A memo from the Prime Minister, Dato Seri Anwar Ibrahim to the Minister of Health, Dato Seri Dr Dzukefly Ahmad was to "follow the law" in resolving the initiative by former MOH DG, Tan Sri Nr Hisham Abdullah to carryout a Parallel Pathway Training (PP) with the Royal College of Edinburgh (RSCEd) for Cardiothoracic Surgery.
The program was conducted illegally and ahead without prior approvals from both the Malaysian Qualifying Agency (MQA) under MOHE and the Malaysian Medical Council (MMC).
More so, RCSEd did not issue the usual Intercollegiate Fellowship of the Royal College of Surgeons (FRCS) diploma prevalent among practising Medical Specialists, but the FRCS International (FRCSI) version.
FRCSI program were organised by the Malaysian Association for Thoracic and Cardiovascular Surgery (MATCVS), instead of Universities.
The training and exposure in Edinburgh seemed intentionally conducted to be too basic and insufficient. It gave a reason for RCSEd to not issue Certificate for Completion of Training (CCT).
FRCSI were awarded but without CCT, trainees could not practise in the UK, the home country of the fellowship. This was the legally unchallengeable ground for MMC to not recognise FRCSI. Decisions made by MMC are never revoked or reviewed.
Illegal and Scam
To circumvent the insufficient training by RCSEd for trainees, MATCVS got certain local Universities to collaborate and provide the training and surgical exposure by RCSEd enticing University Deans with honours and conferred in glamourised gowned ceremonies.
It came at the expense of local programs. The honoured doctors and Deans were in cloud nine and became indebted to RCSEd. Allegedly the honours came with commitment to suppress local University post-graduate surgery programs.
This made PP technically a local program and required prior MQA approval. Either way, the FRCSI pursued by PP are deemed illegal. MATCVS officebearers and colluding Deans have broken the law and could be prosecuted.
On the part of RCSEd, the 500 year old esteemed institution commited a scam to issue fellowship and receive fees and annual dues for merely name lending.
BUT, without the legal responsibities and commitment to ensure its fellowship for Malaysia meet the standards and received recognition for professional practise.
Collusion to break the law
Salam
Saya Dr Mohd Hamzah Kamarulzaman. Cardiothoracic Surgeon (CTSurg) now in private practice. Formerly Head of Service for CT Surgery KKM. I was with Dato Jahizah in Penang.
Based on a mandate by Director General Tan Sri Nor Hisham in 2014, we (together with my colleagues in our Society) collaborated with the Royal College of Surgeon Edinburgh (RCSEd) to start the Fellowship in CTSurg. At that time there were no Masters in CT surgery in any of the Public University or even IJN.
Those who trained as CTSurg were from General Surgery (GS) who had their Masters in General Surgery. Few came across to do CTSurg as - they had to serve as General Surgeon before they could join us. Many good potential candidates were lost because they were not ‘released’ by their bosses or left for private practice.
So when we collaborated with RCSEd, it was by no means meant to be step back to colonial days. Rather, it was to ensure continuity in the number of surgeons servicing not only the 7 Government Centres, but also succession planning for IJN and also the University Units that were providing CT Surg services throughout the country. As it is, quite a number of the centres are run by single surgeons with a long waiting list.
We followed the UK curriculum and eventually, came up with our own National curriculum (not that much different - heart and lung disease are almost similar all over the world. RCSEd conducted TOTs, inspected and accredited the centres as well as the trainers - IJN, Penang, Serdang, JB and UM.
We set criteria for applicants and an interview process was carried out. I presented (in presence of senior colleagues incl. Tan Sri Yahya, and Prof Raja Amin) the program to the DG with the Jawatankuasa Khas Perubatan in 2014 and was given the mandate to do so, as it was deemed a pre-existing qualification.
The trainees go into a six year program and rotate between as many centres. A standard set of expected outcomes has been set and the are assessed continuously as well as yearly.
