In my earlier article, I discussed some of the problems facing specialist training in Malaysia: seniority versus merit, service requirements versus training, variable standards between training centres, and the danger of prioritising specialist numbers over quality.
Some of these problems may be cultural. We are often reluctant to question senior colleagues, avoid openly discussing failure and sometimes confuse respect for authority with an unwillingness to examine whether decisions are fair or effective.
We also have worthy national aspirations. We want more specialists, wider services and continued progress.
However, increasing numbers without addressing quality, fairness and accountability may simply make existing problems larger.
The system has existed long enough. It is time for it to mature.
This does not mean abandoning local training programmes or returning entirely to the old Royal College model.
It means retaining the strengths of our present system while incorporating some of the strengths of the previous one: transparency, merit, independence and accountability.
Democratising Specialist Training
My main suggestion would be to democratise the training process. The system should be genuinely open.
Entrance examinations already exist in many disciplines, such as MedEx. These should not be confused with the Part 1 or basic sciences examinations taken after entering training.
Today, passing the MedEx does not necessarily guarantee entry. Candidates may still be affected by departmental recommendations, available posts, seniority, and administrative decisions. A transparent system should allow all eligible doctors to apply.
Once a candidate passes an objective entrance assessment, national programme coordinators should carry the responsibility of identifying suitable placements in appropriately accredited hospitals.
Selection should be based on published criteria. Candidates should understand how marks are awarded, interviews are assessed, and final decisions are made.
A system cannot claim to be merit-based if candidates do not understand why they were accepted or rejected.
A Staged Training Model
The early stage of training usually focuses on basic knowledge, clinical skills and foundations relevant to the chosen speciality.
Trainees could be given a stipulated period to pass the relevant Part 1 or basic examination. During this phase, training could occur in any accredited hospital providing appropriate clinical exposure, supervision, and teaching.
However, trainees should be allowed to apply to these hospitals rather than being allocated entirely according to manpower needs. This could improve standards.
Hospitals with strong reputations for training would attract more and better applicants. Good training centres would have a stronger pool of candidates from which to select.
Centres with poor supervision, inadequate exposure, or little interest in teaching would attract fewer applicants, providing an incentive to improve.
As discussed in my earlier article, training should occur during day-to-day clinical work. Tutorials, teaching and increasingly online programmes should complement this, not replace it.
Candidates could pay their own examination fees during the initial phase. This introduces some personal responsibility, although mechanisms would be required to ensure capable candidates are not excluded purely because of financial limitations. With examinations conducted locally, costs should remain relatively affordable.
Candidates who fail to pass Part 1 within a stipulated period or number of attempts should have to reconsider their suitability for the programme. They may need additional training, transfer to another unit, or ultimately leave the pathway.
This may appear harsh, but specialist training cannot provide indefinite progression without evidence of achievement.
Failure, however, should not be treated as a personal weakness. Candidates should receive proper feedback and a fair opportunity to address deficiencies.
This structure could also allow scholarship providers and public service bodies such as the Public Service Department (JPA) to define clear KPIs before committing substantial funding to advanced training.
JPA would obtain its required period of service for assessment without initially paying course fees. It should also be remembered that a doctor serving in any government hospital is still serving the people.
Progression To Advanced Training
Once trainees pass the initial examination and demonstrate satisfactory clinical performance, they could apply for advanced training.
At this stage, scholarships or government sponsorship could be provided because trainees have demonstrated ability, commitment, and progression.
Advanced posts should be awarded based on merit, performance, and the needs of the discipline, not merely years of service.
This introduces competition, but competition is not necessarily harmful if the rules are fair and transparent.
Trainees would understand that progression depends on performance. Training centres would understand that capable trainees will favour centres offering strong supervision, adequate clinical exposure, and good outcomes.
Market forces should not control medical training, but allowing trainees some choice could create useful pressure for centres to improve.
Independent And Impartial Examinations
Universities, the Ministry of Health (MOH), professional colleges, and specialist bodies can all contribute to setting standards and conducting examinations.
However, strict impartiality must be maintained. As far as possible, trainers should not examine their own trainees in high-stakes assessments.
Theory papers must remain confidential. Reports or rumours of leaked questions or favoured candidates are extremely damaging, even when difficult to prove. Examinations must not only be fair; they must be seen to be fair.
External examiners, cross-institutional panels, and anonymous written papers should be used wherever practical.
