For Future Doctors: Step by step approach to subspeciality in Medicine
I received a lot of queries regarding the steps and timeline to do subspeciality in Malaysia from various budding doctors who are about to complete their undergraduate degree. Even though I have mentioned some of the steps in my earlier articles under the “For Future Doctors” series, somehow a more detailed explanation seem to be warranted. So, in this post I will write in detail on how to become a Physician and subsequently a subspecialist. I will not touch on surgical speciality.I will write this article in a “frequently asked question” format based on questions that was asked by these budding doctors in my blog.
1) What is MRCP?
MRCP (UK) is a diploma offered by Royal College of Physicians of the United Kingdom. In UK, it is an entrance exam to speciality and everyone needs to pass MRCP in order to pursue their speciality training. In Malaysia, MRCP is considered as an exit exam where upon finishing the exam and completing 18 months gazettement process, you will be considered as a General Physician. MRCP is an internationally recognised degree and widely accepted worldwide.
2) How is MRCP conducted?
MRCP consist of 3 parts. MRCP Part 1 consists of 2 papers of 100 questions each. It covers basic science as well as clinical questions. The questions are multiple choice questions (MCQ) with “best of five” answers. You are eligible to sit for MRCP Part 1, 12 months after your graduation and medically employed. This means that you need to complete at least 1 year of housemanship before sitting for MRCP Part 1.
After passing your MRCP part 1, you will be given 7 years to clear your Part 2(written) and Part 2 (clinical). You can sit for either of the Part 2 exams at any time. If you fail to clear both this exams within 7 years, you will have to sit for Part 1 again.
Part 2 (written) consists of 3 papers of 90 questions each. The questions are multiple choice questions (MCQ) with “best of five” answers.
Part 2 (clinical) is a clinical/practical exam. It consist of 5 stations assessing you on history taking, physical examination, making a diagnosis, investigations, management and communication skills. Station 1 and 3 will have real patients with physical signs of cardiovascular, respiratory, abdomen and neurology. Station 2 is on history taking and Station 4 will be on communication skills of explaining certain medical diagnosis to patients etc. Station 5 consists of 2 brief clinical scenarios where you have to take a brief history and do quick physical examination and come to a diagnosis, simulating a scenario in a day to day clinic.
3) What are the passing rates of MRCP?
Generally, the passing rate of each part of MRCP is about 45-50% worldwide. Very rarely, a person passes all the part in first try.
4) How long will I take to clear MRCP?
If you pass all the parts in first try, you can complete the MRCP in less than 5 years; the best will be 4 years after graduation.
5) What are the other options in becoming a Physician?
The only other option in becoming a Physician is to do local Master’s programme by UM, UKM or USM.
6) I planned to work in medium-sized hospital in Sabah or Sarawak to learn as much as I can without too much competition (HO overflow). but your advice is after I pass part 1 and 2 MRCP, I should apply for transfer to bigger hospital for training purposes to handle part 3, even if I’m in a rural hospital?
First of all, there are only few hospitals in Sabah and Sarawak which can take housemen, namely Kuching, Miri, Sibu, probably Bintulu soon, Queen E and probably Sandakan/Tawau hospitals soon. Rest of the hospitals do not have consultants to supervise housemen. As long as the hospital have consultants and has adequate training facilities for junior doctors, you should be able to sit for MRCP. Unfortunately, only major hospitals have adequate specialities for you to train as a physician. You must understand that MRCP is not just an exam for you to sit and pass without adequate clinical knowledge. You can sit and memorise all the textbooks but you will not be able to pass MRCP if you do not practise clinical skills. As far as possible, you need to undergo rotations in various subspeciality units to get adequate clinical knowledge before sitting for MRCP. Rural hospitals do not have subspeciality units for your training. That’s the reason, it is better to do your training in big general hospitals.
Furthermore, you need a supervisor who can testify that you are fit to sit for the exam, especially for Part 2. Thus, you need a proposer who can certify that you have undergone adequate training to sit for the exams. After passing all the parts, you also need a MRCP holder of at least 8 years to sign the testimony to receive the diploma.
7) What is gazzetment process?
Since MRCP is not a specialist exam in UK, Ministry of Health of Malaysia has made it compulsory for you to complete 18 months of gazzettment process before being recognised as a specialist and to receive the specialist allowance. Thus, after 18 months of further training in a tertiary hospital, you will have to get your HOD to recommend you to be gazzeted as a specialist. The gazzettement period can be shorter on a case by case basis depending on your duration of training before passing MRCP. This will be decide by MOH gazzettement committee.
8) After the gazzetement, what’s next?
How do I apply for sub-specialty training? Where do I apply? Can I apply while I’m still under the gazzetement process? Will I be accepted as soon as I apply, or it’s subjected to seats availability? In short, I would like to know about the sub-specialty training, and maybe as specific examples, you can tell me the route on to cardiologist and neurologist.
After gazzetement, you can apply for subspeciality training via Ministry of Health. Depending on the field of subspeciality that you are applying, the waiting time can vary from few months to few years. Popular fields like cardiology and gastroenterology take the longest time to get a training post. At the moment, subspeciality training in Malaysia can only be done in Ministry of Health hospitals or University hospitals. Only certain hospitals are designated for certain training. For example, cardiology training can be done at Penang Hospital, Serdang, Kuching and JB, as far as I know. Neurology is usually done in HKL and Penang.
Most subspeciality training in medicine is for 3 years. Usually, you need to do the training in 2 different centres. The final year can be done as an attachment overseas and you may be given a fully paid scholarship by MOH. From 2011 onwards, you need to sign a contract upon confirmation of your training post in subspeciality by MOH. You will be bonded for 3-5 years depending whether you do all your training locally or partially overseas. Previously, you are only bonded if you choose to go overseas during your final year.
All in all, it will take roughly 10-12 years upon graduation for you to become a subspecialist.
9) If I got accepted by Singapore as MO post-MRCP, is it certain that I will be absorbed into the sub-specialty training after 1 year? After I have completed my specialist training in Singapore, is my license recognized in Malaysia, and is my license recognized internationally for that matter.
There is no guarantee that you will get the subspeciality training post in Singapore. It depends on your performance and which field that you are choosing. If you stay long enough, you will get it, as long as you show interest and your superiors support you. Subspecialist training in Singapore is a very structured training programme and well recognised internationally. There is no problem for you to return to Malaysia as a subspecialist.
10) Is Malaysian specialist license recognized internationally? And what are your recommendations for internationally recognized sub-specialty programmes post-MRCP?
This is a difficult question to answer. Whether another country recognises our subspeciality training depends on that particular country. Generally, our local Master’s programme is NOT recognised elsewhere except for some Middle East countries. So, it is very likely that as a Master’s holder, you will not be able to work elsewhere as a specialist except on attachment basis. Certain countries like Australia have their College of Physicians to assess the particular consultants experience and then will decide whether you can be recognised as a sub-specialist.
11) What is FRCP?
After 8 years of holding MRCP (UK), you can apply to the respective college for FRCP(fellow of the royal college of physician). To be accepted into a college as a fellow, you need to have contributed a lot to clinical medicine and medical educations. Publications in journals are also important. Furthermore, you need a proposer who is a FRCP holder to propose you to be accepted as a fellow. The respective college councils will go through your CV and publications before deciding whether you can be accepted as a fellow. Being a FRCP holder gives you an international recognition in medical field.
For more info on MRCP, please visit http://www.mrcpuk.org/SiteCollectionDocuments/MRCP_Regulations.pdf