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Postgraduate Medical Education: Future Needs and Challenges
Address by Datu Dr Mohamad Taha b Arif
Director-General of Health Malaysia at the Workshop on Specialty & Subspecialty Training
on 9 March 2002
Over the years, postgraduate medical education in Malaysia has produced many specialists from the masters programmes in the local universities or through the memberships/fellowships examinations from the Royal Colleges of UK, Ireland and Australia. The fact that we have trained many doctors is in itself commendable. Up to the mid-80s, the combination of the local programmes and the overseas programmes could train about 50 specialists per year. In 1995, with all the three universities actively embarking on postgraduate training, the output had steadily increased to about 100 to 120 per year. However as these are residency training programmes conducted largely in the Universities, the increasing intakes of trainees into the programme have resulted in a shortage of senior doctors to provide the services in the public sector.
Thus in 1996 the “Open System” was introduced where trainees can register with any of the three Universities but allowed to pursue part of their four-year training in an accredited MOH hospital affiliated to the University. Accredited MOH specialists will participate in the teaching and learning activities as well as monitor and supervise the progress of the trainees. Support for student learning by distance education are delivered through teleconferencing, printed packages and periodic intensive courses. This system has allowed greater number of specialists to be trained through more optimal utilisation of MOH facilities and specialists. Since the start of this new system, the three universities have enrolled almost 1800 doctors to pursue training in the 16 courses offered. This is a huge number and as the programme requires trainees to spend varying periods of residence in the university, the ‘opening’ of the system still causes substantial disruption of services in MOH hospitals.
Together with the increasingly complex nature of medical practice, the time has come for us to work towards giving opportunities to all doctors to undergo postgraduate training before assuming independent practice. This will mean providing opportunities for training in all specialties, including family medicine, public health and the other clinical specialities. All these have implications in the planning of postgraduate medical education. How can we achieve this?
Traditionally in the MOH, trainees, supporting the work of consultants, have provided the service to a great extent. The system has virtues but also many flaws. Trainees may spend excessive time in areas where they are already competent when they need experience in another area. We need to achieve a balance and remember that training exists to support the service and not the other way round.
We need to review our current approach to more effectively implement the specialist manpower development plan. We need a system that creates greater opportunities for training and yet be reasonably flexible to cope with the rapid changes that are occurring around us. We may need to consider flexible training schemes to meet the needs of those who are unable to train full-time, which should be anticipated with the increasing proportion of women in the medical profession. This is already done overseas and has been shown to be popular. Training should no longer remain within the public sector but must maximally optimize the expertise and resources available in the private sector. Accreditation and credentialing mechanisms will have to be strengthened and for this to happen the structure, systems and resources must be in place.
The local Universities have successfully produced about 2000 specialists since 1986 and about 1400 more are being trained. Although the number of specialists trained locally and abroad has tremendously increased, it can be appreciated that we will still be short of our target. Overseas postgraduate examinations are still popular especially the MRCP (Adult Medicine and Pediatrics) which are also held annually in the country. The recent changes in the structure and conduct of the FRCS and MRCOG however will affect the number of doctors pursuing these overseas examinations. Doctors wishing to take up surgery, for instance, have to sit for the MRCS or AFRCS before being permitted to undergo a formal 4-year surgical training programme leading to the FRCS. Places for the latter programme are limited and there is no guarantee that our doctors will be offered places. With this uncertainty, the local Masters programmes are probably the best option for them.
As for subspecialty training, there is certainly a need for a national training programme that will be better organised and with better coordination between the MOH, the Universities and the private sector. As is the trend overseas, we are also moving towards a programme, which is more structured, more closely supervised and with a more formal assessment. With the new move, we hope the professional bodies who are well placed to define the standards of care in the specialty, will be playing a leading role in determining the training requirements, curriculum and the competencies within their own field. A minimum of 3 years training after general specialist training has been generally recommended for most of the advanced medical and surgical training although it can be longer for some specialties such as cardiothoracic surgery and neurosurgery. This is comparable to the current specialist training overseas which now extends up to 5 to 6 years. In general the programme is designed to provide trainee with progressive experience and responsibility to acquire the proficiency of a consultant in the specialty. The training should be rooted in quality service, which is led by consultants who invest time and effort in keeping up-to-date information and improving their own practice. The training should also develop professional values, high standards of practice, ability to assess outcomes, recognition of weaknesses and self-directed continuing education. While the MOH has been taking the lead in subspecialty training, the professional bodies will be expected to take over the accreditation of training programmes and certification of trainees in the future.
