The training of specialists in Malaysia has been strongly debated over the past few years. Much discussion has focused on the number of specialists being produced, recognition of qualifications, and the frustrations of junior doctors trying to enter training programmes.
Some obvious reasons for the present situation are regularly highlighted. The more uncomfortable ones are often carefully avoided. It is perhaps in our nature not to offend anyone, particularly those in positions of authority.
A recent case in point was when an entire surgical department appeared to be revolting against its leadership, senior hospital administrators, the state health administration, and perhaps even the health minister.
Two days later, an explanation was issued in the usual fashion, attempting to explain away the situation.
Whether every allegation was correct is not the main issue. The significance was that a group of doctors felt sufficiently frustrated to express their dissatisfaction publicly.
Such events should not simply be managed as public relations problems. They should be regarded as symptoms of deeper problems within the system.
Having observed specialist training over several decades as a trainee, specialist, senior consultant, trainer, examiner and academic, I believe the time has come for an honest discussion.
Four groups stand out, namely patients, trainees, who are the future specialists, trainers and training centres, and the government and health care administrators.
Each has legitimate expectations and pressures. The problem arises when these interests conflict.
The Patients
Patients are, so to speak, the customers of the health care system. More importantly, they are the reason the system exists.
They expect specialists to be competent and sufficiently experienced. They would prefer this expertise reasonably close to where they live, but most understand that not everything can be provided a stone’s throw away.
They also expect specialists to have access to the tools, equipment, facilities and supporting services necessary to deliver proper care.
It is not enough to place someone carrying the title of “specialist” in a distant town and declare that specialist services have been provided.
The person must be adequately trained, competent, and supported by the infrastructure required to practise safely.
The number and geographical distribution of specialists are important. However, neither should become more important than the quality of care provided.
A patient in a smaller town deserves the same assurance of competence and safety as one in a major city.
The Trainees: Future Specialists
Trainees are junior doctors aspiring to progress within the profession. Their motivations vary.
Some want to improve themselves. Some genuinely enjoy a particular speciality. Others believe becoming specialists will allow them to serve the community better.
We should also not ignore that doctors need to make a reasonable living. They have families, financial responsibilities and personal ambitions. Some may progress through the public system before eventually moving into private health care.
These motivations do not make someone a bad doctor. They remind us that trainees are human beings.
In the 1980s and 1990s, many Malaysian doctors sat examinations conducted by overseas professional bodies, particularly the Royal Colleges in the United Kingdom.
The examiners were usually people we had never met and who had no personal or institutional interest in whether we passed or failed.
The system had disadvantages. Examinations were expensive. Candidates paid examination fees and often travel and accommodation costs.
Many attended weekend courses at their own expense. Some saved money or did locums to fund their postgraduate training.
But that system had one major strength: if a candidate fulfilled the published requirements, he or she could sit for the examination.
Heads of department, Ministry of Health (MOH) officials, or administrative bodies could not usually prevent a candidate from attempting an external professional examination merely because the individual lacked seniority.
The Royal Colleges prescribed minimum training periods and other requirements to ensure adequate exposure and experience.
If a more senior doctor was unable to pass, a more junior but motivated doctor could still progress. The system rewarded performance more than seniority.
When Seniority Replaces Merit
Today, doctors may face formal and informal restrictions before entering specialist training.
These may relate to rural service, years spent in a discipline, recommendations from heads of department or availability of posts.
I have nothing against rural service. Doctors should contribute to health care outside major cities.
However, rules must apply fairly. Not everyone appears to be subjected to the same requirements, and those sufficiently well connected may sometimes find ways around them.
There are also unwritten seniority rules. A doctor may be expected to “wait his or her turn” before applying for postgraduate training.
This can result in less motivated or academically weaker candidates entering programmes because they are more senior, while better and more ambitious candidates are told to wait.
Such a system risks frustrating talented doctors and eventually driving some out of the public service or even the country.
