The Parallel Pathway vs Master’s War: Clash of the Titans Part 4, the final nail in the coffin?
By now, everyone would have got a rough idea on how all these issues evolved over the years. Let’s look at the issue and what I feel eventually should or will happen. it is going to be a long final article. By early 2000, the Master’s program were expanded to include an open system. This […]
By now, everyone would have got a rough idea on how all these issues evolved over the years. Let’s look at the issue and what I feel eventually should or will happen. it is going to be a long final article.
By early 2000, the Master’s program were expanded to include an open system. This means, a master’s candidate can be placed for training in KKM hospitals. By doing this, the local universities can increase their number of candidates. This open system may include all 4 years in KKM hospitals or part of it. The supervisors are appointed by the respective universities and the students must fulfil all the requirement as per the closed system candidates.
Since the open system started, there were voices in the fraternity that we should abolish all other pathways to become a specialist. By this time, basically MRCP, MRCPCH and MRCOG were the only main royal college programmes that were still recognised as specialist qualification. FRCS changed in 2001 to MRCS which was not considered as a specialist exam. Thus, since then the only way someone can become a surgeon is via the master’s pathway, unless you complete your training overseas with a recognised specialist degree. From mid 2000, KKM recognised the MAFP/FRACGP program for Family medicine when it was made to be a 4-year program and needing 12-18 months gazettement. KKM also made those who passed MRCP etc to complete at least 4 years of training (including 18 months post MRCP) before they can be gazetted as a specialist. The list of recognised postgraduate degree is available HERE
Along the way the number of Master’s program and intake also increased with new universities coming on board such as UPM, UiTM, UIA and a private KPJ University college (using UKM curriculum). The number of intakes increased from about 500 to about 1000+ (for all speciality). Even subspeciality Masters were introduced like Neurosurgery (USM), Plastic surgery (USM), Paediatric surgery and the latest being cardiothoracic surgery by UiTM. Thus, by early 2010, the demand to abolish the parallel pathway was growing stronger.
Fortunately, MMC was under KKM and NSR was not legal, yet. The 2 DGs (Dato Ismail Merican & Dato Hisham) who were holding the post during these periods were strong supporters of KKM’s parallel pathway. They were confident that KKM’s parallel pathway is good enough to train new specialist and that we need more specialists in the country. For a matter of fact, most subspecialist are trained in KKM hospitals anyway. As I had mentioned in my previous articles, by 2016/2017, KKM began to implement elements of the National Postgraduate Curriculum into the parallel pathway.
What happened to MMC?
By 2012, the Medical Act 1971 was amended. The amended medical act 2012 came into force on 1st July 2017. MMC became a corporate body with a CEO. The composition of the council also changed as below:
The DG of Health remained as the chairman of the council (despite many suggestions to make it elected from the members of the council)
Appointed University representative increased from 6 to 9 members (both public & Private, currently 5 public uni and 4 private uni reps)
Appointed Public sector representative remained at 3 members (all KKM).
Appointed Private sector was given 3 new posts.
Elected members increased from 9 to 15 members. Out of the current 15 members: 8 from KKM, 5 from public university and 2 from private university.
Sabah and Sarawak remained at 1 elected member each (both from KKM currently).
Thus, the total members increased from 21 to 33 (including the DG as the chairman). I have already spoken about how MMC became the legal guardian of NSR from the same date. So, out of the total 33 current members: 13+1 from KKM, 10 from public university, 6 from private university and 3 from private hospitals. 30% of the members are from public universities and if you include private universities, that will increase to almost 50%!
The Cardiothoracic issue
i) Before 2016
It is interesting to note that before the official parallel pathway came about, KKM has been training cardiothoracic surgeons for years. You have to be either a general surgeon FRCS holder (before 2001) or a Masters in Surgery graduate to enrol yourself into the cardiothoracic training pathway under KKM. It was a 4-year programme. Some may go overseas for the final year to complete the training as part of KKM scholarship/HLP programme. This is similar to all other subspecialty program currently available in KKM or university hospitals. Cardiothoracic was always considered as a subspecialty under general surgery. However, no entry or exit exams needed at that time. It was basically an apprentice style programme with minimal structure , lacking objective assessment without proper curriculum or syllabus entirely relying on the senior surgeon’s willingness to train.
