What Changes are Needed to the Training Framework?


Dr Noor Hisham Abdullah
MOH

As Dr Nazirah says, collaboration between public and private entities is crucial in facilitating convergence between the two sectors. A pertinent area in this regard is the amount of time it takes medical graduates to take up their post on a housemanship programme. Dr Awang, where do you stand on this matter?

Professor Dr Awang Bulgiba Awang Mahmud
UM

The time medical graduates have to wait to begin their housemanship placement is sometimes up to six months or even a year, which is very long. My concern is that the situation is exacerbating the external brain drain and adversely affecting the sustainability of wider talent-development initiatives. From a personal point of view, I completely understand why a young professional would choose to start working in a place like Singapore straight away rather than waiting around for an employment opportunity to materialise in Malaysia.

Ahmad Shahizam Mohd Shariff
Pantai Holdings

Pantai has implemented an initiative specifically aimed at new graduates waiting to begin their housemanship placement. The scheme does not offer them clinical employment but it does provide them with the opportunity to work in an area relevant to them and their studies.

Dr Nazirah Hasnan
UMMC

FOM, UM and UMMC have a similar initiative in which graduates are offered the chance to become research assistants while they wait to take up their housemanship placement. This scheme is a direct attempt to stop the external brain drain during what can be a frustrating period for a young professional.

Dr Noor Hisham Abdullah
MOH

Efforts to resolve the length of time spent waiting to begin a housemanship placement are ongoing and multifaceted. The waiting time itself is directly related to the Public Service Department, which is restricted from creating new permanent posts.

In the past, medical graduates were offered temporary posts, with permanent contracts dependent on performance. Now, they are all offered permanent posts upon graduation. This is significant because not only are there more graduates than positions available, but also the provision of permanent posts means it is difficult to remove a graduate if they perform badly, thereby freeing up a space for someone else.

As a result, the government is taking steps to reintroduce the system of temporary posts at the placement stage as part of the process to reduce the waiting time. As of December 2016 approximately 2,600 medical graduates will be employed on a contractual basis to serve in government facilities. Doctors will be able to work for the government for up to four years on this contractual basis and after the housemanship is complete, excellent houseman will be absorbed into the public system immediately as permanent medical MOs. One of the drivers of this change is the belief that a merit-based system will help to produce more specialists from the top-performing housemen.

Dr Zaleha Abdullah Mahdy
UKM Medical Centre

These steps to shorten the waiting time of graduates taking up their placements are positive. However, in order to create an environment in Malaysia that is fully conducive to training, a number of rigid public health policies need to be removed, including two related to the housemanship scheme.

The first concerns the length of time the housemanship scheme itself lasts, which is two years. Not only do many medical graduates view this as overly long, but it is also significant in relation to the external brain drain. This is because one alternative to the local scheme for Malaysian medical graduates is a one-year housemanship in Singapore.

The second issue concerns the period directly after the housemanship placement. In Singapore, for instance, if medical graduates perform well during their housemanship they are offered immediate access to postgraduate training. In Malaysia, however, individuals who complete their housemanship training have to commit to another two years of compulsory service before they can begin postgraduate training. Students also view this period as too long and it acts as another contributory factor to the external brain drain.

It is therefore crucial that steps are taken to streamline the housemanship scheme, from start to finish.

Dr Noor Hisham Abdullah
MOH

Housemanship training was extended from one year to two years in 2008. The aim was to enhance students’ clinical training by increasing the number of major disciplines taught from three to six. Nevertheless, the Malaysian Government understands the benefits of a vertical approach in terms of individual development and discussions have been held on this matter. Consequently, as of 2017, the very best medical graduates will be fast tracked through their housemanship placement in approximately 18 months or less.

Dr Zaleha Abdullah Mahdy
UKM Medical Centre

That is a positive development. A further step is to introduce greater variety into the housemanship programme. For example, after my one-year placement, I undertook ‘houseman MO training’ in which I chose to receive O&G training for four months. Therefore, a similar development to allow medical graduates to undertake more personalised and specialised training in their chosen field after their housemanship is complete is one possible alternative. This will help to ensure that students progress to specialist training with key basic skills in that particular area. While not every houseman knows exactly in which area he or she wants to specialise after the first year, many do. Thus, it is important to facilitate the path to specialty training for top performing individuals who do have a clear sense of their career trajectory in medicine.