The trend towards more specialisation is an integral part of continuing professional development of a specialist. While there is a definite need for a subspecialist to provide the best possible to the community, there has also been some concern on the dwindling number of general specialists. In the pursuance of specialisation, we must, however, not foresake our unique training system, which teaches us to be competent in the common medical emergencies, for example, and yet retain the right to provide highly specialised services whenever the need arises. Malaysia is still short of specialists and the public hospitals, especially in the periphery hospitals, are still having difficulties to even have specialists in the basic disciplines. Under such circumstances, a specialist with special interest in subspecialty areas can play an important role and is probably a better strategy to meet the increasing needs and expectations of the community. In the current scenario when the country is still faced with shortages in various disciplines, there need to be a balance in the training of the subspecialists and the general specialists. We also need to balance the training of specialists in the more ‘marketable’ disciplines against the less popular but equally important ones such as infectious diseases, geriatric and endocrinology.
CHANGING THE CULTURE OF POSTGRADUATE MEDICAL EDUCATION
The trouble with medicine is that training often seems never ending. The inherent danger in such a system is that eventually for many learning becomes a great effort. Reconciling educational requirements within service needs has proved a planning nightmare in some of our hospitals. Teaching programmes require planning and organization, ideally by someone with training in teaching methods. If these requirements cannot be met, the teaching programmes may be less effective. Specialist training in most hospitals sometimes indicates that service commitment rather than training dominates the scene.
Consultants have found their workload increasing but also need to find time to provide the educational input. The lack of consultant numbers in most disciplines has had a further major impact here. Consultant expansion is urgently needed, not only to train the specialists of the future but for the current exigencies of service needs. There is too much reliance on service provided by trainees, service that cannot be regarded as training as it is unsupervised and often unskilled.
The next generation of doctors will face an exploding volume of literature, rapid introduction of new technologies, more demanding patients, deepening concern about escalating medical costs, and increasing attention to the quality and outcomes of medical care. Some educational responses to these issues are outlined below:
Teach scientific behavior as well as scientific facts
Promote the use of information technology
Adapt to the changing doctor-patient relationship
Help doctors to shape and adapt to change
Promote multiprofessional team working and care
Help doctors handle broader responsibilities
Reflect the changing pattern of disease and healthcare delivery
Involve health service employers and users
Most needed to begin during basic education, be refined during the postgraduate training, and maintained or updated through continuing medical education. Even with effective educational programmes, it is more difficult to change attitudes and patterns of thinking in practicing doctors than to get it right with medical students from the beginning. We wish to see the emphasis of the training of this country’s doctors redirected to concentrate on modern principles of adult learning.
Future doctors must learn not only the theoretical scientific basis of medicine but also the scientific basis of clinical practice. If they can easily access up-to-date and comprehensive information through computers, why do they need to memorize vast quantities of factual information? The new generation of medical graduates is coming from undergraduate medical courses that are quite different from the didactic courses of the past. The problem based learning, or problem oriented learning approach to undergraduate training produces a doctor whose communication and practical skills are likely to be excellent and who is likely to be very questioning of the way of the world. They are likely to be selectively weak in factual knowledge and thus a new approach to teaching is needed by consultants.
A second challenge is how to change an educational system that is largely driven by performance in examinations, which reward memorization and recall of factual knowledge and in which teachers perceive their role to be that of a content expert that covers the subject on behalf of their students. Such a system ill prepares doctors for a world, which demands the ability to acquire, appraise, and use information in order to solve clinical and other problems efficiently.
Medical education also needs to be accountable to those who pay and use health services. Another challenge is how to resolve the internal conflict between the autonomy of medical academics to determine the content and process of medical education and the requirement of medical education to prepare a doctor who meets society’s needs.
REVISING THE TRAINING
In response, training programmes must define more rigorously the specific objectives and competencies needed for adequate professional advancement. Training programmes need to place greater emphasis on evaluating the experience of trainees, their competencies, and the use of their training for their future practice. Continuity for planning for patient care management, effective communication with others in the care teams, integration of care plans with other health professionals, and determination of the outcomes of care are training objectives that deserve greater emphasis. Some disciplines may need longer training.
PREPARING FOR AN UNCER TAIN FUTURE
However unpalatable, doctors will increasingly be required to weigh cost as well as quality considerations in making resources and treatment decisions. They will need to balance needs of individual patients with the needs of the community. Doctors will not be able to avoid a political role and will be involved in making management decisions about resources allocation and in difficult ethical debates.
Medical education has been slow to help doctors acquire the expertise necessary to play these roles well. One solution that might help this and other challenges is to learn from the experiences with the education and training of other professional groups, including those outside the health sector. They, too, are grappling with training professionals for an uncertain future and are likely to have some good ideas that can be applied to medical education.
