CodeBlue’s Guide For MPs To Parallel Pathway Issue

CodeBlue’s guide for MPs to the parallel pathway issue: it’s essentially about proponents wanting an exemption or less regulation for the parallel pathway for medical specialty training, by amending Act 50, because they believe doctors can “self-regulate”.

KUALA LUMPUR, June 24 — The parallel pathway issue may be brought to Parliament if Health Minister Dzulkefly Ahmad introduces a bill in the current meeting to amend the Medical Act 1971 (Act 50).

CodeBlue has prepared a straightforward guide for MPs (and the general public) to grasp this issue involving medical specialty training that has split specialist doctors across both the Ministry of Health (MOH) and the Ministry of Higher Education (MOHE).

Essentially, parallel pathway proponents want a formal exemption from the law or reduced regulations by amending the Medical Act, even though its 2012 amendment was enforced just seven years ago in 2017.

For a two-page mini guide version, click here to download the PDF.

1. What is the parallel pathway?

The Parallel Pathway is a set of training programmes by the MOH for medical specialties in collaboration with the Academy of Medicine of Malaysia (AMM), local medical associations, and foreign royal colleges, primarily from the UK and Australia.

The programme consists of 48 months (four years) of training and six months of gazettement.

There are currently 18 specialist qualifications from parallel pathway programmes with foreign institution exams in various specialties, 14 of which were endorsed or recognised by the Malaysian Medical Council (MMC) in 2017, “notwithstanding that these qualifications had not been accredited” by the Malaysian Qualifications Agency (MQA) or MMC, according to MMC’s June 15 affidavit filed in the High Court here. Only four specialist qualifications in the parallel pathway, including the FRCS Edinburgh in Cardiothoracic Surgery, are not recognised by MMC.

The royal college examination offered in the parallel pathway programme — specifically the cardiothoracic surgery parallel pathway with the Royal College of Surgeons of Edinburgh (RCSEd) — is an international commercial programme tailored for markets like Malaysia, Singapore, Brunei, and Hong Kong, presumably to boost local capacity in these countries.

This exam is not equivalent to the domestic examination offered by the same institutions in the UK. In essence, the parallel pathway is similar to a twinning programme where all the training and curriculum are conducted locally, and the exam is endorsed by the royal college.

However, unlike a twinning programme offered by a local university in partnership with an overseas institution, the parallel pathway is conducted without a local higher education institution counterpart.

Instead, for the cardiothoracic surgery parallel pathway, training is carried out fully in MOH facilities, while the curriculum was “designed and developed by the Malaysian Association for Thoracic and Cardiovascular Surgery (MATCVS) in collaboration with the RCSEd”, according to a March 20, 2023 email by RCSEd to MMC, obtained from court filings.

Assessments are carried out by MATCVS, while MOH provides training slots and facilities, supervision, and financial assistance, according to MMC’s June 15 affidavit.

Universiti Teknologi Mara’s (UiTM) cardiothoracic surgery postgraduate programme is NOT a parallel pathway programme; it’s a local university programme.

2. What is a local Master’s programme?

A local Master’s programme is a four-year training programme in various subspecialty areas conducted by local universities.

The first local Master’s Medicine programme started at Universiti Malaya in 1973. Currently, 11 public universities offer 25 Clinical Master’s specialist programmes, with at least four more at a private university.

However, admission to these programmes is limited due to scholarships from the Public Service Department (JPA) and funding constraints from the MOHE.

UiTM’s cardiothoracic surgery postgraduate programme, in collaboration with the National Heart Institute (IJN), is the country’s first such local programme. It includes a two-year Master in Surgical Sciences (Cardiothoracic) and a four-year Doctorate in Cardiothoracic Surgery.

The UiTM-IJN cardiothoracic surgery postgraduate programme received provisional accreditation from MQA from August 13, 2020, to August 12, 2025. Full accreditation will be granted once the first cohort reaches their final year, after which the accredited programme will be listed in the Malaysian Qualifications Register (MQR).

