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Message from the Master
Professor Dato’ Dr Khalid Abdul Kadir
The Future Of Specialist And Subspecialty Training In Malaysia: Are We In Tune With The Rest Of The World?
On behalf of the Council, I wish all fellows and members a happy, healthy and productive year in 2007 which also coincides with the year of the wild boar.
With the coming of the New Year, we wish to reflect on and report on what is happening to specialist and subspecialty training in Malaysia and how we fare in terms of developments in the rest of the developed world as we strive to achieve developed nation status and our vision of 2020.
Several events in 2006 highlighted the need for us to re-look at our specialty and subspecialty training, and the need for a National Specialist Register especially with the coming of the new Medical Act when it is passed by Parliament soon.
The most recent and important event, sending reverberating waves to the profession is the recent decision by the recently retired President of the Federal Court, Judge Tan Sri Normah Yaacob, that doctors who profess to be specialists and practise as specialists will be judged by the standards of practice of a specialist, following the judgment made by an Australian Court, in contrast to that of a British Court judgment. In a sense, it is the reason why specialists are required to pay higher medical indemnity insurance premiums as opposed to non-specialists. Having professed to be trained as a specialist, the doctor is expected to practise to that standard .
The implications are many. First we urgently need to formalize our National Specialist Register (NSR), so that those who profess to be specialists/ consultants are assessed and admitted to the fraternity by colleagues who judge their training/ experience/ qualifications/ capabilities as equivalent and having reached the standards of a specialist in that field of specialty. Fellows and members are urged to register with the NSR, maintained by the Academy. This NSR may in future cases be made the reference standards by courts of law.
Secondly, specialists and consultants are expected to maintain their standards of practice consistent with new developments in medicine and surgery, participating in continuing medical education (CME) and continuing professional development (CPD). In some countries there are efforts to make CPD compulsory for recertification. The Specialists Committees of the Academy are in the process of determining the CPD programs, contents and requirements, using that developed by a committee in the Ministry of Health headed by Puan Sri Dr Suraiya H Hussein, as a template.
Thirdly, we need to be consistent with our practice as specialists or consultants; as a senior colleague had commented to the Academy that he is practising as a vascular surgeon, not as a general surgeon, and thus he should be registered as a vascular surgeon. In practice, however it can be difficult for most specialists to practise only in their specialty. Neurosurgeons, urologists, cardiac surgeons and others usually only practise in their specialty, but some surgical colleagues in other fields may be required to practise as both; general surgeons and as subspecialty surgeons, for example in breast and endocrine surgery or vascular surgery, due to lack of general surgeons in government hospitals, or when they are starting their private practices. In internal medicine and paediatrics, a similar situation arises in government hospitals and academic institutions, where one is expected to practise as a generalist and at the same time run a specialty service, for example in adult or paediatric endocrinology. In private practice, some colleagues with MRCPs practise as general practitioners, but some have mixed general practice and specialty practice. On the other hand, one may practise as a cardiologist or neurologist but may still look after non-specialty problems such as diabetes or hypertension, which are common diseases. There is thus a rather mixed picture in real life practice, and the NSR need to adjust itself to such situations rather than be a static or rigid register. In other words, one may start off as a specialist general surgeon, then as he/she trained in a subspecialty, he/she can register as a general surgeon with say vascular surgery as a subspecialty. As he/she progresses on and does subspecialty work in more than say 80% of the time, he/she may register only as a vascular surgeon, to avoid having to do general surgical work which he/she may wish not to do and not be liable for any mishaps in that field should that arise. However, the mixture of general practice and specialty practice especially in small towns needs to be catered for, as the aggrieved person may sue the practitioner as a specialist whereas he/she may be looking at the patient as a general practitioner, but somehow misdiagnose or mismanage the condition, for example dengue fever which turns out to be a dengue hemorrhagic fever or Hanta virus infection. Will the Court judge it based on specialty standards because he/she holds an MRCP/FRCP or as a general practitioner because he/she is practising as a general practice? These issues need to be clarified, and insurance premiums need to be so adjusted to the type of main practice.
