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Impact of the National Medical Licensing Examination in Indonesia: Perspectives from Students, Teachers, and Medical Schools

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Impact of the National Medical Licensing Examination in Indonesia: Perspectives from Students, Teachers, and Medical Schools Impact of the national medical licensing examination in Indonesia: perspectives from students, teachers, and medical schools. Rachmadya Nur Hidayah Submitted in accordance with the requirements for the degree of Doctor of Philosophy The University of Leeds School of Medicine February 2018 The candidate confirms that the work submitted is her own and that appropriate credit has been given where reference has been made to the work of others. This copy has been supplied on the understanding that it is copyright material and that no quotation from the thesis may be published without proper acknowledgement The right of Rachmadya Nur Hidayah to be identified as Author of this work has been asserted by her in accordance with the Copyright, Designs and Patents Act 1988. © 2018 The University of Leeds and Rachmadya Nur Hidayah ii Acknowledgement In the name of God, the most Gracious, the most Merciful. Firstly, I would like to thank the Indonesia Endowment Body for Education (Lembaga Pengelola Dana Pendidikan – LPDP), the Ministry of Finance, Republic of Indonesia, who fully supported my study at the University of Leeds. I hope this study can contribute to a better Indonesia. My sincere gratitude to my supervisors, Trudie Roberts and Richard Fuller, for the continuous support of my PhD study. Their encouragement and trust kept me on the right track throughout this journey. It has been a wonderful and enjoyable experience to learn and share ideas with them, which I will always treasure. I could not have imagined having better advisors and mentors for my PhD study. My heartiest appreciation of Rebecca O’Rourke, for her remarkable role as a postgraduate tutor and helping me to improve my writing and research skills. Her patience and guidance made it possible for me to complete writing this thesis. It was her tremendous effort in supporting PhD students which made me feel that “I am well and have done well” when the hard times came. I am immensely grateful to the participants in this study for their willingness to spend their precious time getting involved, and for their invaluable contributions in sharing their experiences and views, which have provided the foundation for this work. I would like to especially thank my colleagues in the Department of Medical Education, Faculty of Medicine, Gadjah Mada University, Indonesia, who provided me with the network and support to complete this study. I would like to thank my PhD colleagues in LIME and my fellow Indonesian students for the joyous moments shared together in Leeds. The light at the end of the tunnel is what we are striving for. My deepest gratitude to my family and friends in Indonesia, for the endless prayers and supports when I was there or away. Finally, for Aulia, Aisya, and Aslan, who always believe in me and hold my hands through the years; thank you for giving me heaven on earth. iii Abstract Impact of the national medical licensing examination in Indonesia: perspectives from students, teachers, and medical schools. Introduction The national examination has been increasingly used worldwide for both licensing and certification purposes. In Indonesia, the national licensing examination (NLE) was implemented in 2007 where it serves as a method of quality assurance for both graduates’ competence and medical schools. Indonesia is a developing country which heightens the impact of introducing the NLE. The high cost and resource intensive demands of the NLE are proportionally higher than they would be for Western countries. This adds to the already high stakes nature of the examination for all stakeholders. Consequently, since its implementation, there have been changes in medical education systems and medical schools. However, the research on how the NLE affects medical education is limited. The aim of this study was to understand the consequences of the introduction of the NLE on Indonesian medical education as perceived by three groups of stakeholders: medical schools, teachers, and students. Methods This study was a qualitative study using a modified grounded theory approach to understand the consequences of NLE from multiple stakeholders’ perspectives. A sampling framework was designed to capture important characteristics of Indonesian medical schools based on region, accreditation status, and ownership (public/ private). Interviews were conducted with 18 medical schools’ representatives (vice deans/ programme directors), while focus groups were conducted with teachers and students from 6 medical schools. The interviews and focus groups were audio-recorded and transcribed. Data was analysed in a rigorous method using open coding and thematic analysis to generate cross- cutting themes and concepts. iv Results This study looked at the intended and unintended consequences of the NLE, which strongly related to the context in Indonesia. Intended consequences were mostly related to the intended outcome of the NLE: achieving a common standard for education, improvement in education practice (including curricula, assessment, and faculty development), improvement learning resources and facilities, which were prominent in new and private schools. Unintended consequences were related to the competition led by the NLE, collaboration, financial impact, and students’ failure. This study revealed cross-cutting themes such as diversity in a rich context of education, the coopetition, and the concept of patient safety in Indonesia. Discussion The current literature on the impact of NLEs were limited to developed countries and Western medical education system. The discourse was mostly based on opinion rather than evidence. This is the first study exploring the impact of the NLE in a developing country and ASEAN network. Some findings on the intended consequences of the NLE confirmed the literature, while some others were a contrast. Indonesia’s unique context as a developing country in Southeast Asia, made it possible for the NLE to create competition leading to collaboration between medical schools and stake holders. This was best explained by the concept of coopetition, which enabled medical schools to overcome challenges, make changes, and improve their quality. This study offers new evidence on how the NLE holds significant role in the improvement of medical education. Conclusion Context matters in the discourse of the NLE. This study demonstrates a novel approach to sampling and analysis of the NLE’s impact. The evaluation of the NLE needs to consider the importance of understanding local factors and consequences. New insights were added to the literature on how the coopetition acts as a key for the impact of the NLE. Moving forward, the future of the NLE is expected to hold an important role in the development of medical education in Indonesia. This study opens opportunities for other area of research, mainly on the impact of the NLE on patient safety, collaboration of stake holders, and students’ failure. v Contents Acknowledgement ...................................................................................... iii Abstract ....................................................................................................... iv Contents ...................................................................................................... vi List of Figures ............................................................................................. ix List of Tables ................................................................................................ x List of Abbreviations .................................................................................. xi Chapter 1 Introduction ................................................................................ 1 1.1 Structure of the thesis....................................................................... 1 1.2 Rationale for study ........................................................................... 2 1.3 Background of study ......................................................................... 3 1.4 Aim of study ...................................................................................... 4 Chapter 2 Context of research: Setting the scene .................................... 5 2.1 The medical education system and the stakeholders in Indonesia ... 5 2.2 Associations of medical schools ....................................................... 7 2.3 Accreditation system in Indonesia .................................................... 8 2.4 The undergraduate medicine programme and the NLE.................... 9 2.5 Admission to Indonesian medical schools ...................................... 10 Chapter 3 Literature review ....................................................................... 12 3.1 Introduction ..................................................................................... 12 3.2 Competence in medical education ................................................. 13 3.3 The history of national licensing examination ................................. 19 3.4 The consequences of the NLE: current debate .............................. 26 3.5 Research questions and objectives ................................................ 30 Chapter 4 Methodology and methods ...................................................... 31 4.1 Research Design ............................................................................ 31 4.2 Methods .......................................................................................... 32 4.3 Time frame ....................................................................................
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