Prof Dr Raja Amin Raja Mokhtar, a senior consultant cardiothoracic surgeon at UiTM and former MATCVS president, proposed opening up admissions to the UiTM-IJN programme to non-Bumiputera. This would allow over 30 trainees and graduates, across ethnicity, of the RCSEd parallel pathway programme to transfer credits and map their curriculum to the UiTM-IJN programme, obtaining their qualifications within six months to a year.

3. What is the problem?

The issue surrounding the parallel pathway programme came to the forefront in December 2023, when the MMC rejected specialist registration applications from at least four cardiothoracic surgery graduates on the NSR.

The MMC stated that it never recognised the parallel pathway programme in cardiothoracic surgery conducted with the RCSEd in the UK.

In response, legal challenges have been initiated against the MMC, including cases by the four cardiothoracic surgery parallel pathway graduates, plus separate lawsuits filed by a neurosurgeon who is a Fellow of the Royal College of Surgeons in Ireland (FRCS Ire) in neurosurgery, as well as six medical genetics pathology graduates from Universiti Sains Malaysia (USM).

4. Are parallel pathway programmes recognised in their home countries?

MATCVS claims that the qualification awarded at the end of the cardiothoracic surgery parallel pathway — the FRCS Edinburgh in Cardiothoracic Surgery — is a fully recognised qualification in Singapore, Hong Kong, and Brunei, besides being acceptable and registrable in the UK.

The exit examination for the cardiothoracic parallel pathway training is the RCSEd Joint Specialty Fellowship (JSF) Examination in Cardiothoracic Surgery.

However, in a response to CodeBlue in May, the United Kingdom’s General Medical Council (GMC) – which regulates the medical profession across England, Scotland, Wales, and Northern Ireland – stated that it does not recognise the FRCS Edinburgh in Cardiothoracic Surgery for specialist registration in the UK. But graduates are eligible to apply to practise as a medical doctor and seek junior positions in the NHS.

The GMC does not consider the JSF exam by the RCSEd — used in the cardiothoracic surgery parallel training in Malaysia — to be equivalent to the Intercollegiate Specialty Fellowship Examination by the Joint Committee on Intercollegiate Examinations.

There are various paths for specialist registration in the UK, including a Certificate of Completion of Training (CCT) for doctors who completed an approved training programme in the UK and the Portfolio Pathway for doctors who have not trained in an approved programme.

The GMC noted that there is no mandated exam as part of the Portfolio application for entry onto the UK Specialist Register. In other words, individuals with or without formal qualifications (from any country) can apply via the Portfolio Pathway to register as specialists in the UK. But each case is evaluated individually based on the applicant’s body of work, hence the name, “portfolio”.

CodeBlue does not have information regarding the status of recognition in home countries for other parallel pathway programmes.

5. Who has legal ownership/ accountability of parallel pathway programmes?

    In both local Master’s programmes in medicine and parallel pathway programmes, training typically occurs within MOH facilities. However, the issue of ultimate responsibility for training ownership becomes crucial, especially in cases of medical negligence.

    For local Master’s programmes, universities can be held legally accountable if issues of medical negligence arise during training. In contrast, the responsible party for legal accountability in the case of parallel pathway graduates is ambiguous.

    The cardiothoracic surgery parallel pathway programme was carried out “solely” on the basis of memorandums of understanding (MOUs) entered into by the RCSEd, the Academy of Medicine of Malaysia (AMM), and MATCVS, according to MMC’s June 15 affidavit. MOH was not a signatory to any of these MOUs.

    “There is in fact no statutory governance over the conduct and administration of the parallel pathway training towards the FRCS Ed CTS qualification,” MMC said in its affidavit.

    There is no law enabling MOH to function as a recognised education provider. Besides serving as the country’s biggest health care provider, the MOH also plays regulatory functions (under various Acts), primarily setting very stringent standards for private health care facilities and services (MOH facilities are exempt from these standards), pharmaceuticals, and medical devices, among others.