The second event last year was actually a series of workshops on specialty and subspecialty training that the Academy organized in conjunction with the Ministry of Health. A detailed report of the recommendations for specialties in Internal Medicine is published by the College of Physicians and need not be repeated here. However the need for a re-look at subspecialty training and certification has become very relevant given the above Federal Court Ruling and also looking at what is happening in the developed world and our immediate neighbours, Singapore and Thailand. The workshops are basically re-emphasizing the need for an earlier start to postgraduate training, starting after the housemanship, and suggesting that the first years be open and that entrance examinations be held to ensure that those who enter the Masters programmes are adequately prepared, and that subspecialty training be started during the last year of the Masters programme or post Masters. Subspecialty training should be structured, monitored and adequately supervised with possibility of an exit assessment. It also realizes that there are different needs in certain specialties and that some "subspecialties" need not have a "basic" requirement of a "generalist", such as neurosurgery, clinical oncology, urology, emergency medicine, etc. Is this a radical change? Actually it is in consonant with specialties such as ENT, ophthalmology and orthopaedic surgery.
Is this different from the developed world's trends such as that in Australia and Britain? At the recent meeting in Hong Kong of the International Association of College and Academy Presidents attended by 23 presidents or representatives, it was clear that the trend is towards early or definitive specialty training and "outcome-based curriculum" instead of the time-based. In the United Kingdom, there will be a "Modernizing Medical Career" initiative starting this year, with two years of Foundation followed by specialist training in a chosen specialty or subspecialty, total period of training being 5 to 7 years. In Australia and New Zealand, there will be a dramatic change of specialist training. The factors that caused the need to change we re the establishment of "Graduate Medical Schools" in most established Universities (similar to that in North America) resulting in older Medical Graduates (average age of graduation will be 27 years) and the realization that "basic training" may not be used by most specialties. Candidates may register for specialty training and sit for qualifying examinations, called "Pre SET" in their final year of medical school, and enter training in the 3rd postgraduate year, with "SET-1" examinations (or ASSET-Australasian Surgical Entrance Test") being conducted every six months. If the candidates pass the SET-1, they enter specialty training after one or more years for some specialties, or directly as in neurosurgery. The exit examinations are called SET-2 examinations and replace the fellowship examinations of the old system. Pre SET registration begins in 2007 and selection into SET-1 will occur in July 2007. The old basic surgical training of the surgical colleges will end by 2010. Specialist training in Australia and New Zealand thus occurs earlier; in fact trainees who passed the Pre-SET in their Medical School will be tutored from their first postgraduate year! The system thus becomes an even more closed system and it will make it difficult for overseas graduates to enter their training programmes, as in the United Kingdom from this year. Singapore is also approaching the same way, direct into subspecialty training, as is Thailand which has always followed the North American model. Where does this leave us Malaysians? First it will be difficult for Malaysians to get training positions in traditional source countries such as the United Kingdom and Australasia, even for subspecialty experience such as interventional radiology, etc. Secondly our aim towards early sub-specialization is in consonant with the rest of the developed world. Perhaps this will address our shortage of specialists, but to achieve our goals, we also need to change, and open up the training positions without compromising standards and without jeopardizing the Ministry of Health's needs for medical officers to provide service. The next few years are exciting and challenging for our young doctors aspiring to be specialists.
National Specialist Register
Why the need to register and pay registration fees
The establishment of the National Specialist Register (NSR) was announced on 29 June 2006 by Y Bhg Tan Sri Datuk Dr Mohd Ismail Merican, the Director-General of Health and officially launched on 24 August 2006 by Y B Dato' Dr Chua Soi Lek, Honourable Minister of Health at the Opening Ceremony of the 40th Malaysia-Singapore Congress of Medicine. This is a joint project of the Ministry of Health Malaysia (MOH) and the Academy of Medicine of Malaysia (AMM) and the AMM has been charged with the responsibility of administering and maintaining the NSR. A NSR Secretariat has been set up at the Academy House.
