Medical Education 1990, 24, 319-327
Academic standards and changing patterns of medical school admissions: a Malaysian study C. M . T A N
Department of Physiology, Faculty of Medicine, University of Malaya, Kuala Lumpur Key words: education, medical, undergraduate/ *stand; *school admission criteria; curriculum; educational status; teaching/stand; Malaysia
Summary. Changing social demands made it necessary for the Medical Faculty of the University of Malaya to accommodate students with a wider range of academic experience than before. However, teachers sought to achieve comparable academic standards to those in the West by striving to maintain a close resemblance to the Western model of medical education in other respects. As a result teachers failed to adapt their teaching methods, assessment techniques and curriculum design to meet the educational needs of the students, thus compromising academic standards. Many students lack basic academic skills and do not know how to learn effectively. In order to help students overcome their learning difficulties innovative teaching was required during the first year at university, designed to foster the joint development of knowledge and basic skills. In the case of less well-prepared students who lack self-confidence, a caring and supportive learning environment is crucial to the achievement of meaningful learning. Lecturers needed to become facilitators of learning rather than transmitters o f knowledge. However, teachers’ objective to retain international recognition of the degree, which presumably reflected the importance of teaching, was not operationalized in terms of its incentive structure such that teachers were constrained not to try to fill the new roles demanded of them. It was assumed that academic distinction accrued through scientific research was essential for the achievement of academic excellence. However, under the prevailing circumstances the two aims were mutually exclusive and incompatible and teaching quality deteriorated.
Introduction
The curriculum, instructional methods and pattern of academic organization of the Faculty of Medicine of the University of Malaya very closely resemble the British model even though University admissions policies and patterns of student intake have become very different to those ofthe British universities over recent years. The Faculty of Medicine was established in 1963 as a centre of academic excellence and its medical degree has been recognized by the General Medical Council (GMC) of the United Kingdom since 1969. The Faculty has continued to seek external recognition of its degree in order to facilitate the further specialist training of its graduates in Britain. Postgraduate training in Malaysia is not well developed and there is a severe shortage of specialists in the country. In the pursuit of comparable academic standards to those in the West the Faculty has set great store by the fact that it has continued to maintain the practice of having external examiners from overseas medical schools to vet professional examinations in spite of the language difficulties and expense involved. Furthermore, although the first 2 years of the medical course have been taught in the National language since 1980, the following three clinical years of the course continue to be taught in English. Following its review ofthe Faculty in 1984, the G M C recomfnended that the curriculum be revised, and extended its recognition of the Faculty’s primary medical qualification for the purpose of full and provisional registration in the UK only up until the end of 1989, further
Correspondence: D r Christine M. Tan, Department of Physiology, Faculty of Medicine, University of Malaya, Kuala Lumpur 59100, Malaysia.
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extension of full registration beyond that date being dependent upon satisfactory implementation of the Council’s recommendations. A revised curriculum was implemented starting in year 1 in 1987. However, the Faculty was informed by the GMC in June 1989 that its degree would be accepted only for limited registration in 1990, a decision which has aroused great concern about slipping academic standards. University admissions policies The high uniform standard of the British undergraduate degree is maintained to a large extent by means ofan elite admissions system, the standard minimum entrance requirement for the vast majority of students being two ‘A’-level passes. However, in Malaysia many university entrants now do not possess the equivalent of two ‘A’-level passes. There are two means of entry into the Faculty of Medicine at the University of Malaya: direct entry from form 6 and dependent upon the student’s Sijil Tinggi Persekolahan Malaysia (STPM)/Higher School Certificate (HSC) results, and indirect entry from form 5 by means of the University’s 2-year matriculation course. The direct entrants are of Chinese or Indian ethnic origin and are primarily from urban areas. The indirect entrants are all Malays of indigenous ethnic origin, most of whom are from the rural areas where the school system is deficient in science teaching. The matriculation course was established in 1977 as an alternative mode of admission to science-based courses. Better-qualified Malay students are provided with government scholarships to study overseas. The present medical first-year intake of 160 students comprises about 62% Malays in order that the student composition reflect the racial composition of the country as provided for in the Malaysian constitution. Response to the changing educational needs of students The Faculty of Medicine has responded to the changing educational needs of its students in various ways: (1) provision of remedial teaching in years 1 and 2 for the lower ability indirect entrants (as determined by examination per-
formance); (2) provision of a brief study skills course at the commencement of year 1; (3) provision of English language instruction in years 1 and 2; and (4)provision of textbooks in the National language.
Remedial tutorials and study skills instruction Since the Matriculation course did not result in parity of the direct and indirect entrants, remedial tutorials were provided for the weakest students in the latter group. However, the remedial teaching was unsuccessful in that it did not result in parity ofperformance in the first and second professional examinations (Danaraj 1988). A large number ofindirect entrants had to sit the supplementary examinations at .the end of year 1 in order to obtain the marks necessary to proceed to year 2. Recent studies revealed that first-year students lacked analytic and reasoning skills as well as many other basic skills necessary for the achievement of meaningful learning (Tan 1988, 1990a,b). However, remedial teaching focused on ‘pounding in the essential facts’ rather than on teaching relevant skills. Furthermore, the short study skills course hadlittle influence on the students’ approach to their studies and they adopted a surface, reproductive approach to all learning, and were teacher dependent and unable to accept responsiblity for their own learning (Tan 1988, 1990a,b).
English language support Since the clinical course is taught in English and instruction in schools is in the National language, years 1 and 2 must act as a transition stage during which time the students become proficient in English. However, instruction provided through additional language classes was not successful and in the clinical years English -language difficulties added to the students’ learning problems. The context in which language support takes place is of crucial importance in determining its success. Although in years 1 and 2 many staff did use English to some extent in their teaching of the basic sciences, the students themselves rarely used it and they made little if any attempt to use English textbooks (Tan 1990b). Their reading comprehension skills were poor (in both English and the National language)
Medical education and non-standard entrants so that students failed to see a sentence as a carrier of meaning. They viewed reading as a purely receptive process in which they must retain all the information ready to be regurgitated word for word in the examinations. Essay scripts had to be written in the National language, and use of English texts would have required the adoption of a new learning technique, since the words could not be committed directly to memory ready to be reproduced in an examination. Students therefore perceived their language instruction as extraneous to the medical course.
