It is with a sense of relief to hear that health minister Dzulkefly Ahmad and higher education minister Zambry Abdul Kadir have decided at a recent meeting to submit a joint memorandum to the Cabinet for proposed amendments to the Medical Act 1971 soon, so as to resolve the parallel pathway conflict.
Most of us are unaware of the actual contents of the joint memorandum.
Is it an amendment to allow the parallel pathway to be recognized by the MMC (Malaysian Medical Council) and subsequently allowing parallel pathway doctors to be included in the NSR (National Specialist Register)?
If this is the case, will it resolve the current imbroglio? It will, and it is a good step forward to immediately resolving the conflict.
But will this permanently solve this situation and resolve future disputes? I strongly doubt it.
One needs to understand why this current imbroglio occurred in the first place, so as to find permanent solutions to the matter.
Amongst the various reasons we are faced with this situation include:
1. The problem with regulatory authorities strictly following the red tape and refusing to budge from their stand on matters when situations demand a necessity to relook such an important issue.
Rather than allowing this to eventually be displayed in public, this matter could have easily been resolved if those responsible for regulatory control had brought the matter to the health minister or the Cabinet to decide if an amendment of the law and Act was necessary in the first place.
Washing dirty linen in public is never the answer to resolving important issues like this.
2. There was an open war between advocates of the Ministry of Health’s (MOH) specialist training pathway and opponents, mostly from university academia.
Why was there a necessity for this in the first place, more so in public?
Ego and pride were blatantly exhibited by one group intending to hold on to their power to maintain postgraduate medical specialty training at all costs. Their excuse is that parallel pathway training, even though good enough to produce well-trained cardiothoracic surgeons, do not have Malaysian Qualifications Agency (MQA) approval.
This has now prompted a judicial review application by the aggrieved party.
3. To make matters worse, many learned personalities resorted to mud-slinging and issuing factually incorrect statements from a very narrow-minded point of view, bordering on an almost comical, which begs the question of their much-lauded credentials.
4. Adding racial elements into the conflict, labelling the parallel pathway “haram”, certainly has not helped at all. There are even those who questioned whether approving parallel pathways equates to being colonised again.
One needs to act immediately to resolve this conflict, which will likely continue indefinitely. It is best to put a stop to this issue that will cause conflicts and divisions within the medical fraternity in the future.
There are a few pertinent questions that need answering.
Will amendments of the Medical Act prevent similar scenarios in future?
What about the future generation of young medical graduates intending to specialise in the future? Will they not be caught up in the mess that our current generation has created?
Have we done enough to ensure that the future health care system and young doctors will not end up being similarly divided and divisive, and form warring factions actively involved in conflicts, or quarrel with each other over similar matters? Will they work together as one?
Why have we, medical specialists, the cream of all professionals, ended up like this?
While maintaining the status quo with two different medical specialist training pathways (i.e. Master’s programmes and the parallel pathway programmes) may resolve this conflict for the time being, will having these two divided and divisive groups ensure that they will work together as one group in future?
We know of many budding and brilliant junior medical doctors who have not achieved their dreams of specialisation, just because their superiors would not support them, either due to heavy work responsibilities, or a downright dislike of the junior doctors.
This is a very common scenario, where just because the superior does not like the junior doctor under his or her supervision, he or she will provids a poor report, thus jeopardising the future of these aspiring candidates.
Also, many junior doctors are transferred to small district hospitals or rural areas, and are left there for years, with promises that they will be given special privileges if they were to apply for specialisation in future. These promises, on many occasions, were never fulfilled.
Many MOs (medical officers) and GPs (general practitioners) deserve better. A number of them were brilliant medical students, and the rest were willing to persevere, but they were unfortunately not given the opportunity to pursue their career paths.
Can this proposed mechanism to resolve this imbroglio settle these problems in the future? Can we sustain our medical specialist programmes with two separate pathways run by two completely different groups in the long term?
If the answers to these pertinent questions above are in the negative, then it is time to establish a single medical specialty training pathway with a single exit examination, by combining all the different factions and training programmes in one single unified medical specialty programme, with no interference by non-medical third parties.
Medical specialisation must be under the guidance and direction laid out by medical specialists themselves, and no one else.
Is this possible?
It is definitely possible if medical specialists move forward and are prepared to conduct such a programme on their own volition by forming a Board of Specialists within their own professional bodies, and to run a single unified Board-certified medical specialist training program.
This can be achieved by professional specialist bodies by developing a curriculum, obtaining accreditation, and recruiting the necessary faculty to start a Board-certified programme for medical specialist training.
Let’s break the impasse and get the ball rolling. It is time we start to think outside the box and be ahead of the pack.
It is time to set the stage for discussions on the formation of the Board of Specialty training in this country with a unified training program for individual specialties — one training with one examination for our medical specialists.
Board Certification Of Medical Specialty Training Programme
The Board for specialty training is formed solely by medical specialists from the related professional body, and includes public, private, and university specialists working together in a unified approach without interference from non-medical third parties.
