not enough doctors in our system. We are producing in fact too many. Only last year we had over 100 students enter our first year. This was indeed a record. The reason we may not have enough is the brain drain, which MAM has been talking about for quite some time now. In the private sector there are only too many doctors. They do not work in the national health service for two main reasons: first, the salary is not competitive; second, even if I decide to enter the service, I am not given a grade according to my experience, but have to start at the lowest grade, which newly qualified doctors usually start off at. This creates a situation where doctors engage in state service only if they are forced due to their circumstances.

So paradoxically, if one had to lower the entry requirements to the medical course, unless one is able to cater for hundreds of students at a time, which would mean that people in hospital are invaded with medical students as one will not have an appropriate balance of clinical bed to student ratio, one would have to consider a closed number. The paradox is that with a closed number, even though on paper the entry requirements are low, it would be still very competitive, and one would still require higher grades, actually probably more than today.

Again this has been the recent Italian experience, after their introduction of the closed number system. Entry standards have thus gone up. Conversely, they resolved their ‘numbers’ problem, in primary care by calculating that a doctor may have from 1,000 to 1,500 patients registered with him or her. Simply dividing the population by 1,000 gave them the number of doctors they needed. In this way private practice was killed however, as nobody will go privately when they are registered with a doctor and indeed are free to change their doctors. When a vacancy arises, a call for applications is made and the doctor must go to that area in which the vacancy needs to be filled. Slowly but surely he or she will build the practice. In Italy ironically, family physicians are still not seen as specialist as the World Organisation of GPs and the WHO recommends, but they still have to do three years of vocational training as required by the EU. The control on the number of students did put health care costs down, but family physicians are not so happy with the system as the referral rate to hospital and to specialist has actually increased. One has not only no incentive to treat a diabetic, for example, but in order to benefit from free medicinals one has to go and see a specialist. The GP will then simply be the guy who writes the prescription. One doctor, at a recent meeting I attended, complained that when he introduced himself in a hotel, the receptionist said, ‘Aah. Quello che scrive ricette!!’. Less qualified doctors are choosing family practice and it is envisaged that within the decade they will have a shortage as we have locally in this public sector.

So we return actually to the usual vicious circle. We cannot simply manage by whims or by partial exigencies, let alone by crises. The number of students entering the medical school, the entry requirements, the primary health care and the number of doctors needed in hospital are really all linked to an equation, which changes from place to place according to the needs of the populations and according to time. It has to forecast for the future, taking into consideration the incentives one has to enter a field. There will come a time when Europe will recognise that we need to harmonise health care systems across Europe if we are to promote, and not simply have freedom of movement. One problem I would find if I had to move to another country with my wife and children is to have to find out how their health system works.

The biggest problem, to return to the main argument, is to recognise that stipends are not a right and the government can indeed have a standard stipend for everyone and a bonus stipend for those areas which need to be encouraged more locally. One has no guarantee that students will remain here, but the bonus may be linked to a short contractual agreement to work in the local sector for a while. This is only fair on the tax payer. Malta’s size precludes it from the luxuries that larger states have. Yet even larger states have recognised the need for closed numbers in medical schools, even though they maintain open numbers in most other courses.

The reality is that medicine, somehow, appeals to many. It is perhaps prestigious as a field. Making it difficult has not stopped students. In fact it even creates that challenge which many, at an age when they want to prove themselves, find engaging. Be this as it may, even if we had to lower the entry requirements, unless we bring in other forms of assessing potential doctors, and unless we are ready to handle all those who apply to enter the medical course, without providing them with an environment, which can handle their education (you cannot exactly increase patients!), then one would have to accept that the solution is restricting the numbers, which would in turn still raise the entry requirements on a ‘market force’, as it were.

From an ethical point of view it has always been difficult to choose the appropriate characters of those who have an aptitude for doctoring, objectively. And in reality, at that age, it is probably inappropriate and not valid. The government is also considering allowing other institutions to open medical schools locally. These will be ‘for profit’ institutions but they nevertheless would have to share the hospital beds with the local medical school.

This begs the question why we have an open number. One reason is that we wish to attract people from outside the EU. Again, as long as one treats EU citizens equally there is nothing to hold the university from reserving a number of paid seats for people outside the EU to promote international understanding. When I studied in Florence, the system was still on a numero aperto, but there were 50 seats reserved for foreigners, giving special consideration to those who came from countries where opportunities were lower due to political reasons. Yet one really has to consider whether it is shortsighted and whether this brings in millions. It may be more appropriate to base it on the principle of internationality rather than on money, while still reserving the places for paying students. In any case, the foreign medical school will not be free, and these are surely to compete for these students. We would be at a greater advantage promoting the internationality of our education environment and the excellent facilities that the University of Malta has to offer.

But, although in principle entry requirements should not be stringent, unless you are willing to pay a consequential high price, and unless you keep them high yourself, the market will. One fact is true, that we do not keep our open numbers because the EU forces us. I can live with the idea that someone’s son did not make it into medical school because the competition was too high. I cannot live with the idea that I pay for ten times the number of doctors we need, and yet we still do not find enough doctors to work in the public sector. The idea of EU citizens being equal has never imposed this upon us and we risk the reputation our medical school has for producing good doctors. If you end up with qualified doctors who have not had enough patient contact you produce William Osler’s quandary: to study medicine without books is to sail an unchartered sea without a map; but to study medicine without patients, is not to go to sea at all.

Pierre Mallia is Associate Professor in Family Medicine, Patients’ Rights and Bioethics at the University of Malta; he is also Ethics Advisor to the Medical Council of Malta. He is also former president of the Malta College of Family Doctors.