Use of textbooks in the National language Instruction in the national language demanded that textbooks be provided in the language. Textbooks are typically structured in ways that do not help students read in order to understand and present content in ways that suggest that learning is a fairly simple process of adding new information to memory (Ramsden 1988). T o use such texts to promote conceptual understanding, teachers must define the content to be covered in ways that differ substantially from the textbook, and should not assume that a form of representation of knowledge that is effective for storage is also effective for learning. Thus, in the case ofstudents who are incapable of consistently using formal reasoning patterns the discussion leading up to and the explanations of the concepts presented need to be carefully planned (Prosser 1983; Ramsden 1988). However, giving good explanations is a very difficult task requiring deep understanding as well as a good command of the language of instruction. Due to the pressure of their research, lecturers had little time to translate their lectures and those who spoke the National language fluently had little teaching experience, so that the teaching merely reproduced the textbook and students were rarely challenged to understand the concepts at a meaningful level. Curriculum revision It is well recognized that the traditional basic medical sciences curriculum is overcrowded with facts and details and emphasizes the learning of content at the expense of process, and as such has little relevance to clinical medicine.
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The GMC’s latest set of recommendations, issued in 1980, suggest that the student’s factual load should be reduced ‘to ensure that the memorizing and reproduction of factual data not be allowed to interfere with the primary need for fostering the critical study of principles and the development of independent thought’. However, curriculum revision in the basic sciences was primarily concerned with the avoidance of overloading through a reduction in contact hours and provision of self-study periods, with little or no concern about the necessity to change the instructional procedures or assessment methods. The students were unfamiliar with self-learning techniques, so that there was little effect on the outcome of learning (Tan 1990b), and the students merely memorized fewer facts. Curriculum revision did little to address the problem of the perceived irrelevance of the basic sciences teaching and examinations continued primarily to test content mastery. Since no study was undertaken to determine which topics should enjoy priority teaching, course content was reduced by teaching the same topics but at a more superficial level than previously, rather by omitting topics of no immediate relevance to the needs of the undergraduate medical student. Clearly, the main learning problem facing students does not lie in the quantity of information but in the way it is organized, taught and assessed. Merely reducing and simplifying course content does not help students to understand and apply their knowledge.
Standards and traditional teaching and assessment methods Since classes were made up of students of differing abilities, using traditional teachercentred methods, the teaching had to be pitched at the level of the less able students with the result that the more able students were neglected. Furthermore, traditional normative assessment techniques continued to be used in which the ranking of students was the principal concern of the assessors, rather than progess and competence. In effect, the less able students, who pulled down the mean grade, were setting standards.
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Lack of course evaluation Clearly, the curriculum was not geared to the backgrounds and educational needs of the students. Little work was done to establish just what these needs were and courses were rarely evaluated to determine the reasons for the students’ learning difficulties. In a recent analysis the main problem was deemed to be deficient science teaching in the rural schools, about which the Faculty ofMedicine could do nothing (Danaraj 1988). Lecturers attributed success or failure entirely to the characteristics of the student, not to their teaching. They frequently stated that ‘good students will do well no matter what’, implying that it was the responsibility of the Government to supply the Faculty with good students, and if it did not the teachers were not responsible for the consequences. Many academicians considered that the students had become so accustomed to spoonfeeding during their school years that they were incapable oflearning without it (Zubir 1988),and attempts to introduce the teaching ofhigher level cognitive skills were met with the standard response, ‘our students can’t do that’. So strong was the commitment to this view that in some instances lecturers who did try to achieve more meaningful learning and provided their own lecture hand-outs and worksheets were told to ‘follow the textbook’.
a debilitating form of malaise among the more
able students, and mediocrity became the accepted order of the day ( N e w Sunday Times 1988) as students learned to live down to what was expected of them. Furthermore, once this approach to learning was established in year 1 it was carried over to subsequent years.
T h e special needs of the Malaysian student The pre-university educational experience of Malaysian students is very different from the British system, with strong emphasis placed on rote learning in schools. As a result students are not equipped to cope with traditional university teaching. Because of their lack of study skills and effective learning strategies Malaysian students have special needs compared with Western students. The learning problems experienced by the overseas student in Britain have been documented (Wright 1982). There is growing recognition by UK universities of the special needs of overseas students, and the fact that although they may be successful in obtaining their degrees they usually do so at the expense of heavy time demands on their tutors and supervisors, such that in the long term they may not be a viable proposition (Kinnell 1988).
Needfor high qualify university teaching The teaching environmenf Lecturers failed to recognize that the students’ approach to learning was to a large extent a response to the teaching environment (Entwistle & Ramsden 1983; Ramsden 1988; Zubir 1988). Thus in the case of physiology many students resented intellectual challenge, they felt threatened and complained when a lecturer did not follow the textbook (Tan 1990b) and they stopped attending lectures. Thus even when the teaching was made more relevant to their vocational aims the students remained uninterested and so the teaching skills of lecturers had little if any effect on the outcome of learning. Authoritarian, examination-oriented teaching reinforced a passive, reproductive approach to learning and strengthened the anti-intellectual atmosphere. Lack ofintellectual stimulation bred
It is probably true that good students will do well whatever the academic context in which they find themselves, since these students are better able than others to ‘manage’ adverse conditions through the employment of various coping strategies (Entwistle & Ramsden 1983). However, even in the West such students form a small proportion of the total number, and the evidence is overwhelming that the quality of student learning is adversely affected by poor teaching. Furthermore, good teaching is especially important in the case of students who lack study skills and effective learning strategies. Poor teaching, badly structured courses, and poor quality textbooks can have a far more damaging effect on these students because of their lack of coping strategies and self-confidence (Entwistle & Ramsden 1983; Mills & Malloy 1989). Furthermore, mixed ability teaching in particular
Medical education and non-standard entrants requires teachers of strong commitment and exceptional skill. UK universities are now demonstrating an explicit concern for the quality of teaching that favourable staffstudent ratios and highly selective intakes may hitherto have made less essential, although still there is much that needs change and improvement (Elton 1988). However, now more than ever before, it is recognized that universities need good teachers to cope with the increase in non-standard entrants (primarily mature students) and to assist the large number of overseas students who have inadequate linguistic and study skills (Wright 1982). A broad-based entry into higher education in Malaysia has made good teaching crucial to the achievement of academic excellence, but yet there has been little ifany concern for the quality of university teaching. Furthermore, apart from being better prepared for university, Western students are also probably more highly motivated than are many Malaysian students. As a result of the shortage of qualified Malays, students are channelled into medicine even though they are not particularly interested in becoming a doctor. Many students also lack drive and determination in their studies, perhaps as a result of the lack of competition to enter university. The Malay student is also far more readily prepared to accept a passive, unreflective approach to learning than is his Western counterpart, as a result offrequent subjection to religious indoctrination, as well as a general cultural disposition to respect authority. As a result, effective teaching is exceptionally difficult and demanding work, and lecturers have failed to respond to the challenges involved.
‘Good pedagogic practice’ Meaningful learning is facilitated by active teaching/learning experiences. Furthermore, where the class is made up ofstudents ofdiffering abilities, instruction needs to be individualized and self-paced. Courses need to be analysed in terms of the skills required to perform the learning task effectively (Tan 1990b). Teaching must be determined by the students’ prior knowledge and their individual needs and a choice of learning methods made available where possible.