Administration of the NSR
A joint Committee (National Credentialing Committee) composing of both MOH and AMM representatives have been working on the establishment of the NSR since 2000. The MOH has appointed Specialty Committees and to date 40 such committees have been appointed. The terms of reference of these committees are:
- To recommend credentialing criteria of specialists
- To identify the list of procedures that require credentialing
- To develop guidelines for clinical competence
- To establish performance monitoring and review mechanisms
These committees shall meet at least five times a year.
Registration Fees and the Need to Register
The AMM Council in consultation with NCC have decided on the following registration fees:
|Member of AMM
|Specialist in the Public Sector
|and Public Institutions
|Non-Member of AMM
This is time-based and is renewable after five years.
The AMM has received queries regarding the payment of the registration fees. These registration fees are received into a dedicated account for the running and maintenance of the NSR Secretariat and for the funding of expenses incurred by the Specialty Committees.
The annual cost has been worked out to be in the region of RM850,000 for
- Administrative expenses (staffing, health insurance, EPF, allowances, upkeep of equipment)
- Utilities (electricity, telephone, faxes, internet lines, postage)
- Printing and stationeries
- Maintenance of computer and software
and lastly and, most importantly, the funding of the expenses of the 40 specialty committees which, according to the term of references, are to meet at least 5 times a year. This will drain considerably on the finances because we have budgeted at least RM3,000 per meeting for the travel and/or accommodation for the committees members - this itself works out to RM600,000 per annum!! Thus, the registration fee payable of RM200 per annum for AMM members and doctors in public service and institutions and RM300 for those not in the above categories. The AMM had received a grant of RM210,000 from the MOH but as the NSR is to be independent financially, the AMM need the funds to ensure its continuity and sustainability!!
The AMM Council has decided that the names on the AMM Specialist Register (as of 24 July 2006) shall be transferred enbloc to the NSR. However, AMM members would still have to complete and submit the NSR registration form and fee to the NSR Secretariat. AMM members would be given up till 31 March 2007 to make their submissions and payment. Those who fail to do so after that date will not have their names included in the NSR.
3rd Academy of Medicine Tun Dr Mahathir Merit Award (2006)
Fellows and Members of the Academy of Medicine of Malaysia are invited to submit nominations for the above award.
The award shall be given to an Academy member as an honor and acknowledgement of his / her contribution to the advancement of the objectives of the Academy.
NOMINATION AND SELECTION PROCESS
The potential recipient shall be nominated by any member of the Academy. The final decision of the choice of the recipient will be made by the Council of the Academy.
The proposer should submit a written background of the nominee to support his/her proposal.
It will consist of a certificate and a crystal vase with the name of the award and recipient engraved on it.
Please submit the nominations to the Academy Secretariat by 30 March 2007.
External Examiners for College of Physicians and Surgeons Pakistan Examinations
Reports from Academy's Representatives
(1) Part II Examination in O & G
15 - 20 July 2006
by Prof Dato' Sivalingam Nalliah
Thank you for nominating me to go to Pakistan for the CPSP 11 in OBGYN on the above dates. I was one of the external examiners (there were four others, one each from Sri Lanka, Bangladesh, Singapore and Nepal). The examinations were conducted at the College premises from Sunday till Thursday on the dates mentioned.
The entire program for the Fellowship is over four years during which the candidates are expected to have done a Dissertation, passed the Part 1 and more recently the Intermediate Module before being able to appear for the Part 11 of the Fellowship. Before they appear for the latter they must have passed the Theory paper. Candidates are given three attempts at the Clinicals. The latter consisted of a TOACS (Task Oriented Assessment of Clinical Skills) and two long cases (one each in Obstetrics and Gynecology). The TOACS consists of 12 stations, of which 7 are interactive and the rest being static (for interpretation of data etc). A total of 53 candidates appeared for the exams and the pass rate was about 25%.
All examiners felt the examinations were well run and were fair. Students were generally well prepared for the clinicals. The atmosphere was friendly and hospitality was excellent.
