Rethinking the Status Quo


Dr Noor Hisham Abdullah
MOH

We have discussed a number of challenges related to talent development and retention in Malaysia, including that of doctors and nurses. To expand on this, I want to switch the focus slightly to the subject of attracting foreign specialists to work in the country as another way of reversing the brain drain. A key part of this is to do so without compromising the high standards of care in the national healthcare system. How can this be done?

Dr Zaleha Abdullah Mahdy
UKM Medical Centre

To identify solutions to the brain drain in the Malaysian healthcare sector it is vital to understand its root causes. As has been discussed, the real problem in terms of the long-term sustainability of the sector is the flight of medical students abroad. The challenge for stakeholders, therefore, is to incentivise these students to conduct their studies in Malaysia prior to working in the national healthcare sector.

Crucial to reversing this brain drain is for the MOH to enact the Malaysian Medical Council’s (MMC) long-standing proposal to revoke the Second Schedule, which is a list of global institutions certified as medical schools from which graduates can obtain provisional registration in Malaysia. Revoking this clause has the potential to make it harder for students to study abroad and then return to Malaysia to find healthcare employment.

An associated problem with the Second Schedule is that the quality of the medical education received in foreign universities cannot always be guaranteed. This often results in graduates with a lack of clinical expertise returning to Malaysia to work in the healthcare sector.

Dr Noor Hisham Abdullah
MOH

The Malaysian Government has held discussions with the MMC about making all graduates from foreign medical schools sit a licensing examination, in line with local university standards, before being granted medical registration in the country. The priority is to ensure that all medical practitioners who work in the country meet a certain standard.

However, it is important to consider potential exceptions to the rule. For example, should a foreign specialist with a highly reputable background be made to sit the local examination, or should they be given an exemption in order to encourage their arrival?

Dr Zaleha Abdullah Mahdy
UKM Medical Centre

One possibility is to devise a list that outlines which specialties would be included for the exemption. This would facilitate the process of deciding whether or not foreign graduates or doctors have to sit the local examinations.

Dr Mohd Azhari Yakub
IJN

The issue of the accreditation of foreign institutions and individuals is an example of how the MMC is too restrictive. For example, IJN is technically a profit-oriented corporate institute, although its mandate is to promote education. Nevertheless, efforts by the institute to attract the best international cardiothoracic talent to develop its ability in areas such as minimally invasive surgery are hampered. This is because the MMC deems that IJN, as a corporate entity, is looking to make commercial gain from this practice and therefore prohibits the arrival of foreign specialists.

It is vital that these kinds of rigidities are overcome to attract leading talent to Malaysia, as well as to engender an environment conducive to the sustainable development of healthcare talent in the country.

Dr Noor Hisham Abdullah
MOH

The government is aware of these types of concerns and has formulated a four-tiered mechanism in response that tasks the MMC with overseeing the registration of foreign-educated specialists.

The first tier conceives of specialists as institutions and involves two aspects. The first involves foreign entities coming to Malaysia as an institution, employing their own internal specialists, and disclosing all information about employment therein, including the duration of each post. The MMC will then grant approval on the basis of the application. The second aspect relates to foreign doctors who wish to work in private hospitals. Herein, all doctors must have obtained an offer of employment in a particular hospital and that particular institution will apply for registration on their behalf. The aim is to prevent doctors educated abroad from working in multiple hospitals on a freelance basis and to guarantee that the individual can only be contracted as a practitioner at the applicant institution. This is important in terms of the State being able to identify both the employee and the employer institution.

The second tier involves the MMC performing an in-depth investigation into a foreign-educated doctor’s qualifications and training, including ensuring that all qualifications and training requirements have been duly completed to a satisfactorily level.

The third tier follows on from the second in which the MMC will conduct a thorough analysis of the individual’s practical experience. It is entirely possible that a foreign-educated doctor has all the right qualifications and has conducted lengthy training in certain disciplines, but that he or she lacks one or two years of clinical experience in the field relevant to the application.

The fourth tier is to substantiate an individual’s world renown. If a foreign-educated applicant claims to be a leading figure in a particular field, the MMC will identify the research publications that corroborate their standing as a recognised specialist in that specific discipline.