This program had also been run by RCSEd in Spore and Hong Kong and in 2018 we became part of a quadripartite arrangements - where candidates from these 3 countries would sit for the same exams which will rotate between the three countries.
The College will come every year to supervise the exams (the three countries would set the exam questions for the question bank) but the College will have the final say. Before each exams they set the standards for the questions and answers to ensure it’s all fair.
Trainers for the candidates sitting for the exams will have to exclude themselves from examining the candidates. The exam candidates will have to go through examiners from the College and the three countries. As of now 3 batches have set for the exams and have got through.
What is upsetting is, in the middle of all these, a new goal post have been set with Malaysian Qualifying Agency, Ministry of Higher Education (MQA) being involved. A ‘clerical’ error made in 2017 stated that the recognised qualification - Intercollegiate Fellowship in CTSurg rather than the FRCSEd CTsurg nomenclature.
The Intercollegiate is the exam, but upon graduation, you are conferred the Fellowship by any of the four UK colleges. We have not roped in any of the other disciplines, but this new ruling have also affected Urology and FMS.
To say that the program is illegal is both an insult and upsetting. And, those in the Unis who want to run the Masters CTS (and we did not object), now want to use the KKM centres and accredit the trainers when previously we were called illegals!
Many meetings and representations were made. Perhaps a legal recourse is the only answer.
The current batch in the UiTM program (which ironically has partial MQA approval and also do not have MMC recognition) will only graduate in 3-4 years . It will take a further 3-4 years before they gain enough experience and maturity.
Most of the surgeons in KKM centres would have retired within the next 2-3 years. Hence the reason why the EXCO of the Society is going all out to make sure the surgeons who have the Fellowship through the parallel pathway be given their due recognition.
He may have received the mandate but the manner it was carried out remained illegal and irresponsibly done. The former DG of MOH allegedly abetted in a crime.
The problem lies in the insufficient training and refusal to conform with well established regulations!
Wrong from the start
The mentioned Prof Dr Raja Amin Bin Raja Mokhtar, whose responses have been twice used in this blog here and here, gave a detailed, lengthy and well informed reply.
He happens to be a former president of MATCVS and was involved in the PP at the early stage with the famous heart surgeon Tan Sri Dr Yahya, but both realised the problem, warned the relevent personalities (but was not heeded), and withdrew support.
His reply below:
I am writing this article as a rebuttal to Dato’ Hamzah’s write up. He is a highly respected senior CT surgeon and a friend. However, with full respect, we should agree to disagree and argue our case respectfully and professionally.
Dato’ Dr. Hamzah Kamaruzzaman and Dr. John Chan are both private practice Cardiothoracic surgeons leading the Parallel Program (PP). Their background were never as teaching academics.
One was previously the Head of CT Services in MOH, thus his main forte is mainly service. The latter, was a reseach based surgeon in UK and later join the MOH service for a short time before leaving for private practice.
Running a training program is a serious endeavour, requiring full time dedication, passion and sacrifice. It is a full time job with:
1. the constant paperwork,
2. Research/ Academic meetings,
3. monitoring of student progress,
4. research work,
5. handling problems related to student affairs,
6. arranging posting and rotations,
7. ensuring candidates have more than enough exposure to get enough experience in management of patients,
8. ensure they get the desired hand skill much needed in surgery.
9. lecture series on weekends,
10. workshops for both trainees and trainers,
11. motivational talks,
12. basic surgical skill courses,
13. journal clubs,
14. multidisciplinary team meetings,
15. bedside / ward round teaching, and
16. operative procedure teaching and many more.
All these have to be documented as evidence for MQA assessment and approval.
Using the program structure provided by RCS and doing the work on a part time basis is just not enough.
We were told by the current MOH head of CTS in the recent MATCVS AGM, that many of the MOH surgeons are not interested in teaching students,
Since there is a need to train new young surgeons and trainees, this can be made mandatory and the universities can help with training the trainers (TTT) courses.