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Content-independent teaching of study and language skills is ineffective and it is unreasonable to expect students to become active, independent learners overnight. The best way to help students seems to be to improve the teaching and assessment programme itself (Ramsden 1987; Mills & Molloy 1989). Research suggested the need for highly structured exercises whereby the students could be explicitly taught analytic and reasoning skills as well as the skills and attitudes necessary for self-directed learning through a gradual weaning process continuing throughout the first year of the course (Tan et al. 1989; Tan 1990b). Furthermore, the indirect entrants had no greater need to acquire basic skills and selflearning techniques than did the direct entrants, although the latter knew more facts, their higher level cognitive skills were not significantly better developed than those of the indirect entrants (Tan 1988; Tan 1990a,b). Instead of remedial classes, better instructional methods were required for the course as a whole and from which all students could potentially benefit.
Academic staff training Lack of staff training and exposure to the newer teaching methods and philosophies has undoubtedly played a significant role in determining attitudes to teaching, particularly o f the more senior staff. Academic staff training programmes have been limited almost exclusively to the provision o f scholarships to obtain higher degrees and to instruction in the National language. T h e latter has suffered from the same problems as the students’ language programme and, furthermore, language proficiency has been judged primarily by examination performance, not by ability and willingness to use the language in the teaching situation. Although Malaysian nationals, in a multi-racial society not all academic staff speak the National language.
T h e incentive structure of the university In order to gain prestige lecturers have been encouraged to obtain similar academic qualifications to their Western counterparts. In the Universtiy of Malaya, just as in the British and
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American universities, the dominant professional press has led lecturers to seek the satisfaction of status and esteem outside the class-room through specialized research (Fenker 1977). The only change instituted in the incentive structure of the University has been to base some lecturers’ promotions on their production of textbooks in the National language rather than on their research productivity. No recognition has been given to the production ofother types of teaching materials, such as self-instructional learning packages, and as a result few resource materials have been produced. Educational research has not been encouraged and the idea that anything relevant can be learnt from research into teaching and learning has not even been entertained.
The conjict between research and teaching
The common, but dubious, belief was held that research in a subject can directly improve the quality of its teaching. The assumption that teachers ‘automatically know their job’ led to many lecturers taking the view that there is little if anything to learn about teaching. However, research findings demonstrate that measures of scientific research productivity cannot be used to infer teaching effectiveness (Page 1972; Fenker 1977; Marsh 1987). In reality, since teaching ability was not rewarded, time spent preparing for teaching assignments was minimal. Furthermore, time devoted to teaching meant less time for research. Many lecturers had the demanding task of setting up a research laboratory after obtaining their PhD from overseas and due to lack of suitably qualified research assistants they had to carry out much laboratory work for themselves. As a result, research and education became rivals, probably to an even greater extent than in developed countries (Bloom 1989), where it has been suggested that the only way to ensure good medical education may be to uncouple teaching and research (Ebert & Ginzberg 1958). Provision of competency-based learning is an all-consuming enterprise not designed for busy people with multiple tasks, and so it is extremely difficult to improve teaching significantly and at the same time carry out traditional research.
Intrinsic motivation to teach
In Malaysia, just as in the West, present views of the problems of poor teaching in universities have also been limited by the lack of recognition of the importance of intrinsic motivation in the instructional staff (Bess 1977). The lack of thirst for knowledge and student disinterest in learning led lecturers to become demoralized and disinterested in teaching. Furthermore, lecturers were required to teach different topics each year, in order it was claimed ‘to demonstrate their versatility’, and this only encouraged them to stay within well-defined, non-experimental teaching roles. The system prevented the teaching experience from becoming a profoundly satisfying one, and lecturers were only too glad to change topics in order to relieve boredom. Maintenance of course standards was not within the teacher’s power to control. Lecturers were not given the opportunity to become expert teachers; could a research scientist become an expert if he had to switch his field of research every year?
The institutional organization
Good class-room practice is ineffective without the right organizational structures to back it up (Ramsden 1988). However, the educational climate was hostile and committed teachers were prevented from implementing changes which research had shown to be desirable. The administrative system perpetuated traditional methods and values. Senior management were unable to accept that power was expandable and few concessions were made to democracy and participation, so that the traditional departmental structure remained unmodified. The University ofMalaya is the oldest university in Malaysia and because of its tradition has been regarded as the premier university in the country. By continuing to imitate the ‘best’ in the West, the University sought to maintain its elite status. Following curriculum revision a number of integrated teaching exercises were introduced into year 2, which took the format of three or four mini-lectures presented by staff from both basic and clinical science departments. A major problem was information overload and integration was difficult to effect since most teachers continued to identify themselves as ‘subject-
Medical education and non-standard entrants
experts’ and taught only within their own subject area. However, staff were not trained in new ways of teaching or thinking and no guidelines were provided, only a theme title, it being tacitly assumed that everyone knew what needed to be taught. Integration demands a lot of time and effort on the part of the teaching team and high motivation. Teachers from different departments need to discuss how to draw out the interrelationships, but n o time was allocated for this and staff were assigned only 1 or 2 weeks in advance of the class. Clearly, there was n o appreciation of the need for teaching to be carefully planned in order to achieve meaningful learning. The external examiner system
In Britain the institution of the external examiner is used to maintain comparability o f academic standards throughout the university system. However, comparability of standards between institutions having very different standards of student admission is clearly not possible. Using norm-based assessment student performance is relative, the standard adjusting to the particular student population on campus. However, since lecturers were not trained in assessment techniques they were reluctant to d o away with the external examiner system as they lacked confidence and preferred someone else to assume responsibility for maintaining standards. As a result the system led to complacency and the development ofa false sense of achievement since many lecturers appeared to believe that external examiners were capable of upholding and ensuring the attainment of some perceived ‘international standard’. Formal course assessment therefore only served to maintain the status quo. Finaricial cortstrairits and the need f o r redejnition of priorities
Although it has been pointed out that financial constraints represent a major obstacle to curriculum development in Malaysia (Roslani & Teoh 1988), it is clear that there is a need to reassess critically the expensive external examiner system as well as the remedial teaching programme, and most importantly the unproductive costly co-mingling of teaching and scientific research.
