It’s Not Easy To Become A Heart Surgeon, Howard Lee — Prof Dr Raja Amin Raja Mokhtar

Responding to Ipoh Timor MP Howard Lee, cardiothoracic surgeon Prof Dr Raja Amin Raja Mokhtar says apprenticeship is an outdated and impractical form of training for specialisation in medicine, stressing monitoring and assessment in a structured programme.

With respect, Ipoh Timor MP Howard Lee appears to understate the sheer difficulty of medical specialisation training, particularly in my field of cardiothoracic surgery, by describing the parallel pathway as the “highest form of apprenticeship”. 

YB Lee also said he is backing proposed amendments to the Medical Act 1971.

A simplistic view from the outside is definitely not the same as those from within the system itself.

Let’s take an example closer to home for our learned Member of Parliament – an apprenticeship to become a chef.

As you go along training to become a chef, a few mistakes are acceptable; learning is perhaps through a process of trial and error. Tolerance to quality, or lack of it, may even depend entirely on the whims and fancies of the Master Chef.

But to become an expert in preparing a pufferfish dish, one must have a licence to handle this deadly delicacy. In Japan, the certification of skills required to remove poison from said fish is only given to a qualified fugu handler. 

I believe that the road to obtaining such a licence is much more stringent and difficult, with strict rules and regulations, before one can dream of better financial renumeration as an end goal. 

I am sure that incomplete skillsets will not be tolerated, as pufferfish consumers may die from tetrodotoxin poisoning, a form of potent neurotoxin that blocks voltage-gated sodium channels in the nerve cell membrane, preventing muscle contraction.

There have been incidents where whole families or guests have died from eating pufferfish in Malaysia. 

Similarly, developing skills to become a heart (cardiothoracic) surgeon will require proper licensing or accreditation to ensure high quality and competency for the safety of the public. 

One cannot take this lightly, as we are dealing with human lives. Zero tolerance for error is mandatory. 

Training via apprenticeship to become a heart surgeon is not comparable to anything – not even to any other subspecialty training within the surgical fraternity.

Apprenticeship Training Of Yesteryears: Promotion Sometimes Subject To Voting 

I remember the time when I decided to become a cardiothoracic surgeon. I was in a four-year Master’s of Surgery course conducted by a local university.

My determination to become a cardiothoracic surgeon did not wane. I applied to join the National Heart Institute (IJN) soon after, and accepted the position of Senior Registrar (a training position) at IJN. 

Thus began a gruelling work schedule and culture, requiring us trainee surgeons to be at the hospital before dawn and end way beyond dusk, at times at midnight.

We handled all matters related to patient care and prepared for teaching sessions, presentations at conferences and seminars, as well as publications in peer-reviewed medical journals.

We adhered to the same insane schedule daily for the next six to 10 years. 

Whether you get to be trained depends on the consultant surgeon that you are rostered or posted to — for a period of three to six months. 

If luck happens to be on your side, you are given more chances to do more procedures within an operation. We have to be at the top of our game to maintain a reputation of high-quality work. 

If you make any mistakes or you’re deemed not good enough, you will be relegated to perform smaller procedures, until a time when your consultant allows you to perform a more important task. 

As you progress in your work over the years, you may end up doing the entire surgery independently. As the number of surgeries you perform accumulates over time, you become more skilled and independent. 

The apprenticeship process is slow, gruelling, and totally at the discretion of the consultant or trainer.

When IJN finally considers promoting you to become a consultant cardiothoracic surgeon, it is only decided after much deliberation at the Board level. and, at times, through a voting process. 

Our future was determined by these Board members, who were consultants in cardiology, anaesthesiology, and cardiothoracic surgery itself. 

To be fair to them, they do know us quite well, having observed our work quality in terms of attitude, discipline, competency, and hand skills. This was mainly done subjectively, with some objective assessment involved.

The last question before deciding whether to make you a consultant surgeon and join their ranks was always: “Would you allow him or her to operate on your close relatives, such as parents and siblings?”

You are at the mercy of your bosses; your future totally depends on their approval and green light.

Trainees wait six to 10 years to be acknowledged as fully trained and considered consultant surgeon material. Some never became consultants even after 10 to 15 years within the Institute.