In our local setting, all of these work are best done by the Universities who are regularly doing this kind of work on an everyday basis.
As evident, the RCS advisor who came to assess the program noted that UM was said to be the best training centre in the PP - indicating that an academic institution will do well running such a program and not centres that are running busy services.
The Parallel Program was started before the Master Program because we thought it could start early and didn’t need to go through MQA. Not realising the consequences of our decision then.
After the start of the Masters/Doctorate Program in UiTM, some of us realised that we could get into trouble because of legality issues pertaning to the fact that the PP being a 100% local training program.
MATCVS/MBCTS couldn’t hold the ‘punca kuasa’ as it was not a local university, and the program also actually needed MQA approval. Neither was it a foreign program since all (100%) the training is being conducted locally and elective overseas training is only optional.
So far none of the candidates have left for an overseas elective posting while in training. Those who when after completing the PP could only use their MRCS to apply for jobs in the UK.
This realization was conveyed to the relevant authorities in MATCVS indicating that it was an ‘illegal’ program.
They were informed of the need to be absorbed into a local university program with MQA certification is a solution but this advice was not heeded until it was too late.
There was no ‘change of goal post’ scenario at all as claimed . It was just an advise and warning not heeded. The goal post was always the same but we were just not aware that it was there.
We had no problems with work and collaboration with RCS but we are concerned that RCS gave us the short end of the stick and we accepted it only to realise later that they given us a diploma that is not recognised in their own country.
Why should we accept this? This issue had nothing to do with ‘ step back to the colonial days’ but was a straightforward legal problem.
Let’s negotiate for better terms for us, like allowing our candidates to sit for the intercollegiate exams which upon passing, gives opportunity to work in the UK. We will be happy to accept that.
Ironically, our MOH colleagues stopped UiTM candidates, who are MOH doctors themselves, from being relieved from MOH and refuse from training in MOH hospital.
Is this helping to train more and increasing the number of CT surgeons in the country?
The excuse given was that many MOH Consultant CT surgeons were not interested in teaching trainees, so refuse to take them into their CT units.
But the head of MOH CTS services confide in one of our senior surgeons that RCSEd specifically said that if MOH took in the (local) trainees, RCS will pull out of the collaboration?
Colonial mentality and deja vu? I let you decide
UK Curriculum may be similar but emphasis are different. Our needs and circumstances are not similar.
The RCS insistence on 1:1 ratio of trainers to trainee is not practical in Malaysia and will never reach our eventual goal of surgeon to population ratio of 1: 250,000. That is where the universities can play a major role in training structures.
At the same time, there are many medical officers (MOs) some are chronically in the CTS units in MOH. Many are not being trained or properly exposed in the CTS units and are just wasting their time there.
They are not involved in surgeries and their jobs are mainly running the clinics and attending to cases at the emergency units.
Why are they not being trained or are being prepared to enter the training program?
Why don’t we replace them if they are not interested in a future as a CT surgeon, with the current trainees in need of valuable experience in the CTS units?
They claim that the PP is important for the training of future surgeons but they show no interest to train up their own MOs.
The UiTM Masters/Doctorate Program have a comprehensive structured training program and willing to take MOs at a young age to undergo extensive basic and later advance training in the Masters/ Doctorate program.
Similar plans will be made for the UM program as we will all be under one Conjoint Board.
To say that Hong Kong and Singapore recognises the FRCS International through the Quadrapatite exams is not true.
Both country / region have their own recognised local degrees and the FRCS qualification is just an extra bonus for their CV.
I was an Observer for the FRCS International in 2 occasions, and an Examiner of the Masters UiTM exams trice. During the last 2 exams, FRCS International did away with essay questions thus made the exams quite easy to pass or rather less easy to fail.