Board certification is a process that demonstrates clinicians’ expertise in a particular medical specialty or subspecialty. It involves completing a rigorous training programme and passing an examination administered by the recognised medical Board.
In order to be eligible to sit for the Board certification exam, clinicians must meet certain criteria set forth by the medical Board. These criteria may include completion of an accredited training programme and demonstrating ongoing professional development through continuing education activities.
Once clinicians pass the Board certification exam, they are considered Board-certified in their specialty. This designation signifies that they have met rigorous standards of knowledge and skill in their field and have demonstrated their commitment to providing high-quality patient care.
These Board-certified clinicians should then be eligible for their NSR certification, based on the criteria they have met for eligibility.
For this, the law must be amended to allow professional bodies to be the sole training pathway for medical specialty training. The professional body will include all specialists in that particular professional body or association or society, namely specialists from public, private. and university hospitals.
The Board will consist of elected and appointed specialists from public, private, and university hospitals, and with a chairman appointed to lead the Board.
Overall, Board certification will be an important milestone in a clinician’s career, one that will demonstrate their dedication to excellence in patient care and ongoing professional development.
It provides patients with assurance that the clinician has met rigorous standards of training and expertise in their chosen specialty by virtue that such training will be led by specialists from their professional body or specialty association or medical society.
Initiating And Running A Board-Certified Training Programme For A Medical Specialty
Initiating and running a Board-certified training programme for a medical specialty involves several steps and considerations, and include:
1. Identifying the need for Board certifying training: The first step in initiating a Board-certified training programme is to identify the need for such a programme in the medical specialty. This can be done by conducting a needs assessment, reviewing current training programmes, and consulting with experts in the field.
2. Developing a curriculum: Once the need for a Board-certified training programme has been established, the next step is to develop a curriculum that meets the requirements set by the relevant certifying board. This curriculum should include both didactic and clinical components, as well as opportunities for hands-on experience and mentorship.
3. Obtaining accreditation: In order for a training programme to be recognised as Board-certified, it must be accredited by the appropriate regulatory body.
4. Recruiting the faculty to the Board: A successful Board-certified training programme relies on qualified and experienced faculty members who can provide instructions, mentorship, and supervision to trainees. Recruiting faculty members who are experts in their field and have experience teaching and supervising medical students or residents would be the objective of the Board.
5. Implementing the curriculum: With the faculty and trainees in place, it’s time to implement the curriculum. Ensure that all components of the curriculum are delivered effectively and that trainees are meeting milestones set by the certifying Board.
6. Evaluating trainee progress: Throughout the training programme, it is important to regularly evaluate trainee progress through assessments, feedback sessions, and evaluations from faculty members. This will help to identify areas where additional support or resources may be needed.
7. Preparing trainees for certification examinations: The ultimate goal of a Board-certified training programme is to prepare trainees to successfully pass the certification examination administered by the certifying board. They should be provided resources such as study materials, practice examinations, block lectures, and review sessions to help them prepare for this important milestone.
As far as financing and resources are concerned, the professional bodies and specialty associations may be able to adequately finance such a program independently.
The faculty is formed by specialists who can voluntarily provide their services without any salary, and the facilities, equipment, and administrative costs can be easily borne by the various professional bodies and specialty associations.
As far as curriculum development is concerned, developing a comprehensive curriculum that meets the requirements of the medical board while also providing trainees with a well-rounded education can be complex and time-consuming.
Ensuring that the curriculum stays up to date with advances in the field can also be a challenge. With the professional bodies of medical specialists leading the Board, all up-to-date comprehensive curriculum may be easily managed by the specialists themselves from the professional body,
It is pertinent to note that:
- The programme must ensure that trainees receive proper supervision and are adequately trained to meet the standard of care for the specialty.
- The trainees must be adequately supervised by qualified instructors to ensure patient safety and minimise the risk of malpractice claims.
Rigorous supervision of the medical specialty training programme can only be effectively conducted by the specialists within the professional body.
A good example of a Board-certified medical specialty training programme is the pioneering Board of Urology, Malaysia, of which much can be learnt from as an example of how such a training programme has been initiated and established in this country.
The Malaysian Board Of Urology
The Malaysian Board of Urology (MBU), which was formed by the Malaysian Urological Association, has been conducting its Board of Urology training and exit examination certification since 2000.
The Malaysian Urological Association (MUA) established the MBU and held its first exit examination in November 2000. Subsequent examinations were conducted by the MUA with the participation of invited external examiners from Asian countries, Australia, and the United Kingdom.
Formal urology training is in many ways unique, since it is driven by a professional society with the involvement of the MOH, together with universities and private-sector urologists.
MBU members are comprised of all the heads of the urology training centres in public hospitals and universities, with the chairman being the national head of urological services for the MOH.