This was the apprenticeship programme that we had to go through. 

I strongly believe that it is an outdated and impractical form of training in this day and age.

Structured Six-Year Training Programme: Trainee Assessment Is A Full-Time Job

After the advent of the structured programme, trainees know what skillsets are needed at which level of year that they are at within a six-year programme. Thus, training is assured for all candidates in the course. 

Trainees come into the programme at a much younger age. They are medical officers, not postgraduate students, and thus, lack maturity, experience, and hand skills compared to those who come in with a Master’s qualification.

This is a point one has to seriously take into consideration.

To have such training at the medical officer level (not postgraduate or Master’s), and for the training programme to be a success, careful monitoring of progress of learning and training outcomes is mandatory. 

If this is not taken seriously and done in a slipshod manner, we will end up with incompetent surgeons with poor decision-making and operative skills. 

This is my area of concern if trainers are doing this on a part-time basis. Surgeons in the Ministry of Health (MOH) are already overwhelmed with running service work as health care providers.

Adding onto them the burden of teaching and training is simply not practical. 

Trainers need to be upskilled via train-the-trainer (TTT) courses and regular updates on training methodology. Trainers must also understand the importance of honest and objective assessments of trainees via supervisor reports. 

These assessments need to be robust, honest, and taken very seriously. It is not for those who wish to do this as a part-time endeavour – while juggling busy government service work or private practice – as seen among current parallel programme trainers.

There are already red flags that indicate that all is not well with the running and implementation of the parallel pathway programme.

Nobody is questioning the quality and structure of the Fellowship of the Royal Colleges of Surgeons (FRCS), United Kingdom. Rather, it is the implementation of the programme that is of major concern.

Training And Assessment In UiTM-IJN Cardiothoracic Surgery Postgraduate Programme

I am a member of the Board of Studies in the cardiothoracic surgery postgraduate programme, via a collaboration between Universiti Teknologi MARA (UiTM) and IJN. 

I perform an average of two to three surgeries per week at UiTM Hospital on Tuesdays and sometimes Thursdays, where I operate together with trainees of the UiTM-IJN cardiothoracic surgery postgraduate programme. 

At times, they will do the major part of these surgeries under my observation. Every day, we perform ward rounds and discuss cases. On Fridays, I run a clinic and give consultations. I also operate and assist in surgeries at Universiti Malaya Specialist Centre (UMSC).

So how is what I do different from what is done by parallel pathway trainers who themselves act as health care providers too?

In the UiTM-IJN cardiothoracic surgery postgraduate programme, we diligently follow a proper structure and record the progress of trainees. We emphasise and insist on accurate assessment by all trainers, currently from UiTM, UM, and IJN. 

We have regular monthly, quarterly, and half-yearly meetings between trainers, as well as between trainers and trainees. We assess them on a daily basis, with all questions and answers, plus scores, recorded into the trainee database.

All assessments — including operative skills, attitude, attendance, proactiveness, as well as 360-degree evaluations — are recorded, documented, and are easily accessible by both trainers and trainees. 

We have an office with six personnel on our team: four clerical staff members and two with MBA degrees, plus a former medical graduate who chose not to be a doctor.

Most importantly, we have a dedicated programme coordinator who ensures that the programme is implemented and run efficiently and diligently. 

In short, we are pushed to teach trainees and collect data to monitor their progress, or the lack of it. With the latter, early intervention can be taken immediately. 

The parallel pathway programme, on the other hand, only has one clerk in their office to answer calls and enquiries. There is no clear line of assessment or proper monitoring of trainees.

One All-Inclusive National Training Programme With Trainers From Universities, MOH, IJN, Private Sector

Howard Lee mentioned that the fundamental notion is “not exclusively KKM parallel pathway or Master’s by universities; it must be both”.

I would like to emphasise, again and again, that the issue was never about which pathway or programme. 

Instead, it is about the need to monitor the progress of surgical trainees in all skillsets, including critical thinking, decision-making, discipline, attitude, interpersonal interaction, and maturity.

We require all trainers from universities, MOH, IJN, and the private sector (optional) to come together under one National Training Programme under one National Board of Cardiothoracic Surgery for Training, not two separate programmes. 

The issue of informal, non-accredited, on-the-job training versus a formal, structured postgraduate clinical programmes accredited by external regulators will be solved.