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T h e exploitation of more efficient and more cost-effective teaching technologies is also essential (Tan 1988). A curriculum tailored to the educational needs .f students
Following the loss o f full G M C recognition, the teachers were despondent and pessimistic about the future, since they perceived that they had done everything possible to provide a suitable curriculum. However, teachers failed to appreciate that the quality of a course depends upon the effectiveness of the teaching and what the students learn, rather than upon what they are taught. Teachers must be responsible for both providing courses and the necessary conditions for learning. In order to be effective the curriculum must be geared to the backgrounds and educational needs o f the students. The latter must be established through critical evaluation o f the teaching/ learning process. The essence of effective teaching is experiment with ideas and practice. There must be an attempt to establish the ‘connections’ between what is achieved and what was desired to be achieved. Continuous evaluation of student learning must form an integral part of the curriculum and this will lead to innovation in teaching. Lecturers must therefore be encouraged to develop a professional approach to teaching (Ramsden 1987, 1988). Analysis o f teaching/learning transactions is more amenable to informal rather than formal evaluation. Examination performance may not reflect the quality of teaching; a less able student w h o has been well taught may perform equally as well as a more able student who has been less well taught. Futhermore, if only the learning outcome is evaluated it is not possible to determine what needs to be done in order to improve instruction. Lecturers therefore need to concentrate less on the extent to which the performance of their students matches perceived standards and more on the process b y which those standards are established. In the last resort the quaiity of a course depends upon the quality of the teaching. Responsiblejudgement by a self-critical group of academics is clearly the chief means of maintaining and improving the quality of teaching and course standards (Ramsden 1987; Elton 1988).
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Conclusion In another Third World medical school convergence of the system with that of the West has also been attributed to ‘importation’ rather than to common functional requirements of different societies (Gallagher 1988). The Alma Ata Declaration states ‘The highest standard of medical education for any country is that which is most responsible to local needs’ (World Health Organization 1978). These needs involve both the validity of the curriculum content with respect to the health needs of the containing society (Abdul Khalid Sahan 1986). and the suitability of the pedagogy and curriculum design with respect to the backgrounds and educational needs of the students. The most appropriate pedagogy for a particular learning task and student populace can only be established through research. Some Third World universities, such as the University of Malaya, have too readily adopted and institutionalized the teaching methods of the West without appropriate adaptation to the educational needs of their own students. This clearly must involve far more than a change in the language of instruction. Through imitating the West, the Faculty of Medicine sought to achieve both academic excellence and international recognition of its degree, as well as academic distinction through scientific research. However, under the prevailing circumstances the two aims were totally incompatible and academic standards were compromised. In the final analysis, the prestige and reputation of a university depend upon the quality of its students. A university can hardly be’ proud of large numbers of highly qualified academicians if they are incapable of educating their students. In practice the task of truly educating students is seen by most academicians as just ‘an impossible dream’, a task too daunting to be worthy of serious contemplation. Before there can be any progress there must be recognition by the universities and by society that serious teaching is a difficult and demanding activity equally as challenging as any scientific research. Good teaching must therefore be recognized as a primary activity in its own right; teaching can no longer be left to ‘untrained’ scientists and clinicians. Professional development and
training of lecturers as teachers must be provided for. Achievement of academic excellence is dependent upon educational research becoming an integral part of the teachingllearning process. This being the case, no other form of research is more relevant to the needs of developing countries in which severe financial constraints demand that research be applied and related to local needs and problems. The professional teacherhesearcher must therefore be recognized as being just as capable of bringing academic distinction to a university as is the research scientist. Progress is unlikely if those who study learning processes are themselves unable to exert influence in the sphere of education.
References Abdul Khalid Sahan (1986) Medical education:reorientation in the context of health for all strategy. Proceedings of the International Conference on Medical Education, Kota Bharu, Malaysia, pp. 1-11. Bess J. L. (1977) The motivation to teach. journal of Higher Education 48, 243-58. Bloom S. W. (1989) The medical school as a social organization: the sources of resistance to change. Medical Education 23. 228-41. Danaraj T. J. (1988) Medical Educarion in Malaysia: Development and Problems. Pelanduk Publications, PetalingJaya. Ebert R. H. & Ginzberg E. (1988) The reform of medical education. Health AJairs 1 (Suppl.), 5-38. Elton L. (1988) Appraisal and accountability in higher education: some current issues. Higher Education Quarterly 42,207-29. Entwistle N. J. & Ramsden P. (1983) Understanding Student Learning. Croom Helm, London. Fenker R. M. (1977) The incentive structure of a university.journal ofHigher Education 48,453-71. Gallagher E. B. (1988) Convergence or divergence in Third World medical education? An Arab study. Journal $Health and Social Behaviour 29,385-400. Kinnell M. (1988) Marketing courses to overseas students: a case study of two universities. In: Restructuring Higher Education (ed. by H. Eggins), pp. 125-36. Proceedings of the Annual Conference 1987, Society for Research into Higher Education. Open University Press, Milton Keynes. Marsh H. W. (1987) Students’evaluations ofuniversity teaching: research findings, methodological issues and directions for future research. International Journal of Educational Research 11, whole issue. Mills A. J. & Malloy S. T. (1989) Experiencing the experienced: the impact of non-standard entrants upon a programme of higher education. Studies in Higher Education 14. 41-54.
Medical education and non-standard entrants N e w Sunday Times (1988) Mediocrity rules academia? 19 June. Page C. F. (1972) Teaching and research - happy symbiosis or hidden warfare? Universities Quarterly 26, 102-18. Prosser M. (1983) Relationship between the cognitive abilities of a group of tertiary physics students and the cognitive requirements of their textbook. Science Education 67, 75-83. Ramsden P. (1987) Improving teaching and learning in higher education: the case for a relational perspective. Studies in Higher Education 12, 275-86. Ramsden P. (ed.) (1988) Improving Learning: N e w Perspectives. Kogan Page, London. Roslani A. M. M. & Teoh S. T. (1988) The training of health personnel in Malaysia with special emphasis on medical education. Report of the Regional Conference on Medical Education, Western Pacific Region, Universiti Kebangsaan, Kuala Lumpur, Malaysia. Tan C. M. (1988) The effectiveness of alternative instructional media in physiology practical teaching. Medical Teacher 10, 33344. Tan C. M. (1990a) Some factors influencing student performance in laboratory experimental work in
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physiology with implications for curriculum deliberations and instructional design. Higher Education 19 (in press). Tan C. M. (1990b) The influence of laboratory experimental work on concept acquisition in a medical physiology course with implications for curriculum deliberations and instructional design. Medical Teacher (in press). Tan C. M., Asmawi M. Z. & Yusof A. P. M. (1989) The influence of instructional media in physiology practical teaching on students’ conceptual understanding. journal ofEducational Television 15,87-96. World Health Organization (1978) Alma Ata: Report of the International Conference on Primary Health Care. World Health Organization, Geneva. Wright J. (1982) Learning to Learn in Higher Education. Croom Helm, London. Zubir R. (1988) Descriptions of teaching and learning: a Malaysian perspective. Studies in Higher Education 13, 139-49.