Dr Nazirah Hasnan
UMMC

In discussions about changes to the housemanship programme, it is important to consider that Malaysia has a broad-based need in terms of healthcare. As a result, a balance needs to be struck between providing junior doctors with a wide-ranging education and enabling those who perform well and who have clear goals to excel in their desired specialty, as Dr Zaleha noted.

In addition, a large numbers of housemen are not completing their placements on time. This results in posts being blocked to new arrivals and delays the training of the fresh graduates.

Dr Noor Hisham Abdullah
MOH

To expand on what Dr Nazirah said, the reason the housemanship programme was extended was for medical graduates to receive training in a greater number of specialties. If a newly accredited MO is posted to a university setting or urban hospital, he or she will gain exposure to a range of clinical scenarios and more intensive supervision from the large number of consultants who specialise in specific areas. If, however, they are sent to a government district hospital, which are far smaller, located in more rural settings and which have few or even no specialists, it will be more difficult for them to acquire the necessary skills. That is why it is important to ensure they have a wider set of abilities prior to becoming an MO.

Dr Zaleha Abdullah Mahdy
UKM Medical Centre

I realise the need to take precautions, especially in district hospitals in which clinical care is often more challenging than in large, urbanised environments. Nevertheless, there is a sentiment that the extension of the housemanship programme from one year to two years is causing a greater number of problems than it is resolving and that it does not add value to the system.

An alternative to the two-year schedule in which housemen undertake six disciplines is for them to conduct three postings, as before, plus one additional posting. The additional posting would be aimed at fulfilling the requirements for placement in more isolated district hospitals following the end of the housemanship programme.

Dr Noor Hisham Abdullah
MOH

The long-standing objective of the two-year housemanship is to ensure that district hospitals are staffed with doctors with broad-based clinical knowledge. However, since a large proportion of hospitals, particularly district hospitals, are run by MOs rather than specialists, there is consensus on the need to increase the number of specialists working in the more rural institutions.

To provide some context in relation to efforts to train specialist doctors in Malaysia, the maximum number of postgraduate places available on an annual basis in the country is approximately 1,100. However, the number of applications received each year is about 5,000. As such, the first step by the MOH to address this shortfall has been to increase the number of scholarships available for specialist training programmes, from 450 in 2007 to 1129 in March 2016.

The second step has seen the government open up a number of alternate training pathways to traditional postgraduate programmes. One of these alternate pathways enables MOs who cannot enter local Masters programmes to pursue training through the UK Membership Programme. This scheme, which includes the participation of a number of British institutions that specialise in distinct disciplines, involves certain examinations being conducted locally in Malaysia.

A second alternate pathway is the move to increase postgraduate training in cardiothoracic surgery. Under this scheme, leading organisations from the industry will provide fellowship training for public sector MOs in cardiothoracic surgery, as an alternative to the traditional master of surgery programme. The fellowship programme will shorten the time taken to train cardiothoracic surgeons from eight years to four years.

The aim of these strategies is to produce more specialists to fill the gaps in Malaysian public hospitals, including district hospitals. Once all public hospitals have secured the services of at least one specialist, the government can then review the length of the housemanship programme and assess the possibility of reducing it back to one year. Significantly, these two issues are interlinked because if the number of specialists in district hospitals increases, housemen can then be posted to these locations for supervision purposes after a year; something that is not possible at present given the lack of specialists in the public sector.

Sherene, the issue of specialists in the private sector relates directly to the work undertaken by the Malaysia Healthcare Travel Council. What is the perspective from the healthcare travel sector in regard to how the shortage can be resolved?

Sherene Azli
Malaysia Healthcare Travel Council (MHTC)

The MHTC has targets to meet, such as exceeding the MYR1 billion of revenue generated in 2015 from the medical tourism sector in 2016. The fulfilment of these targets is directly linked to the supply of specialists in the country, as well as investment in new tertiary-care private hospitals, and it is important that these targets are met in order to engender the growth of the healthcare travel sector.

