Ensuring Malaysian medical specialists are trained, qualified, and safe to practise

AFP Relaxnews

IN the early 1990s, the Malaysian Medical Council (MMC) and the Health Ministry (MOH), under the able leadership of director- general Tan Sri Abu Bakar Suleiman, initiated many activities to set standards and develop procedures for accrediting programmes in medicine, nursing, dentistry and pharmacy.

This was way before the Education Ministry established the National Accreditation Board to assure the quality of programmes offered by private sector institutions in 1996.

Knowing my interest in medical education Abu Bakar urged me to develop an accreditation system for the medical and health sciences. He secured World Health Organisation Fellowships for me to study accreditation systems, and to visit institutions in Australia, Britain, and the United States.

Seminars and workshops were held with the assistance of the late Dr Nancy Gary who was president of the Educational Commission for Foreign Medical Graduates. Abu Bakar was able to get representatives from universities, the MOH, and specialty societies to work together to develop accreditation standards and procedures using the American accreditation system as a guide. In trying out the system, visits were made to four training institutions, and reports were submitted to the respective councils and board.

During his tenure as DG, Abu Bakar was also invited as an expert by the World Federation for Medical Education to set standards for undergraduate, postgraduate, and continuing medical education. It was also during his time that findings from my MD thesis would be used to help develop the Continuing Medical Education credit system for renewing the Annual Practicing Certificate, and to start the open learning in Family Medicine as a collaborative venture among Universiti Kebangsaan Malaysia, the MOH, and the College of General Practitioners (now known as the Academy of Family Physicians).

These experiences with the MMC and the MOH had a profound influence when I was developing the Malaysian Qualifications Agency (MQA) Bill in early 2004, together with Datuk Jagjit Singh who was in the Drafting Division of the Attorney General’s Chambers and who had previously served as legal advisor to the MOH.

It can be said that the procedures and standards used by the MQA were modelled on the accreditation system earlier developed and used by the MMC. In fact, the MQA Act was developed to ensure that professional bodies such as the MMC had absolute power in selecting accreditation panels and making decisions about approving programmes of study, and giving the final accreditation. The MQA was a secretariat for handling logistics and to ensure that rules and ethics of accreditation were followed.

The MQA system worked well from 2007 onwards. However, when the Medical (Amendment) Act 2012 was enforced in July 2017, the MMC could not register graduates of the “parallel programme” with the National Specialist Register. There are many solutions to this legal problem. The government has chosen to hastily amend the Medical Act by way of the Medical (Amendment) Bill 2024.

It would appear that the word “accreditation” is a problem because it has disappeared in the 2024 Amendments. This is disappointing because the Medical Council’s DNA is in the accreditation system of the country. The council must be proud of pioneering the accreditation system.

It is important to emphasise that any amendments to the Medical Act 1971 must enshrine accreditation at the heart of regulating the profession through a register (Medical Register and Specialist Register) to ensure that all practicing doctors have appropriate education and training, and that they abide by recognised standards of professional conduct while serving their patients.

We can learn from systems in other countries.

The Medical Board of Australia is responsible for regulating medical practitioners through six types of registrations. It specifically states that accreditation of programmes of study and education providers is the primary way of ensuring that Australia's medical practitioners are suitably trained, qualified, and safe to practise. Public safety is the priority.

The responsibility of accrediting education providers and their programmes of study is given to the Australian Medical Council, a company limited by guarantee and a registered charity.

The council assesses providers and their programmes of study against approved accreditation standards published on the Medical Board of Australia’s website. The providers are medical schools and specialist colleges such as the Australian College of Dermatologists, Royal Australasian College of Surgeons, and so on.

The Australian Medical Council provides accreditation reports to the Board, which may approve, or refuse to approve, the accredited programme of study as providing a qualification for the purposes of general or specialist registration. An approval may be granted subject to conditions.

This process is similar to the MQA practice.

The Australian Medical Council also conducts the CAT MCQ examination for three pathways for international medical graduates who wish to practice in Australia. (CAT stands for computer-adaptive test, meaning the difficulty of the questions adjusts based on performance, while MCQ is multiple-choice questions.)