Received 19 September 1989; editorial comments t o authors 17 November 1989; accepted forpublication 9 January 1990
Academic standards and changing patterns of medical school admissions: a Malaysian study C. M . T A N
Department of Physiology, Faculty of Medicine, University of Malaya, Kuala Lumpur Key words: education, medical, undergraduate/ *stand; *school admission criteria; curriculum; educational status; teaching/stand; Malaysia
Summary. Changing social demands made it necessary for the Medical Faculty of the University of Malaya to accommodate students with a wider range of academic experience than before. However, teachers sought to achieve comparable academic standards to those in the West by striving to maintain a close resemblance to the Western model of medical education in other respects. As a result teachers failed to adapt their teaching methods, assessment techniques and curriculum design to meet the educational needs of the students, thus compromising academic standards. Many students lack basic academic skills and do not know how to learn effectively. In order to help students overcome their learning difficulties innovative teaching was required during the first year at university, designed to foster the joint development of knowledge and basic skills. In the case of less well-prepared students who lack self-confidence, a caring and supportive learning environment is crucial to the achievement of meaningful learning. Lecturers needed to become facilitators of learning rather than transmitters o f knowledge. However, teachers’ objective to retain international recognition of the degree, which presumably reflected the importance of teaching, was not operationalized in terms of its incentive structure such that teachers were constrained not to try to fill the new roles demanded of them. It was assumed that academic distinction accrued through scientific research was essential for the achievement of academic excellence. However, under the prevailing circumstances the two aims were mutually exclusive and incompatible and teaching quality deteriorated.
Introduction
The curriculum, instructional methods and pattern of academic organization of the Faculty of Medicine of the University of Malaya very closely resemble the British model even though University admissions policies and patterns of student intake have become very different to those ofthe British universities over recent years. The Faculty of Medicine was established in 1963 as a centre of academic excellence and its medical degree has been recognized by the General Medical Council (GMC) of the United Kingdom since 1969. The Faculty has continued to seek external recognition of its degree in order to facilitate the further specialist training of its graduates in Britain. Postgraduate training in Malaysia is not well developed and there is a severe shortage of specialists in the country. In the pursuit of comparable academic standards to those in the West the Faculty has set great store by the fact that it has continued to maintain the practice of having external examiners from overseas medical schools to vet professional examinations in spite of the language difficulties and expense involved. Furthermore, although the first 2 years of the medical course have been taught in the National language since 1980, the following three clinical years of the course continue to be taught in English. Following its review ofthe Faculty in 1984, the G M C recomfnended that the curriculum be revised, and extended its recognition of the Faculty’s primary medical qualification for the purpose of full and provisional registration in the UK only up until the end of 1989, further
Correspondence: D r Christine M. Tan, Department of Physiology, Faculty of Medicine, University of Malaya, Kuala Lumpur 59100, Malaysia.
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extension of full registration beyond that date being dependent upon satisfactory implementation of the Council’s recommendations. A revised curriculum was implemented starting in year 1 in 1987. However, the Faculty was informed by the GMC in June 1989 that its degree would be accepted only for limited registration in 1990, a decision which has aroused great concern about slipping academic standards. University admissions policies The high uniform standard of the British undergraduate degree is maintained to a large extent by means ofan elite admissions system, the standard minimum entrance requirement for the vast majority of students being two ‘A’-level passes. However, in Malaysia many university entrants now do not possess the equivalent of two ‘A’-level passes. There are two means of entry into the Faculty of Medicine at the University of Malaya: direct entry from form 6 and dependent upon the student’s Sijil Tinggi Persekolahan Malaysia (STPM)/Higher School Certificate (HSC) results, and indirect entry from form 5 by means of the University’s 2-year matriculation course. The direct entrants are of Chinese or Indian ethnic origin and are primarily from urban areas. The indirect entrants are all Malays of indigenous ethnic origin, most of whom are from the rural areas where the school system is deficient in science teaching. The matriculation course was established in 1977 as an alternative mode of admission to science-based courses. Better-qualified Malay students are provided with government scholarships to study overseas. The present medical first-year intake of 160 students comprises about 62% Malays in order that the student composition reflect the racial composition of the country as provided for in the Malaysian constitution. Response to the changing educational needs of students The Faculty of Medicine has responded to the changing educational needs of its students in various ways: (1) provision of remedial teaching in years 1 and 2 for the lower ability indirect entrants (as determined by examination per-
formance); (2) provision of a brief study skills course at the commencement of year 1; (3) provision of English language instruction in years 1 and 2; and (4)provision of textbooks in the National language.
Remedial tutorials and study skills instruction Since the Matriculation course did not result in parity of the direct and indirect entrants, remedial tutorials were provided for the weakest students in the latter group. However, the remedial teaching was unsuccessful in that it did not result in parity ofperformance in the first and second professional examinations (Danaraj 1988). A large number ofindirect entrants had to sit the supplementary examinations at .the end of year 1 in order to obtain the marks necessary to proceed to year 2. Recent studies revealed that first-year students lacked analytic and reasoning skills as well as many other basic skills necessary for the achievement of meaningful learning (Tan 1988, 1990a,b). However, remedial teaching focused on ‘pounding in the essential facts’ rather than on teaching relevant skills. Furthermore, the short study skills course hadlittle influence on the students’ approach to their studies and they adopted a surface, reproductive approach to all learning, and were teacher dependent and unable to accept responsiblity for their own learning (Tan 1988, 1990a,b).
English language support Since the clinical course is taught in English and instruction in schools is in the National language, years 1 and 2 must act as a transition stage during which time the students become proficient in English. However, instruction provided through additional language classes was not successful and in the clinical years English -language difficulties added to the students’ learning problems. The context in which language support takes place is of crucial importance in determining its success. Although in years 1 and 2 many staff did use English to some extent in their teaching of the basic sciences, the students themselves rarely used it and they made little if any attempt to use English textbooks (Tan 1990b). Their reading comprehension skills were poor (in both English and the National language)
Medical education and non-standard entrants so that students failed to see a sentence as a carrier of meaning. They viewed reading as a purely receptive process in which they must retain all the information ready to be regurgitated word for word in the examinations. Essay scripts had to be written in the National language, and use of English texts would have required the adoption of a new learning technique, since the words could not be committed directly to memory ready to be reproduced in an examination. Students therefore perceived their language instruction as extraneous to the medical course.