The College is sited in the Heart of the City and has developed into a premiere centre for postgraduate examinations. The Fellowship given by the College is much sort after although both the MS and MD programs are run by the Universities. With a broad network east of the Mediterranean, the FPSP is also conducted in Riyadh and Katmandu. Several branch campuses are run in the big cities of Karachi.
The Main campus is run by a dedicated President (Mr Sultan Farooqui) with a resident Secretary (Surgeon) and a CEO. No central funding is available and all funds are generated by the College through the leadership of the President, a remarkable man who has dedicated his entire life to the College (a non-salaried job). The college has facilities for conducting all examinations (in all disciplines), has its own electricity and water supply (it never rains in Karachi), has a printing press and Medical Education Unit, produce a monthly indexed medical journal, facilitate candidates to get all clinical literature through a well equipped library, have dedicated biostatiscians and an IT Department that makes all correspondence electronic. Numerous courses are conducted, some of which are compulsory for candidates to attend to comply with examination requirements. A Diploma in Medical Education together with Health System Research and Reproductive Health are new additions.
There are facilities for accommodating over 150 doctors at flats within the campus and a canteen is available for all candidates. The landscaping and gardens has been winning the city's annual award for the last 8 years.
I am convinced this one-stop centre of remarkable standards exceeds many centers in the world and has been producing specialists of good calibre. There is much we can learn from the CPSP especially in the conduct of postgraduate education. I would urge we develop a more proactive role in our own activities considering it is possible for a Professional College (CPSP) to be the Prime Institute playing a pivotal role in giving postgraduate degrees apart from those given by the local institutes.
(2) Part II Examination in Medicine
by Prof Dato' Mrs S T Kew
I have the privilege to participate in the Fellowship of the College of Physicians & Surgeons Pakistan FCPS Part II Examination in Medicine in Karachi (Headquarter of the College, Dec 05 - Jan 06) and in Lahore (Nov 06). This is an exit examination, successful candidates will be awarded College Fellowship, and will practice independently as physicians. The programme in Medicine is similar to other postgraduate programmes conducted by the College: total of 44, in addition to 9 in secondary specialties.
It is basically a 4-year on-the-job training for physicians. First step to the Fellowship is the FCPS Part I Examination. Candidates have to pass the Part I before joining the training programme. The College accredits 100 medical institutions, 800 departments and units all over the country for the purpose of training. The College also appoints Fellows as trainer-supervisors. Candidates undergo 4 years of "specified training" in approved institutions under the charge of supervisors. Besides doing general medicine, trainees go through 3 monthly rotations in Cardiology, Dermatology, Intensive Care and Psychiatry; plus another 2 of the following 4 sub-specialties: Endocrinology, Pulmonology, Nephrology and Neurology. During these training years, candidates have to document all activities in their log-books. The log-books are verified and signed by their supervisors regularly, and the summary sheets submitted to the College at yearly intervals.
The first 2 years of training, inclusive of rotations, constitutes the intermediate module. Trainees have to pass the Intermediate Module Examination in Medicine before proceeding on to the next 2 years. Trainees also have to undertake research, and submit a dissertation a year before sitting for the Part II Exam. During the period of training, trainees have to attend 3 mandatory workshops (on computer & internet, research methodology & dissertation writing, and on communication skills).
The sequence of training is as follows:
Part I Exam -> 2 years of training (inclusive of rotations) -> Intermediate Module Exam -> 2 more years of training, submission of dissertation at end of 3rd year -> Part II Exam (Theory & Clinical).
Part II Theory paper in Medicine is held 3 times a year. It consists of 2 papers, each of 3 hours duration. Paper I has 10 SEQ (short essay questions), while Paper II has 100 MCQs (75 single best answers and 25 extended matching).
