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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 1^st July 2017. MMC became a corporate body with a CEO. The composition of the council also changed as below:

1. The DG of Health remained as the chairman of the council (despite many suggestions to make it elected from the members of the council)
2. Appointed University representative increased from 6 to 9 members (both public & Private, currently 5 public uni and 4 private uni reps)
3. Appointed Public sector representative remained at 3 members (all KKM).
4. Appointed Private sector was given 3 new posts.
5. 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.
6. 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 1^st 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 1^st 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 1^st time , Masters and Parallel  trainees receive comparable training standards with  unified curriculum   The National Postgraduate Curriculum in CTS is as below:

1. Training Centres

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 halal.

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 “halal” 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.

Till mid 1990s, there were only 3 universities offering medical program: UM, UKM and USM. UPM started somewhere around 1996. Thus, the number of training post under the local Master’s program were small and limited. The “parallel pathway” was still the main pathway of someone becoming a specialist.

Our father of privatization aka pirate-tisation, Dr M decided that it is time to pass the buck to the private sector aka make someone rich. Thus, he tabled the Private Higher Education and Institution Act in 1996 and got it approved. Prior to this, there were no private institution of higher learning in Malaysia offering their own degree program. There were some private colleges offering programs with collaboration with foreign universities. The best example would be law colleges running programs for University of London etc. This is similar to the medical parallel pathway. Trained here but sit for foreign exams. Courses are coordinated by the respective foreign universities.

What happened in 1996?

PHEIA 1996 was passed in Parliament, opening doors for private universities and university colleges. This allowed private universities to run their own program and offer their own degree. The 1^st private medical college was IMU and subsequently tonnes of new medical colleges were formed till 2016. I don’t have to write about these issues anymore as I have written about it gazillion number of times.

Till 1996, all public higher education were under MOE. Thus, the quality of education is usually handled by the university themselves with MOE at the background. As far as I am aware, there were no formal accreditation process.

LAN Act 1996

Lembaga Akreditasi Negara(LAN) was formed together with PHEIA Act to monitor and accreditate all educational programmes offered by both public and private higher education. These acts were passed together. Basically, LAN is the quality controller and degree recogniser. When this act was debated in Parliament, there were heated debate when it came to professional courses (by opposition members). What is the role of MMC in recognising a medical degree when it is LAN which will decide the degree that is going to be recognised by the government etc? When LAN act was passed, it made LAN as the sole body to accreditate a degree which is then officially recognised by JPA and any other government body. This is also needed for scholarships and PTPTN, which was introduced at the same time.

Obviously, debate is just a debate in the Parliament as the ruling government had 2/3 majority and can pass any law. LAN Act went through, and this caused a massive headache to MMC. MMC was still a body under KKM. MMC power to recognise a degree has now been taken away by LAN as far as Malaysia is concerned.

Joint Technical Committee 1999 (JTC)

As per our Malaysia boleh style, people who create laws never look at the implications and contradiction with other laws which eventually will lead to chaos. The then DG of Health had various discussion about this and finally came up with JTC. JTC was formed in 1999 which is basically a joint technical committee which consist of MMC, MOE, LAN and JPA members. It is chaired by MMC and the purpose is to advise LAN on accreditation of medical courses. The whole idea of this is to avoid any conflict between LAN and MMC. Our DG did not want a situation where LAN accreditates a medical programme, but MMC refuse to recognise the degree. This was formed outside of the LAN Act.

Malaysian Qualification Agency ACT 2007

By 2007, our government decided to amend the LAN Act 1996 and renamed it MQA Act 2007 which still stands as of today. When MQA Act was formed, the JTC was included into the act under Section 51 & 52. For all professional courses, the JTC is formed by the respective professional legislative body to advise MQA on the accreditation process. Thus, it is the duty of JTC to advise MQA whether the degree/programme can be accredited and if not, to provide valid reasons why it can’t be accredited. The reasons will then be forwarded to the respective universities to rectify and to be reassessed later. The power to issue the certificate of accreditation solely lies with MQA. Since the JTC is formed by respective professional body aka MMC, you cannot say that you will not recognise the degree when you’re the same body who advised MQA to accreditate the programme.