All trainees will undergo training through a rotation posting to all hospitals throughout the country.

Being institutes of higher learning, universities will be familiar with monitoring the progress of trainees and are able to objectively assess learning outcomes. Thus, they will play that role.

MOH hospitals, IJN, and university hospitals, which provide health care services, will also provide places where training can be conducted. Trainers will be given instructions on how to train via courses provided by universities. 

The MOH should not play an additional role as educator and trainer, but stick to its core function as a health care service provider, and work together and function synergistically with higher education institutions.

There is no “monopolisation” of recognition and accredition of local Master’s programmes in medicine, as alleged by Howard Lee. Nor is there an issue of “cutting out the largest health care provider in the country”. 

Instead, we should have an all-inclusive National Training Programme. There is no need to have separate pathways or programmes, but one programme for all trainees in specialisation in medicine in Malaysia.

However, similar to the pufferfish dish analogy, the quality of the training programme will require accreditation (licensing) to ensure quality and safety.

Royal College of Surgeons of Edinburgh vice president Tim Graham and Joint Committee on Intercollegiate Examinations chairman Dr Michael Lewis reportedly said that parallel programme candidates would “undergo assessments via the UK’s portfolio pathway, similar to the practice in other countries, including Malaysia, before being registered as specialists”. 

They are in total agreement with what we have always said – that trainees must undergo assessment. There is no direct recognition or amendment of the law. Just undergo assessment – in the case of Malaysia – by the Malaysian Medical Council (MMC).

Why is it that we respect the authority of the UK General Medical Council (GMC), but not the MMC? 

Since a National Training Programme will be totally run in Malaysia by Malaysian trainers, it will be a fully local programme, thus arguably requiring assessment by the Malaysian Qualifications Agency (MQA). 

Comprehensive Stakeholder Engagements Necessary, Don’t Bulldoze Bill Through Parliament

The MOH and the Ministry of Higher Education (MOHE) will need to engage and discuss with stakeholders – both opponents and proponents of the issue – before tabling any amendment bill in Parliament, although I personally do not believe there is a need to amend the law.

So far, the MOH has only engaged with the Malaysian Association for Thoracic and Cardiovascular Surgery (MATCVS) that currently does not represent cardiothoracic surgeons, as only 28 per cent of its members are certified on the National Specialist Register (NSR).   

The remaining MATCVS members are trainees, medical officers, and other specialist doctors in fields related to cardiothoracic surgery, such as cardiology, anaesthesiology, and respiratory medicine.

The government will need support from all sides through comprehensive stakeholder engagement meetings, rather than try to bulldoze a potentially faulty bill through Parliament in a few weeks with huge ramifications.  

This is especially crucial, because medical specialty training is a highly complex issue that is barely understandable to legislators who will be making a decision for the entire medical profession, unlike, say, an anti-tobacco bill.

For the Control of Smoking Products for Public Health Bill, the MOH held a whopping 129 stakeholder engagement sessions over a period of about two years – including with tobacco and vape companies – before the Bill was passed by Parliament in December 2023 as the country’s first standalone tobacco and vape control Act.

If the MOH could engage even with Big Tobacco, Public Enemy No. 1, then surely fellow medical professionals in the ministry can meet us – their very own colleagues – on an issue that concerns our profession?  

The Society of Thoracic Surgeons of Malaysia was formed by NSR-certified cardiothoracic surgeons as the right representative and stakeholder from the cardiothoracic surgeon fraternity.

We appeal to the Honourable Ministers of Higher Education, Health, and the Prime Minister himself to meet with us, discuss, and understand our viewpoints and perspectives before making a momentous decision that will define the direction and policies for the medical profession in Malaysia.

As I previously emphasised, parallel programme trainees are not competently trained – yet. They are only competent at their current level, but will require more monitoring and assessment before they can be made fully independent consultants. 

Remember the surgeon’s motto: Primum non nocere – first do no harm.

Prof Dr Raja Amin Raja Mokhtar
MBBS (Malaya), M. Surgery (Malaya), FRCSEd
Senior Consultant Cardiothoracic Surgeon
President of the Society of Thoracic Surgeons of Malaysia

  • This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.

You may also like