This four-tiered mechanism will enable the MMC to grant registration to the best available talent in line with the government’s efforts to advance the overall quality of care in Malaysia. Moreover, it will help to address the shortage of both local and foreign specialist talent in the private sector.

Ahmad Shahizam Mohd Shariff
Pantai Holdings

As an operator of private hospitals in the country, my preference will always be to employ Malaysian specialists as a way of aiding the development of local talent, but the shortage of consultants in the country makes this difficult. Therefore, I welcome the government’s four-tiered mechanism and urge stakeholders to jointly devise a common national agenda to define the priorities and opportunities moving forward in terms of specialists, both national and foreign.

Dr Noor Hisham Abdullah
MOH

In addition to efforts to stem the brain drain by attracting foreign specialists to the country, it is important to emphasise cross-sector talent development. One of the goals in this regard is to establish a rotational model in which doctors perform postgraduate training across both the public and private sector to provide them with a more holistic experience. Another goal is to maximise existing resources, in both the public and private sector, particularly since the government projection for specialist training applications over the next few years is approximately 10,000, compared to the 1,000 places available at local universities.

Thus, how can postgraduate training become more rotational and how can expertise and resources be maximised to address the specialist shortfall?

Dr Zaleha Abdullah Mahdy
UKM Medical Centre

One important step is to address existing rigidities in public policy, as I mentioned previously. For example, Act 586, the Private Healthcare Facilities and Services Act 1998, which regulates clinical practice in the private sector, dictates that MOs who are not specialists are not allowed to practise in private setups except for the emergency department. This is hindering the movement of doctors and training expertise across the two sectors and highlights the need for greater flexibility in public health policy.

Professor Dr Awang Bulgiba Awang Mahmud
UM

Our university is one of the largest medical schools in the country, providing both postgraduate and undergraduate teaching with an academic staff of almost 600. It is renowned for its postgraduate training and, in terms of medicine, is one of the very few Malaysian institutions to provide specialist training in disciplines such as oncology and sports medicine. As such, one of its goals is to prioritise the production of more and better medical specialists by focussing exclusively on postgraduate training.

In terms of maximising existing expertise, the only way in which UM is able to focus exclusively on postgraduate training is if the government enables its undergraduate responsibilities to be shared with other medical schools around the country. For example, sharing of this type via collaboration with the government resulted in the university cutting its annual quota of 220 undergraduate medical students to approximately 140 in 2015. This freeing up of resources resulted in funds being diverted towards the postgraduate scheme. As a result, the number of specialists trained at UM has risen from around 250 to 350 students a year. In order to help meet the needs of the country, however, it is necessary to produce closer to 500 specialists a year.

Dr Mohd Azhari Yakub
IJN

In terms of maximising existing resources, one quick win is to appoint established experts in their field as associate professors to private sector institutions, as occurs in the public sector. These experts could then contribute towards the formation of specialist trainees.

The identification of incentives to attract potential participants will be critical in the success of any such scheme. However, many doctors, particularly senior ones, are far more motivated to leave a legacy than by potential financial gain and I know that a number of specialists in the private sector are keen to engage in an initiative such as this.

Dr Noor Hisham Abdullah
MOH

That is a very interesting suggestion. In terms of putting it into practice, preliminary collaboration between the public and private sector, including IJN, to gauge feedback and opinion on the idea is required. If the response is positive, the government can begin to formulate an announcement.

Dr Zaleha Abdullah Mahdy
UKM Medical Centre

It is important to make alterations to the existing system if this is to become a reality, including clarifying legal issues related to Act 586. For example, while it is possible to teach postgraduate students in university hospitals, doubt exists as to whether it is permitted in the private sector.

Dr Noor Hisham Abdullah
MOH

To clarify the legal situation regarding the provision of postgraduate training in private hospitals and the perceived restrictions imposed by Act 586, this legislation states that only qualified specialists are allowed to practise in the private sector, with the exception of accident and emergency departments, as noted by Dr Zaleha. The key word here is ‘practise’. There are no legal restrictions to postgraduate training in the private sector because the student is classified as ‘training’ rather than ‘practising’. Accordingly, the student is categorised under the supervision clause that stipulates that he or she is the legal responsibility of the respective practising clinician.