Seniority has its place. Experience matters in medicine. However, seniority should not be confused with ability, commitment or suitability for specialist training.
The Government And Health Care Administrators
The government should be commended for establishing and expanding local Master’s and postgraduate specialist programmes. These have increased specialist numbers and reduced our dependence on expensive overseas qualifications.
However, after several decades, the system must mature.
When I was a junior specialist, the explanation was often that Malaysia urgently needed more specialists and quality could be addressed later.
Today, the argument is that we need even more because specialist services must be provided in smaller towns and underserved areas. Both arguments have validity.
However, the objective cannot simply be to fill a post with someone carrying a specialist title. It must be to produce and deploy specialists who are competent and appropriately supported.
Administrators have their own pressures. They must provide services, fill rosters and respond to public demands. Consequently, junior doctors may be prevented from joining training programmes because of “manpower shortages” or denied transfers more suitable for their career progression.
Hospitals cannot function without doctors. But service and training should not automatically be regarded as competing activities. Properly organised clinical service should itself provide the foundation for training.
In the past, many of us trained as we worked, although we also often paid our own way.
Trainers And Training Centres
Many doctors want to be recognised as trainers, and many departments and universities want to be recognised as training centres.
Some have genuinely altruistic reasons. Others may view trainees as a solution to manpower shortages or as adding prestige to the institution.
There is nothing inherently wrong with trainees contributing to service. Specialist training has always involved supervised clinical work.
The problem arises when trainees are primarily used to fill service gaps rather than being given structured opportunities to learn. A unit should not be recognised as a training centre simply because it needs junior doctors.
I do not believe the best training units are necessarily found in major cities or universities. Some may be in smaller hospitals where senior specialists are genuinely interested in training and ensure that both patients and trainees are well cared for.
Conversely, some large and prestigious units may provide poor training because there is little genuine interest in teaching. This can include universities with professors and academics but surprisingly little teaching.
Some big-name experts appear to believe training occurs merely by trainees standing next to them, watching and listening.
Training requires dedication and commitment, not merely seniority, titles, or name recognition. Not every excellent clinician is automatically an excellent trainer. Likewise, not every senior doctor is suited to supervising trainees.
A proper training centre requires appropriate equipment, adequate clinical exposure, supporting services and trainers prepared to provide guidance, feedback and supervision. Regular educational activities including multidisciplinary meetings, journal clubs, case discussions and formal tutorials should be part of training.
Education must be prioritised alongside patient care. It cannot simply be an incidental by-product of service.
Training Is A Continuous Process
In the past, training was understood to be a continuous process. It occurred daily through the patients we saw, decisions we made, operations we assisted with and performed, and discussions and debates with our seniors.
Today, there appears to be an increasing belief among trainees and trainers that training occurs mainly through conferences, workshops and special teaching programmes.
These are useful, but they are not substitutes for supervised day-to-day clinical work. Medicine is a continuous, on-the-job learning process.
A two-week course cannot compensate for months of poor supervision. A conference cannot replace daily clinical discussion. A workshop cannot make up for inadequate exposure to patients and procedures.
Training is also not about getting trainees to memorise standard answers. In the real world, two patients with the same diagnosis may require very different management strategies. Learning how to make those decisions requires discussion, debate, experience and guidance.
Formal programmes should support clinical apprenticeship, not replace it.
Ultimately, specialist training exists for one purpose: to produce competent doctors capable of providing safe, effective and compassionate care.
The number of specialists matters. Where they practise matters. The needs of trainees, trainers, hospitals and government all matter. But they cannot matter more than the patient.
Every policy governing specialist training should therefore be judged by one simple question: does it produce better specialists for the patients we serve?
Dr Vicknes Waran is the chairman of NeuroSphere, and a consultant neurosurgeon at Subang Jaya Medical Centre, Columbia Asia Bukit Jalil, and University of Malaya Specialist Centre.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