So, the general process was 2 years HO, 2-3 years MO, then 4 years master’s in surgery, 1-2 years of general surgery before being eligible to enrol into CTS training program which is 4 years. Total duration to officially become a CT surgeon would be a minimum of 14 years from graduation assuming you get into masters in 2 years post HO and clear all your exams on time. I have written about this over HERE in 2013.
ii) From 2016
The DG of health felt that we need to have a structured training system from medical officer level in place for CTS and make the process shorter. This was in line with global trends in training, including in the UK where senior house officers with strong surgical background were enrolled into 6 year Cardiothoracic training program instead of general surgeons .This program was designated as national training programme approved by the GMC together with Royal Surgical Colleges and became the route towards a career in Cardiothoracic surgery in the NHS UK.
Furthermore , surgical fraternity in Malaysia and KKM were no longer keen to allow general surgeon graduates to enter Cardiothoracic training due to critical manpower shortage of general surgeons in many public hospitals locally. During these times, efforts to start a local Masters CTS training programme in UKM and UM failed to take off due to various bureaucracy and approvals required and these efforts were spearheaded by current surgeons in UiTM .Therefore , it must be reinforced that when the Parallel programme in CTS was started by KKM, Masters CTS programme did not exist .
Fuelled by these frustrations , the DG of Health in a landmark meeting in December 2013 recommended that the CTS surgeons fraternity represented by MATCVS (Malaysian Association of Thoracic and Cardiovascular Surgeons) to work together with Royal College of Surgeons of Edinburgh RCSEd and KKM to come up with the Parallel training programme in CTS leading to the award of Fellowship in CTS qualification . Traditionally, all fellowships post training and examination conferred by RCSEd were fully recognised by Jawatankuasa Khas Perubatan and JPA as valid specialist qualifications from the early days of the Malaysian public service.
On 27th August 2014, KKM and the College of Surgeons (Academy of Medicine, AMM) signed an MOU with FRCS Ed to run this program which will enable the graduates to obtain FRCS Ed degree in CTS. This new program modelled after UK training will make the process shorter, and it is a 6-year program conducted by KKM with Hadiah Latihan Persekutuan, without the need for candidates to become general surgeons before enrolment. Remember, by this point, it was also becoming increasingly difficult to get into the master’s in surgery program with increasing number of doctors and limited post. This new program will make the process shorter without the need to complete Master’s in Surgery, even though Masters is still considered as one of the criteria for enrolment to year 3 of the program.
By March 2015, the Jawatankuasa Khas Perubatan in KKM approved this program to be implemented. Just to reiterate, that NSR was not legal yet at this moment but since NSR was under the Academy of Medicine, it is considered approved program as the MOU was jointly signed by College of Surgeons.
The 1st selection interview was done in December 2015. The parallel FRCS Edin CTS program started officially in July 2016 with accreditation and supervision from RCS(Edin). The curriculum was based on UK training program with some adjustment to Malaysian context. The program was not only monitored by KKM but also by RCS and upon completion of the training, the candidates will be eligible to sit for the Joint Surgical Fellowship (JSF) exit exams and be conferred FRCS(Edin) CTS degree. Interestingly, among the 1st 4 candidates, only 1 was from KKM, the other 2 was from IJN and 1 from UM!
On 15/09/2018, RCSEd and AMM signed an MOU with College of Surgeons of Hong Kong and the Joint Committee of Specialist Training Singapore to include Malaysia in the JSF examination as well as to get Malaysians to be examiners. It was also agreed that the exams will be rotated between Malaysia, Singapore and HK. Malaysia was a late entrant into this examination arrangement which has already been ongoing for more then 15 years in those countries . To date, FRCS Ed CTS remains the only qualification accepted by Singapore and Hong Kong for their local trainees . Some Malaysian graduates who were enrolled in the programme in Singapore have already returned home and were readily accepted for registration in our National Specialist Register as early as 2007.
Interestingly, in April 2022, UM joined the bandwagon by signing another MOU with KKM, AMM, MATCVS and RCSEd to jointly govern the parallel pathway with UM providing the Certificate of Completion of Training (CCT) for GMC registration. The JSF examination is similar in scopes, standards, and format to Joint Colleges Intercollegiate Examination (JCIE) conducted in the UK. JSFE is for training done outside of UK but the standards and the curriculum followed is the same, targeted to the level of a day 1 consultant Cardiothoracic surgeon in the NHS UK .
