Safeguarding specialist training

The purpose of the amendments to Act 50 is to close legal loopholes – to ensure doctors who took the recognised pathway towards becoming a specialist and meet requirements laid out by MMC will be properly entered in the NSR.

THE amendments to the Medical Act 1971 (Act 50) that were passed in the Dewan Rakyat last week have one primary purpose: to facilitate a smoother training, qualification and registration process for Malaysian medical specialists in keeping with consistent, established, and highly rigorous standards.

The previous wording of Act 50 before these amendments did not reflect a number of key realities on the ground, and brought into question the legal status of both specialists in training as well as existing specialists – creating a problem that urgently needed solving.

This pre-amendment wording resulted in legal loopholes, through which a few specialists in training have fallen through. Such difficulties have generated a great deal of frustration all around, and perpetuate the problem of brain drain in the medical profession.

The purpose of the amendments to Act 50 is to close these loopholes – so that every doctor who undergoes a proper, established and recognised pathway towards becoming a specialist and meets all the strict requirements for qualifications as laid out carefully by the Malaysian Medical Council (MMC) will be properly entered in the National Specialist Register (NSR).

There is an urgent necessity to make these amendments because Malaysia is already considerably understaffed when it comes to medical specialists.

As of 2023, Malaysia had 8,953 registered specialists working in the public sector – consisting of 15.7% of doctors in Malaysia.

In developed countries, between 41% and 60% of doctors are specialists.

In order to have a better ratio of specialists to doctors and the general population, we would need to have about 22,435 specialists in the public sector by 2030.

Under these circumstances, it is all the more important that the processes through which doctors are trained, assessed, registered and retained as specialists in Malaysia be made as streamlined, smooth and efficient as possible – while adhering consistently to the highest possible standards.The amendments to Act 50 that have been tabled were designed to accomplish this exact goal, and here we will detail exactly how and why these amendments were needed.

We will begin with an overview of specialist training in Malaysia.

There are two pathways to becoming a registered specialist in Malaysia, traditionally called the Master’s pathway as well as the parallel pathway.

In both pathways, a doctor will have to go through at least four years of apprenticeship under senior specialists in facilities throughout the country; log all procedures that they perform under supervision in a log book; sit for qualifying exams; and then undergo a period of gazettement.

The only major difference between these two pathways concerns the qualifying exam and the institution that confers the qualification after those exams. In the Master’s pathway, the conferring institution is a local Malaysian university while in the parallel pathway, it is an international body such as one of the Royal College of Surgeons in the United Kingdom.

Before a candidate can be admitted into the NSR, a panel of MMC assessors will do a final assessment of the candidate. The same panel assesses candidates from both the local Master’s pathway and the parallel pathway, and is responsible for ensuring that each and every candidate meets the very highest standards of qualification before they are admitted into the NSR.

It is important to note that the current number of local Master’s programmes in Malaysia will not yet be able to produce the number of specialists needed. This means the parallel pathway will continue to be a key element in that effort.

Of course, we are happy to see local capacity increase in the form of more and more Master’s programmes in the future.

The recent controversy about parallel pathways emerged around December 2023, when four doctors who completed the cardiothoracic surgery parallel pathway programme had their application to be registered as specialists in the NSR rejected.This case was a particularly urgent problem that needed solving because there are some 1,500 patients on a nine- to 12-month waiting list in Malaysia that need a cardiothoracic surgeon.

The applications were not approved because it was found that the qualification conferred by the Royal College of Surgeons in Edinburgh was no longer listed as a qualification that was recognised for candidates in the parallel pathway.

In search of a solution, the Health Ministry and the Higher Education Ministry decided to seek a legal opinion from the Attorney General’s Chambers (AGC).

The AGC made a number of recommendations that would improve the way in which the list of recognised qualifications can be managed transparently.

In studying the matter, the AGC also found one glaring legal loophole.

Section 14B (b) of Act 50 states (prior to the amendments) that: “A person is entitled to be registered as a specialist under this Act if ... he has attended specialised training in that specialty in a recognised training institution.” There was a problem with the phrase “recognised training institution”.

About 90% of specialists in training from both pathways undergo their training in public hospitals under the Health Ministry, as there are neither enough hospitals nor patients under the Higher Education Ministry to accommodate the training of such a high number of specialists.

Hospitals under the Higher Education Ministry are “recognised training institutions” while hospitals under the Health Ministry are technically not, legally speaking.

The AGC concluded that this law could be read to mean that anyone who had not been trained exclusively at a training hospital under the Higher Education Ministry was not procedurally properly registered as a fully qualified specialist.

Both ministries thus concluded that in order to accurately reflect the established reality on the ground and to remove any legal ambiguity whatsoever, Section 14B (b) of Act 50 needed to be amended, so that the de jure (legal) reality more accurately reflected the de facto (factual) reality on the ground, as well as to safeguard against any legal ramifications that may flow from this discrepancy.

Following these amendments, the process of assessing and approving the application of candidates to be fully recognised and registered specialists under the NSR will be just as rigorous and consistent as before.

These amendments to Act 50 solve existing problems by streamlining the processes, making sure the exact letter and wording of the law correctly reflects both the reality on the ground, and is the best way to facilitate growing the number of specialists in the country – as is urgently needed.

Doctors deserve the same level of care and dedication that they show to ordinary Malaysians every single day.

This amendment is the latest, but not the last, in a series of initiatives that the Health Ministry will keep pushing in order to better support and encourage doctors who are doing their level best to serve their patients and their country.

Datuk Seri Dr Dzulkefly Ahmad is the Health Minister of Malaysia. The views expressed here are the writer’s own.