Roundtable participants agree that more specialists are required and that public and private actors must work together to overcome the associated challenges. From the MHTC perspective, an important issue that arises during related discussions is how to secure more active involvement from the private sector to help finance specialist training. Significantly, some private hospitals are interested in pursuing a more active role in this respect, while others are more reluctant. For example, when I engaged the APHM on this matter and explained that the MOH was requesting private sector collaboration to enhance the supply of specialists, only a limited number of hospitals agreed to form part of the plan. One of the reasons for this difference of opinion in the private sector is because the system itself is not conducive to a training platform and it will take time to prepare the necessary training facilities, particularly since large numbers of private specialists are not incentivised to perform training, as has been discussed.

Conversely, university hospitals have a functioning system that is highly conducive to a training environment. Therefore, it is important that the industry uses this strength as a starting point from which to build efforts aimed at collaboration. The creation of the alternative pathways mentioned by the Director General shows that progress is being made towards increasing the number of specialists. What is lacking is for stakeholders to be more aggressive in seeking further progress towards this end.

My overall aim is not only to boost medical tourism to the country but also to contribute to the broader improvement of Malaysia Healthcare. To achieve this, it is especially crucial for us to address the supply of specialists in our healthcare system. This requires overcoming long-standing obstacles that are blocking the pipeline of new specialists. The only way to clear these obstacles is through spaces of dialogue, such as this roundtable, in which the government, the university hospitals and the private sector are all represented.

Dr Heric Corray
Queen Elizabeth Hospital

The goal to increase the number of specialists is very important and it must be fulfilled in tandem with efforts to stem the brain drain. Otherwise, all new specialists entering the system will simply end up working in the private sector.

In government hospitals, the brain drain is more prevalent among subspecialties. For example, at Queen Elizabeth Hospital we have lost a liver surgeon, a number of gastroenterologists, and others who have all moved on to the private sector. Therefore, a structure is required in which specialists who leave the public sector are able to return and receive adequate remuneration. The present framework is rigid and poses too many barriers, for example the system in which specialists who return to the public sector and receive pay in the form of sessionals or honorarium is insufficient. The goal is to have a system that not only facilitates but also incentivises the movement of specialists across the public and private sector.

Dr Noor Hisham Abdullah
MOH

I would like to change track from doctors to concentrate on another area in which the brain drain is substantial: nursing. Ahmad, Pantai is heavily involved in this area so could you provide us with some context?

Ahmad Shahizam Mohd Shariff
Pantai Holdings

The brain drain of nurses in Malaysia is more substantial than the one affecting doctors, although the solution is more straightforward. Essentially, the response requires greater flexibility in the ecosystem to plug the gaps in the training and development of nurses in the country.

The majority of private hospitals are able to keep entry-level nurses for approximately three years. However, once they complete their first post-basic degree, which is an advanced-level qualification, they commonly move on elsewhere. Some join the Malaysian public sector, which is fine, but many more find work abroad. Putting an end to this external brain drain is the major challenge.

In order to retain the talent in this country, it is vital that the national nursing ecosystem is modified to offer more training opportunities and incentives for nurses to stay. From this perspective, the private sector can play a more comprehensive role. One approach is to allow more flexibility in terms of post-basic nursing programmes, which would improve the supply.

Chong Yee Mun
Prince Court Medical Centre

I spent a number of years working at Assunta Hospital, which has a well-known and reputable College of Nursing. In discussions about reforming certain aspects of the nursing profession, it is important to begin with the basics. One of the hurdles that nursing in Malaysia has had to overcome in recent times is a perception that it is not a serious profession and that the brightest students seek jobs in alternative fields. As such, nursing colleges often struggle to find the appropriately qualified students to fill their places. The requirements for students taking up a nursing qualification were loosened a few years ago and this has contributed to the negative perception about nursing as a career option.

Regarding what Ahmad said, once nurses have completed their post-basic training and accrued approximately four or five years of experience, it is common for them to secure jobs in a foreign country, particularly in the Middle East or Singapore. Conditions overseas can be very attractive, with the chance to earn up to four times the salary on offer in Malaysia, and therefore we cannot blame them for taking that decision.

Furthermore, some post-basic training courses, including at the MOH level, were recently extended from six months to one year. This creates an additional cost, and in terms of Prince Court, the biggest impact of this change has not been financial but logistical in terms of the availability of staff at the centre. When a member of our staff attends a training course, we still pay their salary. While the money is generally not an issue, the challenge relates to the amount of time that team member spends away from their job, and given the shortage of nurses in Malaysia, this is problematic for the private sector.