The process of accreditation.

All programmes conducted by any higher education need to be accredited by MQA. The license to start a programme/university/university colleges is issued by MOE. Once they receive the license to start, the respective universities must apply to MQA for accreditation. These programmes will be given provisional accreditation by MQA if they fulfill the start-up criteria. A full accreditation is only given when the 1^st batch reaches the final year. So, basically the 1^st few batches are taking a risk enrolling into a provisionally accredited program. Also, if MQA failed to accreditate the program at final year, the parents will be at the throats of the university, MQA and MMC. So, we all know what the final outcome is going to be. It is very rare for MQA not to accreditate a local program, eventually.

Accreditation of Master’s and Parallel pathway

So, after all these came about, all local institution’s educational program must be accredited by MQA. The local medical Master’s program have to undergo the same process. Local Master’s program also has open system for their candidates, which uses KKM hospitals as training centres since early 2000. I have written about post graduate education in Malaysia many years ago under my step-by-step series.

However, the parallel pathway does not need to do this as KKM is not a higher educational institute. KKM is a service provider. The previous DG had mentioned before that parallel pathway do not need MQA accreditation as the exams they are sitting is well known exams conducted by mainly UK and Ireland colleges which have been conducting these exams all over the world for many years. Most of the degrees offered by these colleges are recognised by KKM for almost 60 years and eventually NSR. So, under Section 14B(c), it is categorised as recognised specialist qualification.

This same rule applies for subspeciality programmes where almost all of it are done in KKM hospitals and some in university hospitals with no master’s programme available except for select few, which is now the source of the problem……

Next…….. the current issue, why it is happening and the hidden agenda……….

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 1^st 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 2^nd 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.

When the act came into force in 2017, I remember the Minister of Health asked all KKM specialist to register with NSR as it has become mandatory. He even said that the paid fee can be claimed from KKM. A circular was issued and I have written(with the circular) about it here: https://pagalavan.com/2017/08/13/for-future-doctors-the-new-rules-and-regulations-for-better-or-worst/

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…….

Next……… PHEIA 1996/LAN 1996/MQA 2007and MMC partnership mess……….

Continued……….

It’s been 6 months since I last wrote an article in this series. In between, I was interviewed by various organisation in relation to contract doctors etc. This will be my last article in this series. 

Despite all the hardship that I went through since my childhood of being a “non”, one thing that was guaranteed for me was a civil service job! This is simply because, there were only 3 medical schools producing about 450 graduates annually and some returning from overseas. There were plenty of post available for us to fill. Interviews by SPA and MOH were conducted in the universities even before we sat for our final year exams. The moment our results were out, we would receive our appointment letters within 2 weeks! I had written about this many times before and thus will not go into the details. I was asked to report to Hospital Ipoh within 30 days. While the salary was pathetic to say the least, we were grateful that we had a permanent job. Two months before we due to finish our housemanship, we need to apply for district posting and induction course (Kursus Induksi). At that time, district/rural posting after housemanship is mandatory. We must make our 3 choices. I was asked to go to Pontian Hospital in Johor for my district posting.

While there was subtle racism wherever I worked in MOH, it is hardly noticeable. This is simply because the staffs consist of mixed races. There were nurses, MAs (Medical Assistant), attendants from all different races. This reminded me of the time I was in school back in 1980s. While the schools were becoming monoethnic in composition of teachers by late 1990s, hospitals and klinik kesihatans were still consist of multiple races working together. In fact, most of the HODs were non-Malays in JB hospital. Unfortunately, things have changed since then. We hardly see any Chinese or Indian MAs working in MOH nowadays. Nurses are predominantly consisting of a single race and the composition of doctors are also becoming predominantly of a single race. I am not saying that these people are not doing their work or discriminating against non-Malay patients, but it is an unhealthy development in a multiracial and multireligious country. Many of the non-Malay consultants and HODs moved to private sector, mainly due to financial reasons. They have accepted the fact that their children will not receive any privileges in education or scholarship. Thus, they have no choice but to move to private sector to earn better revenue to support their children in the future. Nowadays we even have shariah compliant hospitals, whatever it means. An Ustaz or Imams are allowed officially into a hospital to say prayers, but similar permission are not given to other religious bodies. 