Use of textbooks in the National language Instruction in the national language demanded that textbooks be provided in the language. Textbooks are typically structured in ways that do not help students read in order to understand and present content in ways that suggest that learning is a fairly simple process of adding new information to memory (Ramsden 1988). T o use such texts to promote conceptual understanding, teachers must define the content to be covered in ways that differ substantially from the textbook, and should not assume that a form of representation of knowledge that is effective for storage is also effective for learning. Thus, in the case ofstudents who are incapable of consistently using formal reasoning patterns the discussion leading up to and the explanations of the concepts presented need to be carefully planned (Prosser 1983; Ramsden 1988). However, giving good explanations is a very difficult task requiring deep understanding as well as a good command of the language of instruction. Due to the pressure of their research, lecturers had little time to translate their lectures and those who spoke the National language fluently had little teaching experience, so that the teaching merely reproduced the textbook and students were rarely challenged to understand the concepts at a meaningful level. Curriculum revision It is well recognized that the traditional basic medical sciences curriculum is overcrowded with facts and details and emphasizes the learning of content at the expense of process, and as such has little relevance to clinical medicine.
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The GMC’s latest set of recommendations, issued in 1980, suggest that the student’s factual load should be reduced ‘to ensure that the memorizing and reproduction of factual data not be allowed to interfere with the primary need for fostering the critical study of principles and the development of independent thought’. However, curriculum revision in the basic sciences was primarily concerned with the avoidance of overloading through a reduction in contact hours and provision of self-study periods, with little or no concern about the necessity to change the instructional procedures or assessment methods. The students were unfamiliar with self-learning techniques, so that there was little effect on the outcome of learning (Tan 1990b), and the students merely memorized fewer facts. Curriculum revision did little to address the problem of the perceived irrelevance of the basic sciences teaching and examinations continued primarily to test content mastery. Since no study was undertaken to determine which topics should enjoy priority teaching, course content was reduced by teaching the same topics but at a more superficial level than previously, rather by omitting topics of no immediate relevance to the needs of the undergraduate medical student. Clearly, the main learning problem facing students does not lie in the quantity of information but in the way it is organized, taught and assessed. Merely reducing and simplifying course content does not help students to understand and apply their knowledge.
Standards and traditional teaching and assessment methods Since classes were made up of students of differing abilities, using traditional teachercentred methods, the teaching had to be pitched at the level of the less able students with the result that the more able students were neglected. Furthermore, traditional normative assessment techniques continued to be used in which the ranking of students was the principal concern of the assessors, rather than progess and competence. In effect, the less able students, who pulled down the mean grade, were setting standards.
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Lack of course evaluation Clearly, the curriculum was not geared to the backgrounds and educational needs of the students. Little work was done to establish just what these needs were and courses were rarely evaluated to determine the reasons for the students’ learning difficulties. In a recent analysis the main problem was deemed to be deficient science teaching in the rural schools, about which the Faculty ofMedicine could do nothing (Danaraj 1988). Lecturers attributed success or failure entirely to the characteristics of the student, not to their teaching. They frequently stated that ‘good students will do well no matter what’, implying that it was the responsibility of the Government to supply the Faculty with good students, and if it did not the teachers were not responsible for the consequences. Many academicians considered that the students had become so accustomed to spoonfeeding during their school years that they were incapable oflearning without it (Zubir 1988),and attempts to introduce the teaching ofhigher level cognitive skills were met with the standard response, ‘our students can’t do that’. So strong was the commitment to this view that in some instances lecturers who did try to achieve more meaningful learning and provided their own lecture hand-outs and worksheets were told to ‘follow the textbook’.
a debilitating form of malaise among the more
able students, and mediocrity became the accepted order of the day ( N e w Sunday Times 1988) as students learned to live down to what was expected of them. Furthermore, once this approach to learning was established in year 1 it was carried over to subsequent years.
T h e special needs of the Malaysian student The pre-university educational experience of Malaysian students is very different from the British system, with strong emphasis placed on rote learning in schools. As a result students are not equipped to cope with traditional university teaching. Because of their lack of study skills and effective learning strategies Malaysian students have special needs compared with Western students. The learning problems experienced by the overseas student in Britain have been documented (Wright 1982). There is growing recognition by UK universities of the special needs of overseas students, and the fact that although they may be successful in obtaining their degrees they usually do so at the expense of heavy time demands on their tutors and supervisors, such that in the long term they may not be a viable proposition (Kinnell 1988).
Needfor high qualify university teaching The teaching environmenf Lecturers failed to recognize that the students’ approach to learning was to a large extent a response to the teaching environment (Entwistle & Ramsden 1983; Ramsden 1988; Zubir 1988). Thus in the case of physiology many students resented intellectual challenge, they felt threatened and complained when a lecturer did not follow the textbook (Tan 1990b) and they stopped attending lectures. Thus even when the teaching was made more relevant to their vocational aims the students remained uninterested and so the teaching skills of lecturers had little if any effect on the outcome of learning. Authoritarian, examination-oriented teaching reinforced a passive, reproductive approach to learning and strengthened the anti-intellectual atmosphere. Lack ofintellectual stimulation bred
It is probably true that good students will do well whatever the academic context in which they find themselves, since these students are better able than others to ‘manage’ adverse conditions through the employment of various coping strategies (Entwistle & Ramsden 1983). However, even in the West such students form a small proportion of the total number, and the evidence is overwhelming that the quality of student learning is adversely affected by poor teaching. Furthermore, good teaching is especially important in the case of students who lack study skills and effective learning strategies. Poor teaching, badly structured courses, and poor quality textbooks can have a far more damaging effect on these students because of their lack of coping strategies and self-confidence (Entwistle & Ramsden 1983; Mills & Malloy 1989). Furthermore, mixed ability teaching in particular
Medical education and non-standard entrants requires teachers of strong commitment and exceptional skill. UK universities are now demonstrating an explicit concern for the quality of teaching that favourable staffstudent ratios and highly selective intakes may hitherto have made less essential, although still there is much that needs change and improvement (Elton 1988). However, now more than ever before, it is recognized that universities need good teachers to cope with the increase in non-standard entrants (primarily mature students) and to assist the large number of overseas students who have inadequate linguistic and study skills (Wright 1982). A broad-based entry into higher education in Malaysia has made good teaching crucial to the achievement of academic excellence, but yet there has been little ifany concern for the quality of university teaching. Furthermore, apart from being better prepared for university, Western students are also probably more highly motivated than are many Malaysian students. As a result of the shortage of qualified Malays, students are channelled into medicine even though they are not particularly interested in becoming a doctor. Many students also lack drive and determination in their studies, perhaps as a result of the lack of competition to enter university. The Malay student is also far more readily prepared to accept a passive, unreflective approach to learning than is his Western counterpart, as a result offrequent subjection to religious indoctrination, as well as a general cultural disposition to respect authority. As a result, effective teaching is exceptionally difficult and demanding work, and lecturers have failed to respond to the challenges involved.
‘Good pedagogic practice’ Meaningful learning is facilitated by active teaching/learning experiences. Furthermore, where the class is made up ofstudents ofdiffering abilities, instruction needs to be individualized and self-paced. Courses need to be analysed in terms of the skills required to perform the learning task effectively (Tan 1990b). Teaching must be determined by the students’ prior knowledge and their individual needs and a choice of learning methods made available where possible.