The Malaysian Government already sends trainee cardiothoracic surgeons to IJN, which is legally constituted as a private entity and, therefore, governed under the provisions of Act 586. Thus, the precedent exists and there is no legal barrier impeding other private healthcare institutions from appointing associate professors to train postgraduate students on their premises.

Dr Mohd Azhari Yakub
IJN

The fundamental point about enabling postgraduates to receive training in the private sector is that it breaks down barriers in terms of how specialist training is conceived. Moreover, the advantages to participating specialist trainers are numerous, including: contributing towards stemming the shortage of specialists in the country; securing a personal legacy by transferring knowledge to the next generation; and boosting professional reputation by acquiring the status of an associate professor, or whatever term is used, at a reputable medical institution. In addition, having a trainee, particularly on a one-on-one basis, will help specialists to relieve workload pressure. These advantages will all help to consolidate the success of the scheme.

Dr Noor Hisham Abdullah
MOH

The next step is to identify a framework under which postgraduate training in the private sector will work. First, it is important for private hospitals to devise their own internal accreditation processes for trainers and trainees. Second, agreement is required in terms of how the training will be conducted, for example whether it is group-based or one-on-one mentoring, as well as the timeframes of the placements.

Once these steps have been taken, the MOH will assess all viable suggestions. It will be important to seek collaboration between the Ministry of Higher Education Committee and the APHM to identify precise ways in which to implement the training, and one critical aspect is to use IJN as a working model.

Our discussion has covered two ways in which to open up private hospitals for postgraduate training: first, by enabling associate professors to conduct specialist teaching in the private sector; and second, to create alternate pathways to facilitate Masters training, which I mentioned earlier. I want to expand on the latter and discuss additional routes for talent development: non-clinical pathways.

One significant example of a non-clinical pathway is research and in Malaysia, there is no formal separation between clinical services and research, which makes it hard for a doctor to become a high-level researcher.

The goal is to have a pool of expert researchers who serve the public and private sector. This requires a reassessment of traditional training pathways and the opening up of new routes that progress from houseman, to MO, to specialist levels. In the U.S. for example, medical students are able to follow the clinical or non-clinical route in terms of examinations, depending on their preference. So how can similar steps be taken in Malaysia to secure this type of non-clinical career development platform?

Professor Dr Awang Bulgiba Awang Mahmud
UM

Perhaps UM can offer guidance on this matter because we have developed and completed a research pathway that is due for implementation at the end of 2016. It is targeted at doctors across all levels, from housemen to specialists, and under the platform individuals are assessed on the outputs and impact of their research, rather than their clinical work.

The truth is that not all MOs are interested in pursuing a clinical career pathway. It is therefore very important that all parties take steps to develop alternative routes in a collaborative effort to overcome the lack of such non-clinical pathways in the Malaysian medical curriculum.

In terms of the research pathway, the example of Duke University Medical School in the U.S. is relevant. There, the third year of medical study is dedicated to biomedical research. If students show no interest in developing research they are able to return to clinical studies, but if they are interested in the field of investigation they can graduate as a physician-scientist with both an MD and PhD qualification.

Dr Mohd Azhari Yakub
IJN

It is essential that the Malaysian healthcare sector begins to address the non-traditional pathways as part of a wider discussion on latest healthcare trends, including health informatics, genomics, big data, management, and health financing, among others.

As Dr Awang noted, non-clinical pathways are not covered under the Malaysian training system. This reflects the fact that the education system is not fully conducive to the development of individuals that specialise in two or more areas. This creates a disconnect between professions. For example, in terms of health informatics, the healthcare system is almost completely reliant on computer science graduates to understand the computer systems that measure the needs of hospitals. This is unsustainable and it is crucial that Malaysia introduces programmes similar to the example of Duke University as part of a more holistic view of education, not only in the field of medicine, but also beyond.