I used to say to my friends that the last government body that use to be multiracial will eventually come to an end, and it happened. Sometimes I should just keep my mouth shut! With the current contract issues and limited permanent position, I doubt the situation will get any better. This coupled with quota system in master’s recruitment and limited post graduate opportunities, will only make the situation worst. What really shocked me the most is when I found out that some of my Malay friends who I worked with as Medical Officers openly expressed their opinion that they would prefer all HODs to be Malays as this is a Malay country! When even highly educated people can think as such, what hope do I have? By mid 2000, I began to realise that this country is heading the wrong direction, the direction of destruction and no return.

The first 10 years of my medical life was a turbulent one. Getting married halfway through my 2^nd year of working life (district posting), passing my Part 1 MRCP on 1^st try and moving to JB Hospital to continue my training was the easy part. With a pathetic salary, busy work life (JB Hospital is one of the busiest hospitals in the country) and studying at the same time really pushes you to the limit. By the time I sat for my Part 2/3 in 2002, I had 2 child and got my 3^rd in 2004. By this time, I was in debt! Looking into the future and where the country was heading, I had to make difficult choices. I quit MOH halfway through my Rheumatology training in Selayang Hospital and joined Monash University in 2006. My wife who sacrificed a lot with me, had to discontinue her Family Medicine Master’s program in 2002, as it was just too difficult for us to manage the whole family with both of us doing postgraduate education at the same time. We lived by ourselves. 

With the help of Professor Khalid Kadir, I was encouraged to complete my Rheumatology training in Singapore while I continue to teach in Monash which was based in Johor Bahru. I am forever grateful to Prof Khalid for this arrangement. This allowed me to complete my Rheumatology training by 2008. Working in Singapore gave me a different perspective of how such a small country could succeed! It is all based on meritocracy and knowledge-based economy. The way they encourage research and development and how they support you to develop new skills and new departments is fascinating. How they attract the best brains from all over the world and keeping their own best brains is something that Malaysia can learn from. Unfortunately, Malaysia is too engrossed with Malay nationalism with race and religion tearing the country apart. The best brains leave to be better received by another country.

Upon returning from Singapore, I encouraged my wife to continue her discontinued post graduate education. She was very eager to complete her post graduate training in Family medicine. She enrolled into the Academy of Family Physicians MAFP/FRACGP program which was a 4-year program. The advantage: you are eligible for FRACGP which is registrable in Australia. As an appreciation of her sacrifice taking care of the family while I was doing my post graduate education, I paid for her course. While Monash gave me a much better salary than MOH, with rising cost of living and higher tax that you must pay in private sector, it was still an uphill task to earn enough for my children’s education, especially tertiary education. As I had mentioned in my past articles, by 2010 I had to remove my children from national schools to private national schools (not international). The racial and religious issues that was happening in the national schools (despite being a missionary school) was not something that I could accept. I do not want my children to grow up with racial and religious dogmatism. It hurts you when your son who is just 10 years old asking you why the Ustaz in his school distributing free food to only Muslim students in the canteen!

Thus, by 2010 with my eldest already 10 years old, I need to save enough money for him to pursue his tertiary education in 7 years’ time. Again, I had to make a difficult decision in my life. While I loved academic life, publishing at least 5 papers in major international journals within 4 years and loved teaching, I had to give up and move to private sector. Columbia Asia Nusajaya invited me to join them as they opened their first hospital in Johor. After much deep thought, I accepted their offer. I was also the Chief of Medical Services for the hospital, for 7 years.