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Content-independent teaching of study and language skills is ineffective and it is unreasonable to expect students to become active, independent learners overnight. The best way to help students seems to be to improve the teaching and assessment programme itself (Ramsden 1987; Mills & Molloy 1989). Research suggested the need for highly structured exercises whereby the students could be explicitly taught analytic and reasoning skills as well as the skills and attitudes necessary for self-directed learning through a gradual weaning process continuing throughout the first year of the course (Tan et al. 1989; Tan 1990b). Furthermore, the indirect entrants had no greater need to acquire basic skills and selflearning techniques than did the direct entrants, although the latter knew more facts, their higher level cognitive skills were not significantly better developed than those of the indirect entrants (Tan 1988; Tan 1990a,b). Instead of remedial classes, better instructional methods were required for the course as a whole and from which all students could potentially benefit.
Academic staff training Lack of staff training and exposure to the newer teaching methods and philosophies has undoubtedly played a significant role in determining attitudes to teaching, particularly o f the more senior staff. Academic staff training programmes have been limited almost exclusively to the provision o f scholarships to obtain higher degrees and to instruction in the National language. T h e latter has suffered from the same problems as the students’ language programme and, furthermore, language proficiency has been judged primarily by examination performance, not by ability and willingness to use the language in the teaching situation. Although Malaysian nationals, in a multi-racial society not all academic staff speak the National language.
T h e incentive structure of the university In order to gain prestige lecturers have been encouraged to obtain similar academic qualifications to their Western counterparts. In the Universtiy of Malaya, just as in the British and
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American universities, the dominant professional press has led lecturers to seek the satisfaction of status and esteem outside the class-room through specialized research (Fenker 1977). The only change instituted in the incentive structure of the University has been to base some lecturers’ promotions on their production of textbooks in the National language rather than on their research productivity. No recognition has been given to the production ofother types of teaching materials, such as self-instructional learning packages, and as a result few resource materials have been produced. Educational research has not been encouraged and the idea that anything relevant can be learnt from research into teaching and learning has not even been entertained.
The conjict between research and teaching
The common, but dubious, belief was held that research in a subject can directly improve the quality of its teaching. The assumption that teachers ‘automatically know their job’ led to many lecturers taking the view that there is little if anything to learn about teaching. However, research findings demonstrate that measures of scientific research productivity cannot be used to infer teaching effectiveness (Page 1972; Fenker 1977; Marsh 1987). In reality, since teaching ability was not rewarded, time spent preparing for teaching assignments was minimal. Furthermore, time devoted to teaching meant less time for research. Many lecturers had the demanding task of setting up a research laboratory after obtaining their PhD from overseas and due to lack of suitably qualified research assistants they had to carry out much laboratory work for themselves. As a result, research and education became rivals, probably to an even greater extent than in developed countries (Bloom 1989), where it has been suggested that the only way to ensure good medical education may be to uncouple teaching and research (Ebert & Ginzberg 1958). Provision of competency-based learning is an all-consuming enterprise not designed for busy people with multiple tasks, and so it is extremely difficult to improve teaching significantly and at the same time carry out traditional research.
Intrinsic motivation to teach
In Malaysia, just as in the West, present views of the problems of poor teaching in universities have also been limited by the lack of recognition of the importance of intrinsic motivation in the instructional staff (Bess 1977). The lack of thirst for knowledge and student disinterest in learning led lecturers to become demoralized and disinterested in teaching. Furthermore, lecturers were required to teach different topics each year, in order it was claimed ‘to demonstrate their versatility’, and this only encouraged them to stay within well-defined, non-experimental teaching roles. The system prevented the teaching experience from becoming a profoundly satisfying one, and lecturers were only too glad to change topics in order to relieve boredom. Maintenance of course standards was not within the teacher’s power to control. Lecturers were not given the opportunity to become expert teachers; could a research scientist become an expert if he had to switch his field of research every year?
The institutional organization
Good class-room practice is ineffective without the right organizational structures to back it up (Ramsden 1988). However, the educational climate was hostile and committed teachers were prevented from implementing changes which research had shown to be desirable. The administrative system perpetuated traditional methods and values. Senior management were unable to accept that power was expandable and few concessions were made to democracy and participation, so that the traditional departmental structure remained unmodified. The University ofMalaya is the oldest university in Malaysia and because of its tradition has been regarded as the premier university in the country. By continuing to imitate the ‘best’ in the West, the University sought to maintain its elite status. Following curriculum revision a number of integrated teaching exercises were introduced into year 2, which took the format of three or four mini-lectures presented by staff from both basic and clinical science departments. A major problem was information overload and integration was difficult to effect since most teachers continued to identify themselves as ‘subject-
Medical education and non-standard entrants
experts’ and taught only within their own subject area. However, staff were not trained in new ways of teaching or thinking and no guidelines were provided, only a theme title, it being tacitly assumed that everyone knew what needed to be taught. Integration demands a lot of time and effort on the part of the teaching team and high motivation. Teachers from different departments need to discuss how to draw out the interrelationships, but n o time was allocated for this and staff were assigned only 1 or 2 weeks in advance of the class. Clearly, there was n o appreciation of the need for teaching to be carefully planned in order to achieve meaningful learning. The external examiner system
In Britain the institution of the external examiner is used to maintain comparability o f academic standards throughout the university system. However, comparability of standards between institutions having very different standards of student admission is clearly not possible. Using norm-based assessment student performance is relative, the standard adjusting to the particular student population on campus. However, since lecturers were not trained in assessment techniques they were reluctant to d o away with the external examiner system as they lacked confidence and preferred someone else to assume responsibility for maintaining standards. As a result the system led to complacency and the development ofa false sense of achievement since many lecturers appeared to believe that external examiners were capable of upholding and ensuring the attainment of some perceived ‘international standard’. Formal course assessment therefore only served to maintain the status quo. Finaricial cortstrairits and the need f o r redejnition of priorities
Although it has been pointed out that financial constraints represent a major obstacle to curriculum development in Malaysia (Roslani & Teoh 1988), it is clear that there is a need to reassess critically the expensive external examiner system as well as the remedial teaching programme, and most importantly the unproductive costly co-mingling of teaching and scientific research.