    RCSEd does not have a local campus, unlike institutions like Monash University that is based in Australia and has a campus in Malaysia.

    MATCVS, AMM, and the College of Surgeons under AMM are registered societies under the Registrar of Societies (RoS), or essentially non-governmental organisations (NGOs), not education providers or training institutions. MATCVS, AMM, and the College of Surgeons also do not function as regulators as they are not statutory bodies, unlike the MMC or MQA.

    According to its website, the principal aim of MATCVS is to serve as a forum for professional discussions, coordinate local cardiothoracic surgeons; activities, and promote cardiothoracic surgery in Malaysia and internationally through global networking.

    MATCVS also advises governmental policy makers on relevant health care issues, including credentialing and accreditation of cardiothoracic specialists via the NSR. However, it does not provide specialist training.

    Similarly, the College of Surgeons under AMM does not provide specialist training, although it does offer preparatory and support courses for its members.

    6. What does the Medical Act say?

    The MMC is a statutory body that regulates the practice of medicine across both public and private sectors. Under the Medical Act 1971, the MMC’s role includes registering medical practitioners and overseeing the practice of medicine.

    Amendments to the Act in 2017 expanded the MMC’s responsibilities to include registering specialists on the NSR and recognising specialist qualifications and training.

    Section 14B of the Act amended 2012 specifies that individuals seeking specialist registration on the NSR must have completed specialised training in a “recognised training institution”, hold a recognised specialist qualification, and demonstrate fitness and good character to the Council’s satisfaction.

    MMC’s powers, outlined in Section 4A of the Medical Act, grant it authority to recognise and accredit medical qualifications based on recommendations from the Joint Technical Committee established under the Malaysian Qualifications Agency (MQA) Act 2007.

    MQA collaborates with MMC specifically on accreditation and recognition activities of medical institutions within Malaysia, but does not have the authority to register medical practitioners that is solely under MMC’s jurisdiction.

    MMC has cited adherence to Section 14B in rejecting NSR registration for several graduates of parallel pathway programmes, arguing that these programmes do not meet the requirement of being recognised by their respective “home” countries.

    7. Without NSR registration, can parallel pathway graduates still practise as specialists?

    Yes, they can — in the public health service. Graduates from four specific parallel pathway programmes have been granted gazettement by the MOH.

    These include the Fellowship of the Royal College of Surgeons of Edinburgh in Cardiothoracic Surgery, Fellowship of the Royal Australian College of General Practitioners, Membership of the Irish College of General Practitioners, and Fellowship of the Royal College of Surgeons of Glasgow in Plastic Surgery.

    Gazettement allows these doctors to practise as specialists in MOH facilities and receive specialist allowances from MOH. They can begin working immediately without needing NSR registration.

    NSR registration is only required for doctors intending to engage in private practice.

    8. What about MMC rejecting NSR registration applications by USM medical genetics pathology graduates?

    Six pathology graduates specialising in medical genetics from USM filed a judicial review against the MMC after their applications for specialist registration on the NSR were rejected, due to the MMC not recognising their Master of Pathology (Medical Genetics) qualification, despite MQA accreditation.

    This legal challenge contrasts with the MMC’s rejection of NSR registration applications from four cardiothoracic surgery graduates from the RCSEd, as the USM case involves a local university programme, not the parallel pathway.

    USM’s medical genetics programme in pathology is not alone in facing these challenges. MMC’s reluctance to recognise certain subspecialties — like clinical immunology, clinical research, or medical doctors holding additional qualifications in non-clinical fields like LLB for medicolegal or MBA for business administration — highlights ongoing concerns.

    While the parallel pathway (at least cardiothoracic surgery) isn’t recognised due to the lack of MQA accreditation or non-recognition in the home country, the MMC also refuses to provide NSR specialist registration to graduates from certain specialties, like those mentioned above, even though these local university programmes are accredited by MQA.