In looking to the future and rising to some of these challenges, it is apparent that postgraduate medical education must be developed from two ends; needs assessment and outcome evaluation. Its offering should be rooted in a systematic study of real needs and the identification of priorities which take into account of the perspective of users and providers of health services, not just the perceived or real needs of doctors. Continuing education is not an end in itself but a means. At the other end of the educational process, providers of continuing medical education need to be rigorous in their evaluation of the effectiveness of their programme in order to provides convincing answers to the most important questions: do these programmes make a difference to patient care and improve health outcomes?
Restructuring the Malaysian Healthcare System
Paper delivered by Tan Sri Dato’ Dr Abu Bakar Suleiman
President, International Medical University at the National Healthcare Financing Seminar on 19 to 22 June 2002 in Penang
The Malaysian healthcare system has developed well, and the public healthcare system is comprehensive and efficiently run. The Malaysian government in initiating studies on health financing in the mid 1980’s has realized that, as with the experience in other countries, it would be more difficult to cope with the rising healthcare expenditure if healthcare funding remains dependent only on the general tax revenue. There will always be major constraints in obtaining increasing allocations for health from the annual budget. The two phases of the health financing studies looked into possible avenues of unlocking additional resources for health spending, and recommended the setting up of the national health security fund. The third phase of the health financing study to address issues from the first two phases as well as to look into the implementation issues has yet to be proceeded, although a number of other related studies have been initiated.
The manner in which resources are mobilized to support the healthcare system, and how it is organised for services delivery and its influence on health status is also important for its influence on the other aspects of the country’s social, economic and political well-being. The overall objectives of the healthcare system include:
improving health status and promoting social well-being
ensuring equity and access to healthcare
ensuring efficiency in the use of resources
enhancing clinical effectiveness
improving quality of services and patient satisfaction
ensuring sustainability of the system.
Health systems account for 9% of global production and a significant proportion of employment. Public and private programmes to finance and deliver healthcare affect government budgets, macroeconomic stability, employment, imports, exports and international competitiveness.
As Malaysia continues to develop rapidly, the issues facing the more developed countries will increasingly become important for Malaysia. Issues such as escalating health care costs, diseases related to life style, increasing numbers of the elderly in the population who will require more and expensive healthcare, the introduction of new technologies, and ever-increasing consumer expectations are familiar issues. Concerns with issues of social justice will increase.
The challenges and pressures from these and other issues are already with us, even if they are not generally recognized. Equity has always been important in Malaysia’s development and especially in health.
Malaysia’s existing healthcare system comprising of the public and private system is a two-tier system. The private system mainly caters for the urban population and those who can pay, while the public system provides access to everyone (including civil servants) with token payments being imposed. A two-tier system is inherently inequitable and inefficient.
Yet within this two-tier system, there appears to have developed in the public system, an internal two-tier system. For example, civil servants on permanent tenure are provided healthcare coverage for life, and this cover is extended to their parents. Civil servants on contract, and non civil servants do not receive this coverage. While some of these and other privileges have been decided administratively by the central agencies, and have not been costed, they have far-reaching implications on health costs, and more importantly on our concern with equity and the nurturing of a "caring society". What this does indicate however is the urgent need to look carefully and restructure the national health system so that the privileges provided to civil servants and their parents, can be extended to all citizens in a health system that is equitable, affordable and sustainable. In this process it is also important for the sake of equity to restructure the existing system, into a one-tier health system.
The existing two-tier system, while inherently inequitable and inefficient, has so far served Malaysia well, and any considerations for restructuring must take into account many issues that are important:
equity must be ensured with better access to health
there must be universal coverage
the values of a "caring society" envisioned in Vision 2020 must be internalised into the system
consistent with the Vision for health, Telehealth blueprint and the eight goals of the health system
the system must be efficient, effective and affordable.
This emphasises the importance of the development of a one-tier health system.
The existing healthcare system, like most around the world, has been organized around acute, often catastrophic illnesses. The healthcare system treats the patients during this episode until they are well again.
In many countries, a "casualty" approach to health insurance has been developed to fund healthcare, based on the fundamental unpredictability of disease and injuries. Expensive health systems have been developed based on this "acute care" model. However major advances in diagnostic and therapeutic technologies have enabled earlier interventions in chronic disease like heart disease and cancer and increasingly more patients can be treated on an ambulatory basis without hospitalisation.