As mentioned in my earlier article, one strength of the old Royal College system was that candidates were often assessed by examiners with no personal investment in the outcome. Our local system should preserve that degree of independence.
One difficulty is that current arrangements require universities to confer degrees. This could perhaps be addressed by trainees registering with universities after Part 1. Universities could continue providing courses, specialised exposure and, importantly, an environment encouraging curiosity, research and development.
Accreditation Of Training Centres
Universities and major MOH units should function as training centres only if they meet defined standards.
Recognition should not be automatic because a hospital is large, a department belongs to a university or its head is a senior figure.
Training centres should demonstrate adequate trainer-to-trainee ratios, facilities, case volume and diversity, educational activities, and reliable supervision.
Placement should be based on training needs, merit and, where possible, trainee preference. Likewise, trainees must understand that acceptance into preferred units depends on their own performance and suitability.
Both trainees and training centres should be accountable.
Independent Review And Feedback
Independent accreditation committees could include representatives from professional colleges, senior consultants, university training programmes, and MOH.
They should periodically visit training centres, meet trainers and trainees separately, inspect facilities, review training records, and examine both trainee logbooks and documented educational activities.
Accreditation should not be permanent. A centre failing to maintain standards should receive time and support to improve. If it repeatedly fails, its recognition should be suspended.
Trainees should also provide confidential or anonymous feedback covering supervision, clinical exposure, teaching, workload, workplace culture, and access to procedures.
Anonymous feedback can be misused, and isolated complaints should not automatically be accepted as fact. However, repeated concerns from multiple trainees over several years should not be ignored.
Training centres could be assessed by examination results, completion rates, clinical and procedural exposure, trainer availability, educational activity, trainee feedback, patient safety indicators, and external accreditation.
A system that evaluates trainees but never evaluates trainers or institutions is incomplete.
Malaysia’s hierarchical administrative culture may make it difficult to criticise a unit headed by a very senior individual or even a chief of service.
However, objective criteria and transparently published results would make findings much more difficult to dismiss.
Responsibilities Of Trainees And Trainers
A fair system cannot place all responsibility on the government, administrators, and trainers.
Trainees must accept responsibility for their own progress. They must attend teaching, read, prepare for examinations, maintain accurate logbooks, and actively seek clinical exposure.
Entering a postgraduate programme should not guarantee eventual specialist qualification.
As discussed in my earlier article, service work is itself part of medical training when properly supervised. The problem is not that trainees provide service; it is when service becomes their only function and training becomes incidental.
Over the years, I have heard trainees complain that they do not have enough “time to study”. But postgraduate medical training is not merely reading books and attending tutorials.
We learn from the patients we see and manage. Greater appropriate exposure should produce a better trainee.
This does not mean trainees should be flogged. It means clinical exposure remains fundamental to postgraduate medical training.
In return for commitment and satisfactory performance, trainees should expect fair opportunities, proper supervision and transparent assessment.
Trainers have responsibilities too. They should be selected because of clinical experience, professional standards and commitment to teaching, and should themselves be periodically evaluated.
Trainer development in assessment, feedback, and supervision may be useful. However, attending a trainer workshop does not automatically make someone a good trainer.
What matters is whether trainers consistently supervise, teach during clinical work, provide useful feedback and take responsibility for developing their trainees.
Training should also be recognised as real work. Doctors with significant teaching responsibilities require appropriate acknowledgement and protected time.
Returning To The Patient
It is time for Malaysia’s specialist training programmes to mature. The present system has produced many excellent specialists.
The argument is not that everything has failed. It is that a system created to meet the needs of an earlier period must now evolve. This will require every stakeholder to surrender some control or convenience.
Administrators must accept that trainees cannot simply fill manpower gaps. Heads of department must accept that progression should not depend primarily on personal recommendations or seniority.
Training centres must demonstrate that they deserve their status. Trainees must accept that progression depends on performance. Universities, professional colleges, and MOH must cooperate rather than compete for control.
The principles are relatively simple: transparency, merit, accountability, and patient need.
Ultimately, specialist training exists to produce competent specialists capable of providing safe, effective, and compassionate care.
As I concluded in my earlier article, every policy governing specialist training should be judged by one question: does it produce better specialists for the patients we serve? If the answer is no, then the system requires reform.
Dr Vicknes Waran is the chairman of NeuroSphere, and a consultant neurosurgeon at Subang Jaya Medical Centre and Columbia Asia Bukit Jalil.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