    Why? As science develops, universities tend to be faster than regulators in adapting and growing new fields in medicine. (With MMC being so closely tied to MOH, there are also potential budgetary constraints with recognising new specialties).

    This situation suggests a need for MMC to adopt a more flexible approach. Such matters, ideally, should be resolved through professional dialogue rather than amendments to the Medical Act. The medical profession itself should lead discussions on these issues, rather than rely on legislators, government officials, or politicians to address them.

    9. How structured is the parallel pathway?

    Former Health Minister Dr S. Subramaniam — who served from 2013 to 2018 — has admitted to a “weakness” in the structure of the MOH’s parallel pathway training with royal colleges in the UK, compared to the “very structured” local Master’s programmes.

    In reference to parallel pathway training with royal colleges, he said: “… although the skill sets are defined, what kind of training you undergo is defined — but they don’t conduct the training. The training is done by us. So it’s up to us to structure the training.”

    Critics have raised concerns about the alleged lack of close assessment and monitoring in parallel pathway training, which they argue could pose risks to patient safety.

    They oppose amending the Medical Act to accommodate what they perceive to be an irregular parallel pathway programme. This irregularity has been acknowledged by lawmakers and the government itself, by saying legislative amendments are needed to “regularise” the parallel pathway.

    Conversely, proponents of the parallel pathway programme argue that Malaysia’s specialist shortage justifies registering parallel pathway graduates on the NSR. Despite the controversy, parallel pathway graduates are currently allowed to practise as specialists in MOH facilities through gazettement by MOH, even without NSR registration.

    10. What is the proposed amendment to the Medical Act all about?

    The proposed amendments to the Medical Act reportedly include provisions for both the parallel pathway training and local Master’s programmes in medical specialisation, though specific details are undisclosed.

    Advocates of the parallel pathway are pushing for the MQA to be separated or decoupled from the Medical Act, which would reduce regulatory oversight of medical education.

    Currently, the Medical Act covers the registration of all medical practitioners, including those with basic medical degrees and specialist doctors.

    If the government were to decouple MQA from the MMC or Medical Act, CodeBlue foresees two scenarios.

    Scenario 1: MQA is decoupled solely from specialist registration.

    This raises questions about why medical specialty training (whether parallel pathway or local universities’ postgraduate programmes) should be exempt when undergraduate programmes remain under MQA regulation. Removing MQA oversight could also potentially relieve local universities of MQA accreditation requirements for their postgraduate medical programmes.

    Scenario 2: MQA is completely decoupled from the Medical Act.

    This means both undergraduate and specialist training in medicine would no longer fall under MQA’s purview, while university education in other fields remains regulated by MQA.

    If responsibility solely falls on the MMC, how would it effectively manage this role? The MMC operates through its Medical Education Committee (MEC) to determine the recognition of medical programmes to register medical practitioners. Without MQA oversight, who will monitor and audit these programmes, whether for postgraduate (specialty) or undergraduate (basic) medical education?

    MMC is not structured to directly oversee medical training, relying on MQA to first recognise educational programmes to ensure proper standards. MMC serves as the final checkpoint, not the primary overseer.

    If MQA were to be sidelined, MMC would need to adapt or establish new mechanisms to uphold the quality and standards of medical education.

    The central issue with decoupling MQA from MMC is whether it will disrupt the entire production of medical doctors across all levels in the country — by opening the floodgates to any NGO, society, college or university to create “basic” or “advanced” training programmes for aspiring doctors or specialists.

    Is the government’s response to non-compliance in the parallel pathway to reduce overall regulation, treating medical training as the “highest form of apprenticeship” akin to TVET?

    Perhaps the medical profession is unique and capable of self-regulation, similar to how the MOH urged the vape and tobacco industry to “self-regulate” after liquid nicotine was removed from the Poisons List to enable taxation on e-liquids.

    As a senior doctor suggests, there may be no need for strict regulation of doctors because “we are all professionals; there is no need for controls.”

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