In the coming decades, this "acute care" model and existing health insurance concept, as well as society will have to deal with the increased predictability of risks of disease. Major advances in immunology, predictive genetics and the human genome project will make it possible to predict disease in many people long before symptoms emerge. The present paradigm of diagnosis and treatment will be replaced by prediction and early management of risk factors and illness. With this development, the "casualty" model of health insurance becomes fundamentally flawed.
Considerations for restructuring the healthcare system must consider the alternative systems of financing, payment and delivery organisation, and how it fits in with the government’s national and health policy goals. It must consider the critical issues of universal coverage, equal access, control of health expenditures, efficient use of resources, equity in financing and consumer choice. In addition, special considerations must continue to be given to the rural population.
The experience from the United Kingdom, USA, Canada, Sweden, Spain, Germany, Japan, Korea, Australia and Singapore are all relevant. The successful strategies that best fit our national and health policies, and are consistent with Vision 2020, Vision for health, the Telehealth blueprint and 8 goals of the health system, can be incorporated into the restructured health system, which is a one-tier system and primarily financed by the health fund.
The History of Medicine in Peninsular Malaysia
This appears to be a never-ending saga. It has been reported that Mr Tate is finalizing the document which contains some very voluminous chapters. It is a good thing that this is a history book!
It has been proposed that the Academy arrange to interview senior members and put on record their views and experiences before it is too late, as it were. The Academy’s Archives Subcommittee will be entrusted with the task of collecting letters, photographs and other memorabilia of historic importance. The respective colleges will assist by contacting their senior members.
No concrete collaboration has been achieved between Medical On-Line despite the signing of an MOU more than a year ago. Efforts are being made to hold a workshop on Telehealth content.
The Steering Committee for Telemedicine has proposed the award of credit points to encourage CME activities online. The assessment and implementation will be overseen by a Committee of the Academy to be chaired Prof Dato’ Sharifah Hapsah.
Fellows Conferral Night
The event this year will be organized by the College of Pathologists on the 5 October 2002. The College is in the process of looking for a suitable venue. All Fellows of the Academy are cordially invited to attend this annual get-together.
3rd National Ethics Seminar 2002
The College of Public Health in collaboration with the Academy Ethics Committee and the Ministry of Health will organize the Ethics Seminar on 27 October 2002 at the Melaka-Manipal College. Topics to be discussed include Genomics and Research, Healthcare Rationing, Reproductive Medicine and the medical and legal aspects of expert witnesses. The proceedings of the seminar will be printed in a supplement of the Medical Journal of Malaysia.
Joint Project on Practice Self-Assessment with the Academy of Medicine, Singapore
A committee comprising members of both Academies has been formed to make proposals on a self assessment programme for physicians. The proposals will be finalized in July and formally presented to the Joint Councils Meeting in Singapore in August for adoption.
4th MOH-AMM Joint Scientific Meeting 2002
The 4th MOH-AMM Meeting will be held from the 10 to 12 October 2002 at the Hilton Hotel in Seremban. The theme of the conference is "Towards a Healthier Future Generation". The 5th Tunku Abdul Rahman Putra Lecture will be delivered by Dato’ P G Lim. The specialties taking part in the meeting include Internal Medicine, Paediatrics, Pathology, Public Health, O & G, Ophthalmology and Surgery. Several Pre-Conference Workshops will be held. The workshops are on the subjects of Human Sexuality & Sexual Health, Qualitative Research and Wound & Ostomy Care. All members of the Academy are urged to attend this meeting.
37th Malaysia-Singapore Congress of Medicine - 2003
Prof Yip Cheng Har from the University of Malaya has been appointed the chairperson of the Organising Committee for the 37th Congress in 2003. Council has agreed to invite Dato’ Seri Abdullah Badawi to deliver the 15th Tun Dr Ismail Oration.
Credit Card Payment
Credit card payment facilities are being arranged with a local bank and in the near future members can pay their subscriptions and conference registration fees using their credit cards.
Consensus Statements / Clinical Practice Guidelines
National workshops have been scheduled to be held on 12 October 2002 at the conclusion of the 4th MOH-AMM Joint Scientific Meeting 2002. The Academy hopes to work closely with the Health Technology Assessment (HTA) Unit of the Medical Development Division of the Ministry of Health for more efficient dissemination of the C PGs.
National Credentialing Committee
A National Credentialing Committee (NCC) comprising officials of the Ministry of Health and the Academy of Medicine of Malaysia has been set up to coordinate all activities related to the Specialist Register and Accreditation of Specialists. The National Credentialing Committee is chaired by the Director-General of Health and the first meeting was held recently. For this purpose Specialty Subcommittees will be set up to advise the National Committee.