What is even more interesting is the fact that the same curriculum was later developed as part of the National Postgraduate Curriculum and was launched in UM on the same day in April 2022. This was a key project for all specialties initiated by the local universities Deans Council and was a superb effort aimed at ensuring for the 1st time , Masters and Parallel trainees receive comparable training standards with unified curriculum The National Postgraduate Curriculum in CTS is as below:
The training centres that were accredited by RCSEd/KKM are as below:
So why has this become an issue …………in 2023/2024……..
It all BOILS down to politics! Unfortunately, this politics is not created by our politicians but politicians and lawyers wanabe from our own fraternity! It is politics of vengeance , “us vs them” phenomenon. It is “we” the academic instituition vs “you” the service provider. The rakyat can die inbetween!
Based on the scenario above, it looks like everything was done to make the parallel pathway a success and to be able to receive a degree that is almost internationally recognised. While JSF examination is considered different to JCIE, the standards and curriculum are similar and the degree conferred is the same no matter from which pathway you obtained training either in the UK or the Far East in Malaysia, Singapore or Hong Kong. Since the training is conducted overseas, outside of UK, you need to apply to GMC to be recognised rather than being automatic, which is a standard practise throughout the world. The degree conferred by RCSEd is the same as you can see below:
The above degree is from someone who is already in practice in Malaysia, fully recognised.
This is from one of the graduates of CTS parallel pathway in 2022.
The entire drama started when a small group of surgeons in one university decided to start their own Master’s in CTS program in 2021, the first of its kind in Malaysia. This is of course provisionally approved by MQA as my previous article. They decided to take 15 candidates who will be graduating in 2027! Just for information, the parallel pathway which started in 2016 were only taking 4-6 candidates average per year as below:
There were also rumours that RCSEd rejected UiTM’s application to be credentialed as training centre under the Parallel programme, the College cited lower surgical volume in the centre as a reason for their decision but had plans to review this in the near future. Also to note that 2 of their own consultant surgeons were trained as CTS surgeon under the old “before 2016” program which is somehow .
Next comes the most important question: where are your training centres? One of the most important criteria in medical training is candidate: supervisor ratio and number of cases. Since the parallel pathway started way back in 2016, the training centres are filled with their candidates as per the RCSEd criteria. So, where does this university’s candidates going to go with 15 candidates onboard? A hasty partnership was cobbled together with IJN but this was not enough, as even IJN had parallel candidates inside just like KKM , and woolah, the clash of the titans has once again resurfaced!
Instead of uniting for the sake of the country, they have decided to dig a hole and go separate ways. KKM being the primary sponsor and led by a DG who was championing parallel were non-commital to pressures exerted by the university in various forms, primarily questioning legitimacy of the programme presumably to gain exclusive control over training positions in KKM which promises good exposure for any trainee.
Pandora’s box was opened and MMC got smashed in the middle but eventually took a side with the university and rejected Parallel for NSR registration. I refer back to my analysis of the MMC members above and you can make your own conclusion. The issue of MQA, NSR etc is now being played with, as I have written in my last 2 articles. In 2018, MQA have said that overseas post graduate degrees do not need MQA accreditation and can be directly recognised by KKM for specialist allowance.
To make matters worse, everyone knows that this university is only open for bumiputras. So, why not throw in the usual race rhetoric as well. You will get a great masala for the world to see. It is also interesting to note that despite a National Postgraduate Curriculum in CTS being launched in April 2022, UiTM program is not following such curriculum.They refused to have a full 6 year programme and rejected entrance examinations requirements made mandatory by the curriculum. They have come up with their own “” and “non-colonised” curriculum (these were the words used against the parallel pathway by the parallel pathway opponents). The National Curriculum which was started by the universities is now being smashed by a university?
It is also an open secret that Master’s program do have a quota system. Being in Malaysia, you can’t run away from this which is unlikely to ever disappear. Thus, many non-Bumiputera candidates were dependent on parallel pathway. What are their chances in becoming a specialist in the future? Time and logic will give you the answer.
