PUNCAK ALAM, April 29 — A senior consultant cardiothoracic surgeon has challenged cardiothoracic surgery parallel pathway advocates to show evidence of direct recognition of the United Kingdom’s (UK) General Medical Council (GMC) for their programme.
Prof Dr Raja Amin Raja Mokhtar – who was president of the Malaysian Association for Thoracic and Cardiovascular Surgery (MATCVS) from 2017 to 2019 – explained his involvement in developing the Ministry of Health’s (MOH) cardiothoracic surgery parallel pathway programme with the Royal College of Surgeons of Edinburgh (RCSEd) during his presidency.
The former MATCVS president even went to Hong Kong in 2018 to sign a memorandum of understanding (MOU) for the Quadripartite Agreement to include Malaysia into the then-Tripartite arrangements between RCSEd, Singapore, and Hong Kong, establishing a new Quadripartite Exit Examination in Cardiothoracic Surgery.
Dr Raja Amin had also tried to identify training centres across Malaysia, especially in the Ministry of Health (MOH), for the cardiothoracic surgery parallel pathway programme and asked RCSEd if trainees could be trained in the UK too.
However, Dr Pala Rajesh, a senior RCSEd representative who was later elected RCSEd vice president, allegedly told Dr Raja Amin that the parallel pathway trainees could not train in the UK because the GMC – the UK counterpart of the Malaysian Medical Council (MMC) – did not recognise the Fellowship of the Royal College of Surgeons of Edinburgh (FRCS Ed) in Cardiothoracic Surgery. This qualification was considered an “International” degree, not the “Intercollegiate” degree recognised in the UK.
“He [Dr Rajesh] said, ‘We are okay with it, just that the General Medical Council in the UK does not recognise it for direct employment’,” Dr Raja Amin told CodeBlue during an interview last Monday at Hospital Al-Sultan Abdullah UiTM Puncak Alam.
“That means you have to still go through a certain screening process, a certain looking at all your paperwork before they can sort of recognise it. So I said, ‘Can we make a special arrangement? After all, we’re going to join the Tripartite, which later became a Quadripartite Royal College – Edinburgh, Hong Kong, Singapore, and Malaysia’. He said ‘No, this is up to the GMC’. So we knew there was a problem.”
Dr Raja Amin claimed that even though Singapore and Hong Kong are also part of the quadripartite Royal College, regulators in both countries, like the UK, do not provide “direct recognition” of the FRCS Edinburgh cardiothoracic surgery qualification.
“‘You have to come in, show us all the work that you’ve done. We will look through it, we will set you up with our doctors, our surgeons, for two years before we can gazette you and make you a consultant’ – Australia does that, Singapore does that, Hong Kong does that.”
Dr Raja Amin also claimed to have sighted a letter from RCSEd to the Malaysian Medical Council (MMC) back then that said the parallel pathway programme was FRCS International, the “commercial arm” of the RCSEd, hence why it isn’t recognised in the UK.
At the time of his MATCVS presidency from 2017 to 2019, Dr Raja Amin was head of cardiothoracic surgery at the Faculty of Medicine in Universiti Malaya that he led for 14 years – after having left private practice in KPJ Johor, where he served from 2000 to 2009 – to help rebuild cardiac surgery services at Universiti Malaya Medical Centre (UMMC).
He then retired briefly for three months in 2022 before joining Universiti Teknologi MARA’s (UiTM) Department of Cardiovascular and Thoracic Surgery, where he is currently a member of the Board of Studies of the cardiothoracic surgery postgraduate programme by a collaboration between UiTM and the National Heart Institute (IJN), the first and only such local programme in Malaysia.
Dr Raja Amin said when MATCVS received confirmation from RCSEd back then that the cardiothoracic surgery parallel pathway programme was not recognised by the UK’s GMC, one of his parallel pathway trainees in Universiti Malaya wrote to the GMC himself and received a similar answer. The doctor then quit the parallel pathway programme and moved to New Zealand.