Life working as a consultant in private hospitals in not rosy either. Yes, you may earn much higher than public sector or universities, but it is no work, no money system. The more hours you work, the more money you get. The more patients you see the more money you get. After some time, you will realise that you are earning enough money, but you do not have a life! I have written about this in this blog as well as in my books. There is no work life balance. The unethical practices that happen in private hospitals is something that I could not accept either. In Malaysia, everything seems to be about money. As one of my friends who is a businessman said, Malaysia is the best place to make money! 

By 2015, my wife has cleared her FRACGP. By this time, the country was in turmoil. The 1MDB scandal and billions of dollars being swindled right in front of our eyes was sickening. Politically, the government has lost it’s 2/3 majority since 2008. Racial and religious politics went into overdrive. What more can politicians use other than race and religion, the well-known propaganda known time immemorial. The government started going after the citizens to collect more tax and penalties to patch up the loss. By 2016, the private specialist doctors became a fresh new target. GST was introduced. With just a single letter, LHDN decided that the private specialist can’t form a company and divert their income to the company (something that has been happening since 1980s and considered legal) and have to declare their income as personal income. They backdated these 5 years (2010-2015) with reduced penalty of 15%! After much discussion between MMA and LHDN, it was reduced to 3 years. We had to rush to settle this by end of December 2016 which was the due date for the penalty of 15%. This is when I realised that the government could screw you when they run out of money. LHDN is the most powerful organisation under the Ministry of Finance who can even charge you in court without going through the police/AG. The DG has absolute power to order any audit or change the rule and can deem anything as a form of tax evasion. 

By this time, I had no choice but to decide my next step. While I was doing well in private sector, it was a one man show. My wife was still a civil servant and my children’s education was totally dependent on me. My eldest son was going for SPM in 2017. We decided that it is best to send our children overseas for education. I wanted them to get a degree which would be more widely recognised all over the world. The world in shrinking and we can’t be living in a cocoon. Fortunately, my eldest was not interested in medicine. I let them do what they are interested rather than coercing them to do what the parents wanted them to do. To date, none of my children are interested in medicine. 

After my wife cleared her FRACGP in 2015, we started receiving calls from recruiting agencies in Australia, offering her a GP position. We rejected all the offers. But something happened in 2016. While I was talking to one my friend from KL, he suggested, why don’t you apply for Skilled Migration Visa (using my wife’s FRACGP) which would give you a PR status in Australia? I was baffled. Is there such thing as getting a PR status without even stepping your foot into a country? Surprisingly, there is such thing and he recommended me to have a chat with a migration agency in Subang. We met with the agent, and everything changed! We thought of giving it a try. It involved a lot of work, from getting the medical registration from Australia (including visits to Australia to confirm job contact), numerous amounts of documents, certification of degrees, English test, police clearance etc etc. It took us almost a year to get all these documents sorted, not to mention the money involved. Finally, by March 2017, we submitted.

There were so many things that went through our mind. Are we really going to leave a country where we were born and grew up? Will our children be able to adapt to the new environment? Would we be able to adapt to a new environment and culture? The worst part, what about me? I am not registrable in Australia as I do not have a registrable degree. It is another long process and money to even apply for assessment. While we were considering all these, and my son was going to sit for his SPM (November 2017), we received another shocking news! In June 2017, my wife’s application for Skilled Migration Visa was accepted and we need to do some final document submission such as medical check-up, police report etc within 60 days. We did it in 30 days and submitted all necessary final documents. Woolah, within 3 weeks, our Visa was approved, and we are officially an Australian permanent resident! This visa is for the whole family, not just for my wife! My children will now be able to enrol into Australian university as domestic students with heavily subsidised fee. 