What is my prediction for the future…….
The force is just too strong from the dark side. I am used to making the worst of any prediction. My prediction is the country will go down the part that we hope it will not go down to. Unless the Minister does the right thing in amending the Medical Act to put a stop to everything, it is a foregone conclusion that the final path will be the path of no parallel pathway in probably 10 years’ time. Our past Health Minister Dato Subra has also concluded the same. While the CTS parallel pathway may win their case in court as they have all the necessary documents to support their program, the future may be bleak for all parallel programs. I am not sure what is the proposed amendments that is being discussed but it may only solve the problem by making KKM a training institution (Section 14). This in turn may subject KKM to MQA accreditation which will eventually unify all the programmes into a single program which will very likely be the master’s program. We may have Master’s program for every subspecialty eventually.
Can KKM even manage themselves as an official training institution when they are already struggling to manage healthcare service of the country? I do agree that a lot of work need to be done for the other parallel pathways(MRCP, MRCOG and MRCPCH) to make it more structured as I have written many times in this blog. As for CTS, I feel that from the word GO, they had full support from RCSEd with clearly defined established adapted UK curriculum, standards and training ratios, monitored by RCSEd themselves with exit exams and FRCS degree, which has been traditionally recognised.
Racial quota is never going to disappear no matter how many new governments come along the way, as you can already see now. Thus, the need for parallel pathway is there to accomodate this injustice. The only other way is to create independent bodies to run postgraduate programs like the royal colleges etc. Will that ever happen?
We may win the battle but lose the war……………………., let the court decide on this CTS parallel pathway……. for now! it is all about “Toxic Ego” phenomenon
Please read Part 2 and Part 3 to understand better.
The Parallel Pathway vs Master’s War: Clash of the Titans Part 2
In March 2007, I wrote an article in MMA Magazine with almost similar title (Academician vs Service providers: Clash of the titans). Seventeen years later, we have not moved on. The heated argument in open media regarding the Cardiothoracic parallel pathway has yet again opened the Pandora’s box. Universities on one side, KKM on another […]
In March 2007, I wrote an article in MMA Magazine with almost similar title (Academician vs Service providers: Clash of the titans). Seventeen years later, we have not moved on. The heated argument in open media regarding the Cardiothoracic parallel pathway has yet again opened the Pandora’s box. Universities on one side, KKM on another side with MMC in the middle. At the end, the “rakyat” will become the sardines!
I thought of writing this piece to explain how all this evolved through time. Why we are in this mess and why, forever this will never be solved………….
Warta Kerajaan
Till 2017, Malaysia never had a legal body to recognise who is a specialist. Since independence, all specialists were trained in KKM hospitals and, what is now known as parallel pathway was the only way for someone to become a specialist till the master’s program was started in mid 1970s. Many will fly to UK to sit for the exams which include MRCP, MRCOG, FRCS etc. Medical training has always been an apprenticeship form of training system.
The DG of health, under the General Order(GO) was the only person who had the right to declare someone as a specialist. This is done via Warta Kerajaan. Once you complete your gazettement process, you need to apply to DG of KKM to be gazetted as a specialist. An example of warta kerajaan is as below:
Once you are declared a specialist, you are entitled for specialist allowance. However, if you leave KKM before you are gazetted, there is no law to say that you can’t call yourself as a specialist in private. In fact, I know many doctors/friends who left KKM immediately after passing MRCP and called themselves as a specialist in private hospitals till today. In mid 2000s, there was also an issue with specialist trained in University hospitals where JPA ordered all gazettement done by MOE to be revoked and a new application must be done to DG of KKM to be gazetted as a specialist. Remember, this also applied to Master’s graduates who have to undergo 6 months gazettement period.
What happened in 2006
By mid 2000, there were plans to amend the Medical Act 1971. One of the main amendments were to include a specialist registry, an official body to recognise someone as a specialist. While the legal process was taking place, the then DG of Health in collaboration with Academy of Medicine, started the National Specialist Register(NSR) in 2006. Every specialist was encouraged to register themselves with the registry for a fee. NSR formed many subcommittees to investigate each application and speciality to ascertain whether they can be registered as a specialist. However, there was no legal requirement for any specialist to do so.