Dr Zaleha Abdullah Mahdy
UKM Medical Centre

A priority in developing non-clinical pathways in Malaysia is the effective communication to all undergraduates of their available career development options. For example, efforts by the MOH to reach out to final year undergraduates to explain the different pathways available are very positive. It is important to extend this initiative to help all students understand that they are not simply expected to become doctors and undertake clinical practice for the rest of their lives.

Dr Noor Hisham Abdullah
MOH

Participants therefore agree on the need to develop these non-clinical pathways, not just in research but also in terms of management, information and communications technology (ICT), big data, economics and other areas. It is important that universities play a key role in driving this forward, in line with what Dr Awang has said about UM and their efforts to branch out into this area.

This move is particularly significant because in a few years it will only be possible for the MOH to absorb approximately 50 per cent of MOs into permanent clinical positions. The remaining 50 per cent will require new pathways being opened to the private sector and universities in order for them to specialise in the aforementioned non-clinical areas.

Our debate about talent development has been framed in the context of the quality of care. As the final topic, I therefore want to discuss ways in which stakeholders can work together to monitor clinical outcomes and the performance of professionals to ensure that the care provided meets the required standard. One way to ensure ongoing performance monitoring is to embrace ICT platforms. Rebecca, why is it so important to incorporate ICT platforms to monitor quality in the healthcare sector?

Rebecca LaNasa
Cerner Corporation

The benefit of ICT platforms is that they can be utilised for real-time monitoring and reporting of quality and performance, as well as acting as a highly effective training resource. For example, ICT can be deployed at the point of care to help professionals make the right clinical decisions. It can also be deployed during the post-care phase, in which it is especially useful for identifying a clinical subgroup or specialty that is not following best practice. The significance of this is that ICT can help to facilitate efforts by healthcare institutions to combine evidence-based practice with local practice in order to create new care plans and to adhere to existing ones.

Much of the focus of this roundtable has been on the entry phase into medical training and the subsequent progression to the next level of a graduate’s formative education. However, it is also important to maintain focus on the area of ongoing training during an individual’s career. This issue is generally more overwhelming than formative training and education because it involves busy and stressed individuals with high degrees of responsibility trying to keep up-to-date with the latest developments in their field.

Since medical research moves extremely fast, the most effective way to transmit the relevant information to clinicians at the point of care is via technology. Furthermore, it is essential that individuals with a medical background lead this technology push, given their in-depth understanding of the concepts involved. Contrary to the popular belief that anyone who uses ICT has to be a technological expert, ICT is merely the enabling tool that can help to make the required change happen. The goal of any such technology is to drive clinical practice, and that is the reason why it has to be healthcare professionals who are involved in designing these systems.

Dr Noor Hisham Abdullah
MOH

As Rebecca says, the incorporation of the latest ICT platforms is crucial for improving real-time monitoring of quality of care, performance, competency and skillsets that are deployed in the national healthcare sector. This will allow national practitioners to substantiate the quality of Malaysian healthcare based on data, rather than hearsay.

Furthermore, this real-time monitoring goes a step further by helping the promotion of the Malaysian healthcare system itself, in which brand trust is built on evidence-based performance.

Sherene Azli
MHTC

As the Director General stated, performance monitoring is a critical part of positioning Malaysia on the international stage in terms of healthcare tourism. It is also essential in order to corroborate claims made by different clinical parties in the country that a particular institution is a centre of excellence in a specific specialty or subspecialty. For example, evidence-based data will help to track whether that institution is performing in line with best practices and global benchmarks. In turn, this will boost MHTC efforts to attract increasing investment and healthcare tourism to the country.

It is important that private entities take steps to follow the performance-monitoring example of IJN, which provides the MHTC with clinical outcomes that are used as a marker. With committed action in this direction, evidence-based findings will help to take the country to the next level of healthcare.

Dr Noor Hisham Abdullah
MOH

A recurring theme from this roundtable in terms of talent development has been the importance of breaking the rigidity in the system that has kept the two sectors apart. This is an important lesson and it is essential that all stakeholders are involved in the process of replacing this system with a new integrated approach in which public-private partnerships focus on the convergence of the three key areas: services, training and research.

Thank you very much.