The range of topics were relevant but covered less areas compared to the local Masters exams which emphasise more basic core knowledge. However, these are different exams with differing emphasis. Thus cannot be compared as apples to apples.
But I believe that when the time comes for the Doctorate exams, it will cover wider areas of clinical and scientific knowledge widening the gap between the two programs and making the overall Masters/ Doctorate Program more suited to our candidates and the need of the nation.
The Doctorate candidates will be encouraged to get exposure in countries like Thailand and Australia in areas of thoracic surgery and Paediatric Congenital Heart Surgery on top of the mandatory posting in Adult Cardiac Surgery.
From the beginning, the PP are having trouble in exposing their candidates in Thoracic Surgery and may fall short of the DOPS (Direct Observation of Procedural Skills) requirements in the syllabus.
Some may only get the exposure after completion of the PP as we simply do not have enough thoracic surgery cases in Malaysia.
By absorbing them into the local program, they will get these important and necessary exposures in Thailand for their future work as consultants.
No clerical error in 2017, warning since 2016. MMC realised that the 2 qualifications intercollegiate vs international were fundamentally different bcos of GMC UK recognition for one not for the latter. Thus they removed the FRCS International from the list deliberately.
Illegal in the sense of qualification not recognised for work in the UK.
Our candidates are of good quality simply because they are screened and are among the better student compared to their peers. So it is not the candidates that is problem, but rather the diploma that is being confered to them.
If this particular diploma is equal to the intercollegiate diploma and they are allowed work in the UK, all of us do not have any problems with the diploma. But the Law says that a degree not recognised in their home country cannot be recognised in Malaysia is a BIG deal.
How can we as a sovereign independent country with one of the best healthcare system in the world accept a diploma not accepted in Universities?
Are our candidates of a lower status or standard than the ones in UK?
If and only if GMC UK decide to change their Law to include the qualifications of our candidates, we have no issues with the FRCSEd International diploma. Why do we have to bend our Law and accept a lower diploma?
Why don’t you pressure the GMC UK to accept our candidates? Then and only then should we accept and recognise their FRCS International diploma. But it has many consequences as I had mentioned in my previous write up.
We have no problem with our colleagues or PP candidates except for our difference in opinion on which diplomas should be accepted and which should not. I am clear on that. Hope everyone is clear too.
No intentions to sabotage anyone, and we need to go beyond this bickering and provide as many training centres in the country.
With the universities monitoring and training both candidates and trainers, to ensure our nationally trained CT surgeons are trained properly in a way our nation see fit on how they should be trained n rather than being controlled by a foreign entity
Threatening us to comply to their standards whatever that may be otherwise we may be renegated is not acceptable.
We should set our own standards, we have the capability to do so and we check our standards by benchmarking with other international standards.
FRCS is not the only system around.
Australia had similar problems with the GMC UK before and they decided on their own standards and do not recognise at all the FRCS diploma.
Any trainees who has the FRCS from the UK, will need to sit through d FRACS exams and its CCT system upon coming back to Australia. And why shouldn’t we do the same?
Dato’ Hamzah is being emotional and quite unprofessional, when he said that since we are considered illegal, why do you need our centres?
This is a’ major ‘clerical error’ on his part.
It is the FRCS diploma that is illegal and not the centres nor are our surgeons in MOH.
The universities under a single Conjoint Board can assist to make sure both hospitals and its trainers/trainees comply to MQA standards for qualification.
Legal recourse had been taken. AG Chambers consulted and they see the issues clearly on a legal standpoint and has advised all to follow the Law.
The Task Force mandated by MOHE also said to follow the Law.
We should just follow the Law.
Instead of getting the candidates to take legal actions against MMC, the candidates should actually turn back onto MATCVS/MBCTS and sue them instead for misleading them and refusal to heed advise from those to noticed the illegality issue when they were doing up the MQA submission for Masters/ Doctorate program.
We have no intention to kill off or sabotage the PP but we just advise them to do something before it was too late.