In 2008, the MBU held its first conjoint MBU/FRCS Glasgow urology examination in collaboration with the Royal College of Physicians and Surgeons, Glasgow, with conjoint examinations held annually every November at Selayang Hospital.
With trainees from Singapore, Brunei, Myanmar, and many other countries in the region sitting for this examination, Malaysia has become the hub for the FRCS Glasgow urology exams in the region.
Having exit examination certification is one noteworthy achievement, but having it benchmarked with the participation of one of the Royal Colleges is a major success.
The curriculum sets out knowledge, skills and personal attributes the trainees will achieve. In developing the curriculum, the members draw on established programmes in the UK and Australia, as Malaysian medical education is traditionally closely linked with these two countries.
The curriculum is structured with transparent processes for all the stakeholders. It aims is to produce competent urologists with the necessary expertise and experience for independent urological practice in Malaysia.
However, the curriculum must also allow for changes which may be necessary from time to time, in view of any advances in knowledge, technology, and practice for the better.
There are currently more than 140 urology consultants in Malaysia. The MBU is the sole body conducting and regulating the Malaysian urology training programme.
The chairman of the MBU is the head of urology services at the MOH, and other members include the heads of urology from public and university training centres. Two private urology consultants are also elected to the Board and serve a term of three years. There are in total 15 board members.
The MBU conducts trainee evaluations twice a year, during which time decisions are made on the progress and rotation of the trainees.
Trainees will also be required to submit a confidential feedback evaluation form regarding their supervisor and training centre to the chairman of the MBU during this time.
Other stakeholders of the training programme include the MUA, which governs the finances of the MBU, and the Royal College of Surgeons, Glasgow, which sets the examination standard and runs the conjoint exit examination.
In the current system, only consultants within the public system are clinical supervisors involved in the training of urologists. There are currently 21 clinical supervisors.
Under an initiative started in 2017, known as the Public Private Partnership for Urology Malaysia (PPPUM), consultants from the private sector are encouraged to participate in the supervision of urologist trainees. They can apply and be selected to undergo a ‘train the trainer’ session before being appointed as a clinical supervisor.
Clinical supervisors will have academic duties, providing tutorials, seminars, supervising ward rounds, conducting advanced urology block lectures, doing research, and providing clinical supervision. At present, there is no reward system for trainers.
There are (as of 2018) a total of 11 MOH training centres and four university training centres.
The duration of training is four years, and the training cannot extend beyond seven years. Progression is not time-based, but competency-based.
Competency at each stage will be evaluated based on logs and formative and summative assessments. Involvement in research, scientific presentation and publication is also required.
Completion of training requires the achievement of minimum standards required, which will lead to the completion of FRCSG (Urology) exit examination and the MBU certificate of completion.
The requirements for training centres include:
- The list of competencies of various procedures and surgeries to be acquired upon completion of training.
- Trainer-to-trainee ratio.
- Minimum qualifications and experience of trainers.
- Minimum requirements for educational resources.
- Minimum qualifications and experience of the Head of Programme.
Further information on the MBU curriculum may be accessed here.
The nephrology fraternity, who work closely with urologists. have also conducted their own successful Board-certified examinations, led by the Malaysian Society of Nephrology.
Coming back to the imbroglio that we are facing, how can a few specialists at a university conduct a full-scale specialist training programme with trainers, logs, referees, and third-party invigilators, and which must be recognised by other specialist peers in this country?
National Postgraduate Medical Curriculum Vs Board Certification
Unlike the National Postgraduate Medical Curriculum devised by the Medical Deans Council in August 2021, which pledged to promptly resolve specialist training issues and harmonise Master’s programmes and parallel pathway programmes, the Board Certification of Medical Specialty training programme is a truly independent Board run by specialists united by their professional medical specialist bodies and associations.
Harmonising or unifying the Master’s programmes and the parallel pathway programme with a single curriculum may temporarily solve the current impasse, and is an efficient temporary solution.
But more importantly, how does the current deeply divided and divisive groups of specialists on both sides work together harmoniously after all that mud-slinging and name-calling?
Remember, medical specialists and consultants are very highly independent professionals who will not sway from what they feel is right. Even if an amendment of the law is done to ensure that there is unification and harmonisation of both sides, there will unlikely be any sort of smooth sailing from hereon.
What we subsequently need is a permanent solution to medical specialty training in this country.
In the Board-certified training programme, the medical specialists themselves should run the Board and direct the training and examination of the medical specialty of their professional body.
The MBU training programme is proof that a unified Board training programme has been highly successful in producing top-notch specialists.
Leading the way with a unified Board specialist training should be the way forward for medical specialisation in Malaysia.
It is best for universities to focus on training undergraduate medical students, and leave postgraduate specialisation and sub-specialisation to professional bodies and specialist medical associations to conduct medical specialty training and examinations.
Although hard to swallow, we have to finally accept that medical specialty training should solely be conducted by medical specialists themselves, represented by their professional bodies, without interference by third parties or non-medical administrators.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