By 2012, UKAPS had advised all private hospitals to make sure their specialists are registered with NSR for the hospital’s license renewal.
What happened in 2012 and 2017
In 2012, finally the amendment of Medical Act 1971 was passed in Parliament, and it is now known as Amended Medical Act 2012. Some of the changes added to the medical act was as below:
It took another 5 years before this amendment came into force (usual Malaysia Boleh style!). On 1st July 2017, the amended medical act came into force and the NSR officially became a legal body of specialist register. Academy of Medicine then handed over the registry to MMC. MMC is now the legal guardian of the NSR.
What DID NOT happen!
The first and foremost issue that should have been sorted way back in 1970s and 1980s was the training system. Malaysia is a unique country when it comes to medical specialist training system. We have the KKM apprentice training system where most specialists are trained and the local Master’s programme conducted by the universities. It is 2 separate parallel system and that’s why the KKM’s training system was later redesigned as Parallel pathway despite being older than the Master’s programme. It should have been the other way round, but politics plays an important role as well.
Both these systems were never unified. Unlike many developed countries where the specialist training system is conducted by a separate entity like colleges etc, this never happened in Malaysia. Even countries like India, Pakistan and Arab countries have a more unified system than us. I was informed many years ago that the reason for this is pure politics!
There were attempts to unify these 2 systems in late 2010s when Prof Abeeba started the National postgraduate curriculum program to standardise the training system. This curriculum supposed to be used by both the Master’s program and the KKM training system. My understanding is that some element of this has already been implemented by KKM since 2017. However, the question is, who accreditates the KKM program, supervisors etc. Running a program is more than just having a curriculum, logbook and hospitals. In this sense, the Master’s program is more structured and accredited compared to parallel pathway, not to say the quality is better at all times. I have written about this many years ago in this blog.
Let’s come to the 2nd issue. When the medical act was amended in 2012 and the above clauses were included, no one knew what the role of KKM is, in gazetting a specialist anymore. I remember raising this issue many years ago in one of my blog posting. When NSR becomes legal, it is the only body who recognises a doctor as a specialist according to the Medical Act 2012. So, DG of Health gazettement under the GO is invalid? Another confusion has now been created.
I raised these issues many times with senior colleagues in KKM then. So, you are a specialist only when your name is in the NSR, so what is the point of doing gazettement in KKM with warta kerajaan anymore? Shouldn’t the application go directly to NSR for recognition as a specialist? KKM gazettes a Master’s graduate as a specialist in 6 months but NSR says must be 1-2 years post-graduation depending on the speciality. So, which one to follow? According to the Medical Act 2012 as above, you can’t call yourself as a specialist if your name is not in NSR and disciplinary action can be taken. Does that mean you have immunity if you work in KKM?
What a mess have we got ourselves into? Does anybody ever think about all these issues before amending an Act? Or is this similar to Private Healthcare Facilities and Services Act (PHFSA)? One rule for me and another rule for private sector? This is exactly what is happening now. KKM says that it will gazette those who had completed the Cardiothoracic parallel pathway as specialist in KKM but MMC/NSR says no. So, is KKM committing a crime? Would the candidates be taken disciplinary action for calling themselves as a cardiothoracic surgeon? Section 14 of the amended Medical Act 2012 is so vague, and that is why our Minister is proposing to amend the act as soon as possible. But I got no idea what the amendment is all about. What does recognised training institutions means(Section 14B(b))? Is KKM a recognised training institutions? Technically KKM is not an institution.
Similar issues have now cropped up for MRCGP(Ireland) and icFRACGP programmes from what I gather. All these issues would not have happened if ONLY someone had the brains to unify all specialist training programmes, way back in 1970s or 80s and to have a single legal entity to recognise a specialist. And this legal entity should assess each degree on case by case basis rather than just saying, we don’t recognise your degree collectively. This is what most countries do and they have proper system in place to assess and license such candidates. Unfortunately, in Malaysia the civil service rules are different than the rules for others. We never had equality in whatever we do. Rules for thee and not for me……..
Whatever it is, what we are watching is just the tip of the iceberg. There is more than meets the eye in this entire saga. It all boils down to POLITICS! A war between UiTM and KKM! or should I spill the beans…….
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