Why am I talking about this? A country which does not even know who we are, gave us permanent residency without even the need for us to step our foot into the country (except I have been to Gold Coast as a tourist). There were NOT a single question of what race or religion we belong to. Those who know me knows that my wife is not an Indian, she is a Malay! What mattered most was your skill and documents! And despite my wife being the main applicant, the entire family received residency status. This is how a country valued your talent and invites you to be part of their country. We are considered equal to their citizens except in voting rights. This is how they attract the best brains. Where are we Malaysia? Race, religion, and nationalism chased away the best brains, only for us to be proud of saying “Malaysian Born so and so……….” Foreign professionals married to Malaysians have to wait close to 10 years to receive their residency status, not to mention the various insults they receive at immigration office. We have a long way to go……

I moved my family to Perth, Australia in December 2017. My wife started working as a GP in January 2018. My eldest son started his university in February 2018 and my other 2 children started their schooling. What happened to me? Well, I had to start my ball rolling. With an unrecognised degree in Australia, I am not registrable in Australia. But as a senior physician I can apply to be recognised (not guaranteed) via the College of Physician. Another long process of degree verification, document collection, English test, interviews etc was conducted by the college (RACP). I submitted my documents in April 2018, called for an interview in Melbourne in May 2018 and finally in July 2018, I received their verdict. I received a “substantially comparable” status which would allow me to work as a consultant with 12 months of peer review before receiving specialist registration. This verdict is only valid for 2 years, which means I must find a job for the 12 months peer review within that timeframe. 

Based on RACP report, there were 145 applications in 2018 from all over the world for specialist assessment. 112 were considered “substantially comparable”, majority of these were from countries where specialist training is recognised by Australia such as UK, Ireland, USA etc. Out of 11 applications from Malaysia, only 4 were deemed substantially comparable and I am one of them. The other 2 options are partially comparable and non-comparable. Partially comparable means you need to do top up training of about 1-2 years as a registrar and may or may not need to sit for Part 2 exams. Non-comparable means, case closed. Once again, as my wife’s visa application, I was extremely lucky to receive the substantially comparable status. This, together with my status as a resident in Australia, I was able to look for a job. This was the next hurdle that I had to endure.

While I was going through all these processes, I was travelling between JB and Perth quite frequently. Then came the 2018 General Election. Everyone was euphoric after the historic result. Many wanted me to stay since a new Malaysia has emerged aka Malaysia Baru. Yet again, based on evidence and sentiments on the ground, I knew this excitement is going to be short lived. I wrote an article in this blog dated 4^th June 2018 with the title “Towards Malaysia Baru? I predicted that if the new government do not perform at a supernatural speed, either the government will fall before the next election or at the next election. My friends laughed at me and said it is unlikely due to overwhelming majority. Nowadays, they asked me to keep my mouth shut as everything that I predicted seem to be happening!

It was only in January 2019 I was invited for a job interview (after trying for 7 months). Again, I was lucky to be given a full-time consultant job in a regional hospital in Western Australia. Hopefully this would be my last leap of faith. I decided to take it and left Malaysia in May 2019. ……. I received my FRACP in 2020. It saddens me to see what is happening to Malaysia since I left. The vision of Wawasan 2020 remains an elusive dream. The country is more divided than the time I grew up in 1980s and 1990s. Racial and religious rhetoric is tearing the country apart. When even a vegetarian food prepared by Gurdwara Sahib can be questioned on halalness and cleaning a temple by Muslims can be haram, where are we heading? 

I can go on writing and ranting but I will stop here. It has been a tough 2 years for most of us. I hope and pray that 2022 will be a better year with disappearance of Covid.

I wish everyone a very Happy New Year 2022………………………

PART 1

PART 2

PART 3

PART 4

I was invited to give a talk at the UKM Career progression workshop which was held on 17/04/2021. I did mention this in my blog on 29/06/2021 where I showed some of the slides from the talk. Many have emailed me and asked me whether I can upload the talk that I gave. It took some time for me to get the recorded video from the organiser and I also had to do some editing to make it shorter.

So, here is the video of my talk and it is almost an hour long……… Some of the documents might not be clear but those documents are available in my blog.

It has been 4 weeks since my last post on the Black Monday campaign by SCHOMOS and the hartal that is being organised by a separate group of junior doctors. I had received a lot of feedbacks for my previous post personally and via my blog. In the background, SCHOMOS/MMA has been working with MOH and finally had a direct meeting with PM on 23/07/2021. On the very same day, the PM’s office issued the following circular:

As I mentioned in my previous post, absorbing all graduates into a permanent position is NOT a long term solution. I had explained the reasons for this very clearly. It is almost impossible for the government to do this looking at the number of graduates being produced. My recommendation is for all doctors who are into post graduate training should have their contract renewed till they complete their training and get gazetted. The postgraduate training should be standardised. I also said that the permanent government positions is not sustainable anymore and all positions should be changed to contract from now onwards but they need equal opportunities etc, similar to other developed countries.