Part II Clinical section is also held 3 times a year. It comprises 2 components: TOACS (Task Oriented Assessment of Clinical Skills), and clinical examination of long and short cases. TOACS is a combination of OSCE & OSPE exam, and precedes clinical exam. There are 15 alternating static and interactive stations, 8 minutes each, with 1 minute interval when changing stations. TOACS which I participated covered wide ranging topics, spread across most medical subspecialties, inclusive of assessment of communication skills with simulated patients (information giving and breaking bad news). Examiners in interactive stations assessed the performance of candidates using a global rating scale. In static stations, candidates submit written responses to be marked by examiners later on in the day. This time round in Lahore, fewer candidates sat for TOACS compared to clinical exam as some of them have already passed TOACS in their previous attempts.
In the Clinical Examination, CPSP is blessed with very rich clinical material. Hospitals in the vicinity give their fullest support in sending patients over to the College for the purpose of examination. Several ambulance loads of patients come to the College in the morning, and the examiners will go through them and select the appropriate ones. Patients are paid Rp100/- whether they are selected or not, and given refreshment. Clinical examination starts with short cases: each candidate gets to see 4 patients, 10 minutes each, usually with pathology of the respective major systems. This is then followed by the long case: 30 minutes of clerking followed by 30 minutes of presentation and discussion. A pair of examiners takes candidate for the short cases, and another pair for the long case. Each examiner gets separate assessment forms for short and long cases. The pair of examiners marks independently. Candidates are assessed on clinical & presentation skills, and discussion on relevant investigation, management plan, prognosis & recent advances.
Disease pattern is quite different compared to Malaysia. Rheumatic valvular heart disease is still common: cases of post-rheumatic cardiac murmurs are always available. Tuberculosis is still rampant, so is chronic obstructive airway disease. Cirrhosis is almost always secondary to Chronic Hepatitis C: up to 6% of the population is infected with HCV, probably due to unethical medical practices in the past.
Candidates fall into the standard Bell's shape curve, with more on the left side (below average) than the right (above average). Some of the weaker candidates tend to be those who are older, and have taken the exam repeatedly. These weaker candidates probably have fallen out of the system of training and supervision. In general, candidates seem to be less prepared in "recent advances". When I first examined in Karachi, proper exposure of female patients was a problem. In Lahore, this has improved, partly because there were two nurses assisting in the exam. On the average, about a third of the candidates were successful in the clinical exam.
Karachi College HQ was a very beautiful setup, and a lot of thoughts were put in when the building was planned. What I am most impressed is the hostel facilities for trainees, where accommodation is available at a nominal fee. College also has very comfortable accommodation for examiners within its compound, and all the Pakistani examiners from outside Karachi stay in. Invited examiners from overseas are put up in hotels in town.
Lahore regional centre is a 2 storey building, newer than the Karachi HQ. It has a multipurpose large hall, put into good use when partitioned. The clinical exam is conducted in this large hall quite comfortably, with sections at both ends used for the exam, while the middle section used as temporary office for examiners. 8 candidates are assessed each day, with 8 active examiners (including me, the only overseas examiner in Lahore), and 3 - 4 observers (training to become examiners). Results of the exam are tabulated, signed by all examiners, submitted to Karachi HQ, and released on the same day in Lahore College on the notice board. A total of 32 candidates sat for the clinical examination over the 4 days' period.
College of Physicians and Surgeons Pakistan has done very well in the provision of postgraduate medical education in the country. Since its inception in 1962, the College has taken great strides in this direction. In the overall scenario of health care delivery service, out of the total functioning registered health care specialists, 10,000 or 80% have undergone training by the College. Presently, Fellowship is awarded to 44 disciplines, and 9 sub-disciplines. The College is very well organized in undertaking this tremendously complex postgraduate training programme in so many disciplines, and is always busy conducting examinations in the various specialties.
The CPSP can indeed serve as a model of postgraduate medical education for the region. It is the shining leadership, the vision, the strong support and cooperation of the Fellows (who come 2 - 3 times a year to serve as examiners), the dedication of various people that have made the College to be what it is today. I am thankful for the opportunity given me to serve as examiner twice, and I come away with much admiration and praise for CPSP.
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