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T h e exploitation of more efficient and more cost-effective teaching technologies is also essential (Tan 1988). A curriculum tailored to the educational needs .f students
Following the loss o f full G M C recognition, the teachers were despondent and pessimistic about the future, since they perceived that they had done everything possible to provide a suitable curriculum. However, teachers failed to appreciate that the quality of a course depends upon the effectiveness of the teaching and what the students learn, rather than upon what they are taught. Teachers must be responsible for both providing courses and the necessary conditions for learning. In order to be effective the curriculum must be geared to the backgrounds and educational needs o f the students. The latter must be established through critical evaluation o f the teaching/ learning process. The essence of effective teaching is experiment with ideas and practice. There must be an attempt to establish the ‘connections’ between what is achieved and what was desired to be achieved. Continuous evaluation of student learning must form an integral part of the curriculum and this will lead to innovation in teaching. Lecturers must therefore be encouraged to develop a professional approach to teaching (Ramsden 1987, 1988). Analysis o f teaching/learning transactions is more amenable to informal rather than formal evaluation. Examination performance may not reflect the quality of teaching; a less able student w h o has been well taught may perform equally as well as a more able student who has been less well taught. Futhermore, if only the learning outcome is evaluated it is not possible to determine what needs to be done in order to improve instruction. Lecturers therefore need to concentrate less on the extent to which the performance of their students matches perceived standards and more on the process b y which those standards are established. In the last resort the quaiity of a course depends upon the quality of the teaching. Responsiblejudgement by a self-critical group of academics is clearly the chief means of maintaining and improving the quality of teaching and course standards (Ramsden 1987; Elton 1988).
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Conclusion In another Third World medical school convergence of the system with that of the West has also been attributed to ‘importation’ rather than to common functional requirements of different societies (Gallagher 1988). The Alma Ata Declaration states ‘The highest standard of medical education for any country is that which is most responsible to local needs’ (World Health Organization 1978). These needs involve both the validity of the curriculum content with respect to the health needs of the containing society (Abdul Khalid Sahan 1986). and the suitability of the pedagogy and curriculum design with respect to the backgrounds and educational needs of the students. The most appropriate pedagogy for a particular learning task and student populace can only be established through research. Some Third World universities, such as the University of Malaya, have too readily adopted and institutionalized the teaching methods of the West without appropriate adaptation to the educational needs of their own students. This clearly must involve far more than a change in the language of instruction. Through imitating the West, the Faculty of Medicine sought to achieve both academic excellence and international recognition of its degree, as well as academic distinction through scientific research. However, under the prevailing circumstances the two aims were totally incompatible and academic standards were compromised. In the final analysis, the prestige and reputation of a university depend upon the quality of its students. A university can hardly be’ proud of large numbers of highly qualified academicians if they are incapable of educating their students. In practice the task of truly educating students is seen by most academicians as just ‘an impossible dream’, a task too daunting to be worthy of serious contemplation. Before there can be any progress there must be recognition by the universities and by society that serious teaching is a difficult and demanding activity equally as challenging as any scientific research. Good teaching must therefore be recognized as a primary activity in its own right; teaching can no longer be left to ‘untrained’ scientists and clinicians. Professional development and
training of lecturers as teachers must be provided for. Achievement of academic excellence is dependent upon educational research becoming an integral part of the teachingllearning process. This being the case, no other form of research is more relevant to the needs of developing countries in which severe financial constraints demand that research be applied and related to local needs and problems. The professional teacherhesearcher must therefore be recognized as being just as capable of bringing academic distinction to a university as is the research scientist. Progress is unlikely if those who study learning processes are themselves unable to exert influence in the sphere of education.
References Abdul Khalid Sahan (1986) Medical education:reorientation in the context of health for all strategy. Proceedings of the International Conference on Medical Education, Kota Bharu, Malaysia, pp. 1-11. Bess J. L. (1977) The motivation to teach. journal of Higher Education 48, 243-58. Bloom S. W. (1989) The medical school as a social organization: the sources of resistance to change. Medical Education 23. 228-41. Danaraj T. J. (1988) Medical Educarion in Malaysia: Development and Problems. Pelanduk Publications, PetalingJaya. Ebert R. H. & Ginzberg E. (1988) The reform of medical education. Health AJairs 1 (Suppl.), 5-38. Elton L. (1988) Appraisal and accountability in higher education: some current issues. Higher Education Quarterly 42,207-29. Entwistle N. J. & Ramsden P. (1983) Understanding Student Learning. Croom Helm, London. Fenker R. M. (1977) The incentive structure of a university.journal ofHigher Education 48,453-71. Gallagher E. B. (1988) Convergence or divergence in Third World medical education? An Arab study. Journal $Health and Social Behaviour 29,385-400. Kinnell M. (1988) Marketing courses to overseas students: a case study of two universities. In: Restructuring Higher Education (ed. by H. Eggins), pp. 125-36. Proceedings of the Annual Conference 1987, Society for Research into Higher Education. Open University Press, Milton Keynes. Marsh H. W. (1987) Students’evaluations ofuniversity teaching: research findings, methodological issues and directions for future research. International Journal of Educational Research 11, whole issue. Mills A. J. & Malloy S. T. (1989) Experiencing the experienced: the impact of non-standard entrants upon a programme of higher education. Studies in Higher Education 14. 41-54.
Medical education and non-standard entrants N e w Sunday Times (1988) Mediocrity rules academia? 19 June. Page C. F. (1972) Teaching and research - happy symbiosis or hidden warfare? Universities Quarterly 26, 102-18. Prosser M. (1983) Relationship between the cognitive abilities of a group of tertiary physics students and the cognitive requirements of their textbook. Science Education 67, 75-83. Ramsden P. (1987) Improving teaching and learning in higher education: the case for a relational perspective. Studies in Higher Education 12, 275-86. Ramsden P. (ed.) (1988) Improving Learning: N e w Perspectives. Kogan Page, London. Roslani A. M. M. & Teoh S. T. (1988) The training of health personnel in Malaysia with special emphasis on medical education. Report of the Regional Conference on Medical Education, Western Pacific Region, Universiti Kebangsaan, Kuala Lumpur, Malaysia. Tan C. M. (1988) The effectiveness of alternative instructional media in physiology practical teaching. Medical Teacher 10, 33344. Tan C. M. (1990a) Some factors influencing student performance in laboratory experimental work in
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physiology with implications for curriculum deliberations and instructional design. Higher Education 19 (in press). Tan C. M. (1990b) The influence of laboratory experimental work on concept acquisition in a medical physiology course with implications for curriculum deliberations and instructional design. Medical Teacher (in press). Tan C. M., Asmawi M. Z. & Yusof A. P. M. (1989) The influence of instructional media in physiology practical teaching on students’ conceptual understanding. journal ofEducational Television 15,87-96. World Health Organization (1978) Alma Ata: Report of the International Conference on Primary Health Care. World Health Organization, Geneva. Wright J. (1982) Learning to Learn in Higher Education. Croom Helm, London. Zubir R. (1988) Descriptions of teaching and learning: a Malaysian perspective. Studies in Higher Education 13, 139-49.
Received 19 September 1989; editorial comments t o authors 17 November 1989; accepted forpublication 9 January 1990