“When that happened, my tenure [as MATCVS president] was finishing. So I told the next committee, ‘You guys need to sort this out. You still have about four years before these guys graduate’,” Dr Raja Amin said.
But four years after Dr Raja Amin’s two-year tenure as MATCVS president ended in 2019, the MMC rejected, in December 2023, applications by four pioneer graduates of the cardiothoracic surgery parallel pathway programme to register as specialists on Malaysia’s National Specialist Register (NSR).
In a March 25 statement, MMC president Dr Muhammad Radzi Abu Hassan, who is also the Health director-general, claimed that the MMC had never, at any time, recognised the FRCS Ed in Cardiothoracic Surgery. Health Minister Dzulkefly Ahmad later announced the government’s plans to table amendments to the Medical Act in the upcoming Dewan Rakyat that begins in the last week of June to enable recognition of the parallel pathway for medical specialty training, although he did not specify what exactly the amendments would be.
Initially Supportive Of Parallel Pathway, But Realised It’s ‘Not As Straightforward As You Think It Is’
Dr Raja Amin said as MATCVS president back then, he was initially supportive of the cardiothoracic surgery parallel pathway programme due to its “big hype” in Malaysia, with then-Health director-general Dr Noor Hisham Abdullah (who was also MMC president) and renowned cardiothoracic surgeon Dr Yahya Awang pushing for it.
At that time, Dr Yahya was chairman of the Malaysian Board of Cardiothoracic Surgery (MBCTS), set up by MATCVS to oversee the parallel pathway training.
“As we saw the paperwork and all the things that happened, we realised this is not as straightforward as you think it is. So we did the due diligence and saw it was not recognised in the UK. We were a bit upset about that. Why are we taking a degree that is not recognised in the UK?” Dr Raja Amin said.
One of MMC’s criteria for recognition of a postgraduate qualification from overseas, he said, is for the degree to be recognised in its home country.
Dr Raja Amin added that Dr Yahya then resigned as MBCTS chairman. Dr Yahya is MATCVS immediate past president, who was in office from 2019 to 2021, succeeded by current president Dr Basheer Ahamed Abdul Kareem.
MATCVS claimed in a statement last April 21 that the UK GMC recognises the FRCS Ed in Cardiothoracic Surgery.
“Tell them to give evidence – written evidence,” Dr Raja Amin said in response, when CodeBlue cited MATCVS’ statement.
The senior consultant cardiothoracic surgeon maintained that there are only two arms of FRCS: International and Intercollegiate, as he accused MATCVS of trying to position the parallel pathway programme as some sort of “third entity”.
“There is no third entity,” Dr Raja Amin said. “This ‘third entity’, when I talked to Pala Rajesh, is the International”.
Dr Raja Amin, who holds an FRCS Edinburgh qualification before Malaysia began the parallel pathway programme with RCSEd and a Masters of Surgery from Universiti Malaya, explained that the four royal surgical colleges – Edinburgh, Glasgow, Ireland, and England – came together in 2010 to hold one Intercollegiate examination and singular training across the UK. These centuries-old institutions then created a commercial arm, International, for countries that do not have their own surgical specialty training structures.
“They [RCSEd] specifically told us, ‘We give you the brand with all the structure because we are a good brand name. But you train your own people. You write your own exam questions. I asked, ‘Why can’t we use from your pool?’. They said, ‘No, no, that’s copyright. You have to create your own [exam questions], but of course we will be around. We will advise you what is good’.”
Dr Raja Amin is now president of the Society of Thoracic Surgeons of Malaysia, a new association that exclusively comprises cardiothoracic surgeons registered on the NSR.