The circular above basically agrees to what I have been saying all this while. The government has guaranteed that they will provide a minimum of 6 years contract (4+2), increase from 5 years (3+2) currently. During the last 2 years extension, if you are enrolled into a post graduate training program, the contract will be extended to a maximum of 4 years. I presume this 4 years comes about due to the 4 years Master’s program. Those who are already in parallel pathway, they should be in their specialist training by the time the 6 years is done, especially for MRCP, MRCPCH and MRCOG. This 4 years extension hopefully will support their subspeciality training programme. So, overall, if you are in specialist training program, you will be guaranteed a job and training for at least 10 years. The government has also agreed to provide Cuti Belajar Bergaji Penuh and HLP if you are enrolled into the Master’s program. The only problem I foresee are for those who are dependent on local Master’s program which predominantly will be the surgical fields.

With large number of graduates applying for local Master’s program, the waiting period is going to get longer. I did mention this many years ago. The number of slots for Masters program is only about 1000 per year for all speciality included. My question is whether these doctors would even be able to get into the Master’s program within 4 years after housemanship. If they don’t , would their contract be not extended? What if they do not complete the training within 4 years, like they get extended etc? What if they do complete their training but wants to do subspeciality training? Would the contract be extended further? There are many unanswered questions but at least this circular clarifies some of the urgent matters and hopefully, further improvement could be made in the future.

However I noticed that the letter did mention about amending the Medical Act which I find it puzzling. The medical act has nothing to do with employment EXCEPT in regards to the compulsory service. Are we looking at an official reduction in the compulsory service in the future? Currently MMC (since Oct 2020) do allow junior doctors to leave the service 18 months after completing housemanship, pending Minister’s approval individually. Would this be lowered further, permanently? Or are we looking at a common licensing exam applicable for all graduates? It will be interesting to watch but again, it is all a political ball game!

Unfortunately, the above circular and reassurance did not seem to satisfy the group of doctors who were organising the Hartal. Yesterday, they issued the following circular, insisting that the hartal will go ahead today:

I also understood that many warnings have been issued to the junior doctors by the hospital Pengarahs and DG himself has issued a reminder on his FB post as below:

Interestingly, the DG has said that the Pension Act will be amended. This again goes back to my last post where I said, permanent post with pension is not sustainable anymore and all government positions should be changed to contract basis with continuous extension as long as the post is needed and for post graduate training. The hospital should be given the right to choose their own doctors based on need. I feel this is how this scenario is heading into the future. In fact, if the pension act is going to be amended, it may affect all other civil service jobs as well.

The world is changing. Jobs are changing as well. Unemployment of doctors is also a norm in many countries. Consultant without full time job is also common in developed countries but at least they get to complete their training. We need to change. We can’t keep on harping on the same benefits and perks as the baby boomers generation where the world population was a third of what it is now!

I will stick to what I have said in my previous blog post. The era of guaranteed job and permanent pensionable job in civil service is over. Every job is the same and will be treated as the same based on need. Doctors are not an exemption. Everything should be based on merit. I hope the selection of doctors into postgraduate training will be done on merit and be transparent. I also hope that a single post graduate training system will be implemented rather than 2 separate system. I might be dreaming but it is the only way forward. A total revamp of the healthcare system will be needed. A National Health financing scheme is needed to sustain at least the GP practise. A Restructured healthcare system is needed to move away from tertiary health care to primary based healthcare!

The question is , are the politicians ready to make this unpopular decisions? Looking at the current scenario, I don’t see it coming anytime soon!

At the time of me writing this piece, this is happening :

https://www.facebook.com/watch/live/?v=6447731198586474&ref=watch_permalink