Nobody likes regulators. But medicine and health care are regulated far more stringently than other fields — for good reason.
It is hardly “irresponsible” – as fulminated by some MPs in Parliament in their defence of the parallel pathway – to question the quality of surgeons.
It would be irresponsible not to, especially when Health Minister Dzulkefly Ahmad himself acknowledged the irregularity of the parallel pathway that, to the Ministry of Health (MOH), necessitates amending the Medical Act, even though the 2012 amendment just came into effect less than a decade ago in 2017.
Although the health minister also claimed that all 120 local Master’s programmes in medicine are similarly “irregular”, despite their Malaysian Qualifications Agency (MQA) accreditation, he did not provide details.
Surgeons are not gods, demi-gods, or Marvel superheroes. Any ordinary Malaysian citizen, with or without a medical degree, has the right to question the quality and safety of any surgeon in this country.
“Who is MQA?” a doctor once proclaimed indignantly at a CodeBlue debate event on the parallel pathway issue.
If senior consultants take umbrage at being questioned, then perhaps the highly regulated medical profession isn’t the right job for them.
The Fellowship of the Royal College of Surgeons (FRCS) is just an exam. What matters is the training.
That’s why the United Kingdom and Singapore only recognise doctors who were locally trained in their respective countries for specialist registration, although these countries also review applications from doctors trained outside on a case-by-case basis, presumably to avoid excluding potential talent.
The Royal College of Surgeons of Edinburgh’s (RCSEd) Joint Specialty Fellowship (JSF) in Cardiothoracic Surgery exit examination conducted in Singapore, Hong Kong, and Malaysia is a case in point. Singapore recognises cardiothoracic surgery trainees who successfully pass the JSF exam for specialist registration, but only those who were locally trained in Singapore.
So why doesn’t the Malaysian Medical Council (MMC)? It’s because the new cardiothoracic surgery parallel pathway programme initiated in 2016 is unregulated – meaning, standards for this training programme are unclear.
“There is in fact no statutory governance over the conduct and administration of the parallel pathway training towards the FRCS Edinburgh Cardiothoracic Surgery qualification,” says the MMC.
“The entire training programme has been carried out solely on the basis of the MOUs (memorandums of understanding) entered into by the RCSEd, AMM (Academy of Medicine of Malaysia), and MATCVS (Malaysian Association for Thoracic and Cardiovascular Surgery).”
As regulator of the medical profession, the MMC was doing its job in upholding the law so it can be confident that any specialist doctor it registers is safe and competent to provide treatment to the general public.
Yet, MMC was unfairly vilified as the villain in the parallel pathway conflict, labelled “cartel” and “gatekeeper”. Yes, MMC is the “gatekeeper” – to protect the Malaysian people in a country where doctors are automatically trusted and their competence rarely questioned.
The keyword here is “standards”. Of course, medical negligence can occur even among doctors who underwent accredited specialist training or postgraduate programmes, but the intention of regulation is to minimise the risk of producing a doctor who cannot do what they are supposed to be able to do – by ensuring first that they fulfil standards.
Doctors should be familiar with the concept of minimising risk in medicine. Should we wait for injury or death to occur, or for a court to convict a doctor of negligence, before we start regulating medical specialty training in the parallel pathway?
No one is questioning the quality of trainers in MOH centres where training is conducted in the cardiothoracic surgery parallel pathway programme. What is in contention is the organising of the programme by the organiser and administrator that appears to be MATCVS.
RCSEd simply provides the exit exam and the FRCS qualification, but the curriculum was “designed and developed by MATCVS” with RCSEd’s collaboration, according to the UK-based surgeons’ society (RCSEd isn’t a university or higher education institution). Assessments are also carried out by MATCVS.
The cardiothoracic surgery parallel pathway programme and its training centres were accredited by RCSEd. But RCSEd isn’t empowered by Malaysian law to carry out accreditation; MMC’s stance is that “self-accreditation” isn’t available for professional programmes under the MQA Act 2007.
Basically, the cardiothoracic surgery parallel pathway is a local programme, not an international one, but run by a non-governmental organisation (NGO) instead of a university.
Can an NGO run a medical specialty training programme and produce specialists of standard? Perhaps it can, but right now, societies registered under the RoS are not legally empowered to do that because they are not higher education providers; nor are they structured for it. And to be frank, neither is the MOH.
MATCVS said in a February 15 statement that trainers involved in the cardiothoracic surgery parallel pathway programme “do so voluntarily and do not receive any payments or honorariums.”
Should medical specialty training be relegated to ad-hoc volunteer work, instead of structured university programmes where professors and trainers are paid to do this as a full-time job, and hence, are accountable for the outcomes of the training?
If there is no capacity to create clinical postgraduate programmes in local universities due to a shortage of specialists to train aspiring specialists, then there simply is no capacity.
Malaysia cannot artificially produce “specialists” from a training programme created outside the law that isn’t legally subject to standards.
MOH should perhaps focus instead on improving its working environment to retain talent, as attrition rates in the public health service rise across all levels: housemen, medical officers, and specialists.
The solution to a regulatory issue isn’t to abolish regulation – especially in the field of medicine. Regulation isn’t a mere “label”; local universities must comply with very stringent regulatory requirements before their Master’s programmes in medicine can be approved (read this op-ed on the intensive work involved in developing UKM’s paediatric surgery specialist programme).
What regulatory processes did the parallel pathway programmes undergo?
Malaysia should be moving forward with postgraduate medical education, not turning the clock back to apprenticeship. Medicine is not TVET.
More importantly, how can the government even think of reducing regulation in medical education or qualification — when the 2012 amendment of the Medical Act was drafted precisely to introduce such regulation with the National Specialist Register (NSR)? Why is the country moving backwards?
“Self-accreditation”, “self-auditing”, or self-regulation isn’t acceptable in medicine.
If the Medical Act amendment bill deregulates medical education (be it undergraduate, or specialty training or postgraduate) in any form, Prime Minister Anwar Ibrahim’s government will be responsible for unleashing – onto an unsuspecting public – medical doctors of unknown standards.
Singapore and other countries will likely also be hesitant to accept Malaysian doctors into their fold. I suppose that’s one way to curb the brain drain.
Anywhere around the world, the medical profession is required to be regulated by an external regulator. Malaysia should not be an exception.
Boo Su-Lyn is the co-founder and editor-in-chief of CodeBlue.