Dr Zaleha Abdullah Mahdy
UKM Medical Centre

Many new changes are required to reinvigorate the nursing sector in Malaysia. The MOH has already begun this process and taken the positive step of introducing a nursing degree. This is in contrast to past practice in which it was possible to enter the nursing profession with a diploma. With a wide range of universities offering nursing degree programmes in 2016, the first hurdle has been surpassed. However, a shortage of posts for new nursing degree graduates is directly contributing to the brain drain of young, talented nurses, so additional steps are required.

By offering a degree course to interested parties, the profession will attract highly intelligent students, which should help to address the perception issue mentioned by Yee Mun. In addition, the way to tackle the brain drain is not only to ensure that jobs are available post-graduation, but also to provide working conditions that are attractive, with manageable timetables and an overall situation that is conducive to a good quality of life.

Sherene Azli
MHTC

It is positive that students can now acquire a degree in nursing. However, feedback I receive from a number of hospitals shows that one of the challenges related to this development is that when nurses graduate, they frequently lack the hands-on skills that are required. This causes problems that extend beyond the competence of the individual, since it results in the graduate being unable to fulfil the necessary tasks. It is important, now that the degree courses are up and running, to ensure that the correct skills are being taught across the board.

Dr Noor Hisham Abdullah
MOH

Another challenge that the government is working to overcome relates to the friction between recent graduates who, theoretically, have the skills necessary to operate in a clinic or on a ward, and more senior nurses who have years of experience and a diploma. The skill-set of the latter is clearly greater than the former, given their professional exposure, while graduates receive the benefits associated with degree-level qualifications, including higher pay grades. This friction can demotivate the experienced nurses without degrees and undermine the system as a whole.

One solution is to upgrade existing diplomas to degrees, although this requires substantial time and resources in terms of training, logistics, funding and scholarship options. As with the need to stem the doctor brain drain, a collaborative approach will facilitate the identification of solutions and the government is open to suggestions. What can be done to resolve the nursing brain drain and this source of friction?

Dr Nazirah Hasnan
UMMC

A greater number of graduate nursing posts in Malaysia will help to stem the brain drain. We see the shortage of degree-level posts at UMMC and so we offer nursing graduates positions as tutors. This approach is not ideal and not all of them want to be tutors, but it is an attempt to incentivise newly qualified nurses to stay in the Malaysian system.

More posts will also help to address the friction mentioned by the Director General. When a new post opens up that requires an individual to oversee treatment quality, coordinate training of nursing staff and plan nursing services, the decision is usually made in favour of the experienced staff nurse with advanced clinical skills. Thus, additional jobs for new graduates will help them in their search for that all-important professional experience.

Professor Dr Awang Bulgiba Awang Mahmud
UM

The most effective way to resolve the lack of posts for nursing graduates in Malaysia is to decouple the system from the Public Service Department’s hierarchy and set about devising a more innovative structure. It is important that this approach looks to develop the career pathway of graduate nurses in a different manner.

Ahmad Shahizam Mohd Shariff
Pantai Holdings

Dr Awang is right that a new structure is required, and this includes the need for nursing to be based on competencies, skills and experience rather than simply holding a degree. Talent development from the bottom up is vital and that is why jobs in the private sector are determined by skills and experience rather than whether a nurse has a particular qualification.

Dr Mohd Azhari Yakub
IJN

The career pathway for nurses with degrees is less well established than for nurses with diplomas. One way to rectify this situation is to create a pathway for graduate nurses to learn experience on the job, as happens with doctors. At IJN, we are taking steps to create such a pathway for certain individuals to help cover critical clinical areas. For example, nurses with a degree are encouraged to become nurse managers. This model that offers a career development pathway is one form of resolving the shortage of posts for nursing graduates.

Ahmad Shahizam Mohd Shariff
Pantai Holdings

Pantai implements something similar in which nurses with diplomas are incentivised to stay at the company in return for post-basic training and degree sponsorship. Once they complete their degree, we offer nurses three clear pathways: a clinical pathway, an education pathway and a management pathway. We find that retaining talent is greatly facilitated by offering them this kind of choice.

Chong Yee Mun
Prince Court Medical Centre

Prince Court follows a similar strategy to Pantai in that nurses with diplomas who wish to pursue the nurse manager route, for example, will frequently be sponsored to undertake a degree. The reasoning behind this is that the best nurses are those with both hands-on experience and a degree.