In the United States, licensing is done by state medical boards and the Interstate Medical Licensure Compact, a legal agreement which offers a new, expedited pathway to licensure for qualified physicians who wish to practice in multiple states, expedited by telemedicine.

The licence that the physician eventually receives from a state medical board is for the general, undifferentiated practice of medicine. American physicians are not licensed based upon their specialty or practice focus.

Certification in a medical specialty, such as by a member board of the American Board of Medical Specialties, is not required to obtain a medical license. However, other practical considerations – such as obtaining hospital privileges – lead most physicians to obtain specialty certification.

To be fully licensed in the United States, a physician must meet predetermined qualifications that include graduation from a medical school accredited by the Liaison Committee on Medical Education; complete at least one to three years postgraduate or residency training, which is accredited by the Accreditation Council for Graduate Medical Education; and pass the United States Medical Licensing Examinations, taken at various points in a prospective physician’s career that tests their knowledge of health and disease management, clinical and communication skills, and effective patient care.

Students in US medical schools routinely take the first two steps of the licensing examination prior to graduation. The final step of the examination sequence is usually taken during residency training. International medical graduates must be certified by the Educational Commission for Foreign Medical Graduates. This entails a verification of their degrees and successful completion of United States Medical Licensing Examinations Step 1 and 2 before entering an accredited residency training programme and fulfilling its requirements.

In Britain, the General Medical Council (GMC) maintains the official register of medical practitioners. It regulates and sets standards for medical schools and postgraduate deaneries (since 2010) through quality assurance to ensure that the necessary standards and outcomes are achieved.

The GMC liaises with other nations' medical and university regulatory bodies over medical schools overseas, leading to some qualifications being mutually recognised. The GMC is also responsible for a licensing and revalidation system for all practising doctors in Britain, separate from the registration system.

The GMC has been a registered charity since 2001, and comprises not only doctors but also lay persons. It is subject to Britain’s Medical Act 1983 and has a statutory duty to cooperate with the Council for Healthcare Regulatory Excellence.

Malaysia’s 2024 Amendments to the Medical Act appear to concentrate powers of recognising providers and programmes as well as qualifications in the MMC without statutory oversight, as in the case of Britain’s GMC. The quality assurance system in the process of recognition is not explicit.

Since the MMC’s membership is not composed like the GMC’s, it will give great comfort and confidence to the public if the quality assurance is independent of the council that also makes decisions on approving providers and programmes. This is because the council is made up of doctors representing those providers – universities, the MOH, and professional societies.

Regulations may be made under the Medical Act to appoint and entrust the MQA to carry out this function, similar to the Australian model. The provisions for the MQA to collaborate with all professional bodies, including the medical and health bodies, in approving programmes and providers and giving the final accreditation are found in the MQA Act.

Regulations can also be made to cater for international medical graduates consistent with the Australian system of establishing pathways and conducting examinations, or the American Educational Commission for Foreign Medical Graduates system.

It will also be comforting if the new schedules (4 and 5) introduced in the 2024 Amendments will only contain qualifications that have been in the administrative list approved by the Malaysian Medical Council, and that new ones are incorporated only after the proposed regulations have been made.

If schedules 4 and 5 contain qualifications that have not been quality assured, I humbly urge the Cabinet to reconsider the Amendments with a view to removing the schedules, which are not really necessary because the MMC can keep an administrative list, which it should update from time to time.

The public holds the medical profession in high regard. The public also understands the need for more specialists. All that they ask is for the registration of medical practitioners and specialists to be done with integrity, and in an objective, fair, and transparent manner that inspires confidence that all medical practitioners are suitably trained, qualified, and safe to practise.

PROF EMERITA TAN SRI DATUK DR SHARIFAH HAPSAH

Kuala Lumpur

The letter writer was the developer of the Malaysian Qualifications Agency (MQA) Act. She is a former vice-chancellor of Universiti Kebangsaan Malaysia, and current president of the National Council of Women's Organisations Malaysia (NCWO).