Now its too late. They never took our advise.
When MMC rejected their NSR applications they looked for a convenient scapegoat for the blame game. Who is the most convenient one if not the UiTM program?
Using racial politics to gain support. But all is revealed when other program for Urology and Family Medicine shows that the problem is the fundamental legality issue of the programs from UK and Ireland and NOT a UiTM sabotage.
Dato’ Rohaizad, the current Chairman of MEC, at that time was a Deputy DG in Medical Development at a meeting, told us that MOH will need 8 new candidates and agree to send to UiTM.
After approval and the interview process, 8 candidates were selected but not allowed to enter any of the CTS centres in MOH to start their first year course.
It resulted in a one year delay and they eventually managed to come to UiTM and to some MOH centres to do Respiratory. Medicine, Anaesthesia and Cardiology, still not allowed to enter CTS except for one hospital in Kuantan.
And they have the audacity to speak about the need to train many surgeons. All they did was sabotage the entry into CTS units in MOH, when their other colleagues from other departments were willing to accept these candidates to fullfill their rotation requirements. SHAME ON YOU!!!
I shall be bold to say that: an act to sabotage the nations own program to ensure the survival of a foreign program is an act of TREASON!!!
With regards to partial approval (PA) by MQA, this is the normal process where a local program will be given a PA and upon completion of the first Masters batch, after MQA reassessment, will give full approval if no issues that may affect the quality of the program are found.
The fact that this Standard Operating Procedure (SOP) is misconstrued shows the lack of knowledge in academic activities in Malaysia.
Through these processes, if the PP candidate were to be absorbed into the UiTM program, since the program is already ongoing, following MQA SOP, early full approval can be given to UiTM doctoral program and immediate registration into the list of approved qualifications for NSR.
However, for UM Program, we hope that they too will get PA soon and once they have start their program, they can apply for full approval at a later date.
Let’s be clear that, UiTM program is not the enemy, we want to work together with UM through a Conjoint Board to see that the PP is made legal through MQA process. We would to see the restoration of our united front like before this unfortunate diferences.
The fault I believe fall on the hands of the leadership of MATCVS, who refuse to heed our warnings and advise or listen to the complaints of its senior live members.
With only 28% NSR certified CT surgeons in its membership list, I’m not sure if you represent us anymore.
CONCERNED SENIOR LIFE MEMBER OF MATCVS
Death on the Operating Table?
There have been a case of PP trainee quiting the program upon confirmation from RCSEd that their fellowship do not allow them to work in UK and FRCSI not recognised by Malaysia and other countries.
This is in contrary to the worldwide recognition claims by MATVCS, colluding deans and same "syndicate" of doctors controlling organisations such as Academy of Medicine, College of Surgeons and certain quarters within MOH.
The trainee realised MMC was justified in their decision and the decision made cannot lawfully be changed. He opted to pursue his specialist training in New Zealand.
As a concerned citizen, this compromise in standard to certify Medical Specialist on fast track basis and the insufficient training and exposure for future surgeons is disturbing.
There is no room for mistakes in the operating theater because patient's life is at stake.
When something go wrong and without proper guidance from trainer surgeons, the failure of an insufficiently trained surgeons are not known. Only the surgeons are aware of the grave error committed. It can be swept under the carpet.
However, surgeons and anaestheticians have whispered to acknowledge increasing regularity of complications or death on the operating table due to insufficiently trained so-called qualified surgeons.
If this program is allowed through without appropriate rectification, there will be 16 medical specialist training programs being shoved and Malaysia will be flooded with risky fast track surgeons.
Over the long run, casualties in operating theaters will be a common occurence and will be an endemic problem in the Malaysian medical practise.
Most of the surgeons undergoing PP intend to practise in the private clinics and participate in health tourism. Can the industry strive with insufficiently trained surgeons practising and god forbid, complication from surgery commonly talked about?
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