UK GMC: Portfolio Pathway Application For ‘Doctors Who Haven’t Completed A GMC Approved Programme Of Training’, Non-JCIE Exam ‘Versions Of FRCS’ Likely Insufficient
In an open letter to Health Minister Dzulkefly Ahmad, published by CodeBlue last April 1, RCSEd president Prof Dr Rowan W Parks did not state that the FRCS Ed in Cardiothoracic Surgery is directly recognised by the UK GMC.
He instead said graduates with that qualification are eligible to apply for specialist registration as cardiothoracic surgeons in the UK via the “Portfolio Pathway”.
The UK GMC’s website, accessed by CodeBlue yesterday, states that its guide on Portfolio Pathway applications to register as a specialist or GP (general practitioner) in the UK is for “doctors who haven’t completed a GMC approved programme of training, but you can show you have knowledge, skills and experience of an eligible specialist/ GP in the UK”.
GMC-approved postgraduate curricula, according to the UK GMC’s website, specifies the Intercollegiate Specialty Board examination in Cardiothoracic Surgery in the approved cardiothoracic surgery curriculum. This is not the exam used in MOH Malaysia’s cardiothoracic surgery parallel pathway programme with RCSEd.
The UK GMC’s guide on Portfolio Pathway applications is complex. It includes Specialty Specific Guidance (SSG) for each Certificate of Completion of Training (CCT) Specialty. The Cardiothoracic Surgery SSG is listed under the Joint Committee on Surgical Training (JCST).
The UK GMC’s Cardiothoracic Surgery SSG document for doctors applying for entry onto the UK’s Specialist Register via the Portfolio Pathway in Cardiothoracic Surgery, updated on November 16, 2023, states that most applications contain around 800 to 1,000 pages of evidence.
RCSEd president Dr Parks, in his letter to Dzulkefly, said the exit examination for the cardiothoracic surgery parallel pathway training is the RCSEd Joint Specialty Fellowship (JSF) Examination in Cardiothoracic Surgery. The RCSEd JSF exam has been used in Hong Kong and Singapore for more than 20 years.
Dr Parks claimed that the RCSEd JSF exam is “to the same standard” as the UK Intercollegiate Specialty Board examination in Cardiothoracic Surgery run by the Joint Committee on Intercollegiate Examinations (JCIE).
However, the UK GMC’s SSG on cardiothoracic surgery specialist Portfolio Pathway applications states that if applicants did not take the JCIE specialty examination, FRCS (CTh) – which demonstrates knowledge appropriate for specialist practice in the UK – they can submit alternative evidence, “but you will need to bear in mind that this needs to be very strong”.
In fact, the SSG document does not mention the RCSEd JSF exam at all. Instead, it lists “other examinations including overseas qualifications, and versions of the FRCS issued by individual colleges that are not the JCIE exam” as examples of part of a portfolio to demonstrate knowledge, “although it is unlikely that any one item would do this”.
On this point, the UK GMC’s SSG states: “A certificate of success alone will not show that you currently have the appropriate level of knowledge. Decisions are made on a case-by-case basis”.
“It is unlikely however that any qualification on its own, other than the JCIE exam, will show knowledge appropriate for specialist practice”.
The UK GMC’s SSG document further states that if applicants do not hold the JCIE or a “comparable qualification”, they can aim to demonstrate the same level of knowledge by providing a “detailed, thorough and succinct cross-referencing mapping exercise, demonstrating how each and every JCIE competency (Part 1 and 2) has been covered in their own qualifications”.
“The evaluators will then determine whether what has been provided is comprehensive enough to demonstrate the same level of knowledge as the JCIE. Applicants must be aware that as no other qualifications are considered directly comparable, this will be assessed on a case-by-case basis and will require the applicant to produce an extensive portfolio of evidence.
“If your portfolio includes other qualifications or tests of knowledge, then you should supply the relevant syllabus/ curricula, show what the qualification tests, and explain how it tests i.e. you need to provide details about the scope and format of the exam. You will need to show how the individual elements of your portfolio combined to demonstrate knowledge appropriate for Specialist Practice in that specialty in the UK”.
