THE debacle that so callously penalised contract doctors at the height of the Covid-19 pandemic is testimony to the incompetence of the Health Ministry (MoH) and the Malaysian Medical Council (MMC), both of which the health director-general (DG) helms.
The Higher Education Ministry (MoHE) has for inexplicable reasons approved the establishment of far too many medical schools, such that we now have 22 private medical schools in addition to the 10 at public universities.
Students also go to foreign medical schools. More than five years ago on March 15, 2016, the DG issued a press release on behalf of MMC. He was responding to the statements made by the Malaysian Physicians for Social Responsibility (MPSR) and the Malaysian Medical Association (MMA).
In the press statement, the DG stated that the MMC was aware of the issues raised by MPSR and MMA, with regard to “Malaysian graduates from foreign universities without minimal entry qualifications, the poor performance of many younger doctors who graduated from certain overseas universities, and the long waiting time for graduates to commence their housemanship training”.
The matters the DG acknowledged still remain unresolved.
Qualifications based on non-standardised assessments
Among the qualifications accepted for entry into medical programmes are the foundation, matriculation, and pre-medical programmes offered by various tertiary institutions.
Upon completion of these programmes and obtaining the requisite scores for entry into a medical school, the only other hurdle is a minimum SPM or O Level grade of B in relevant subjects. MoH has repeatedly sought to raise this to a grade of A in the relevant subjects but MoHE has not relented.
Moreover, MMC may be able to monitor if the local institutions have complied with this hurdle requirement, but certainly not if the foreign universities have done so.
Unlike STPM or A-Levels, the assessments for these qualifications are non-standardised and are usually administered in the form of a combination of coursework and final examination set by the institution’s lecturers.
There is justifiable concern about the quality of these institution-administered assessments.
No-objection certificate
For a while, MoHE issued a no-objection certificate for medical students wishing to do a foreign medical degree, but this was largely ignored by foreign universities.
Some even ran dubious matriculation courses, used as the basis for entry to their medical schools. The no-objection scheme fell into disuse.
Recognition of foreign degrees
In accordance with the Second Schedule of the Medical Act 1971, MMC recognises 367 qualifications from 31 foreign countries, and graduates from these universities are given provisional registration.
There are no publicly stated criteria for MMC recognition – which is granted when a university, or more correctly, its recruiting agent approaches MMC for recognition.
The latest changes to the list were of two programmes from Russia, one in 2018 and another in 2019.
Maintaining a coherent list of recognised foreign degrees is an arduous task that MMC finds difficult to sustain.
In June, MMC suspended applications by fresh medical graduates from 31 foreign institutions in eight countries (five from Malaysia) whose names or qualifications differed from those gazetted under the Medical Act.
Universities do, from time to time, change their names, those of their degrees, or even their affiliations for a variety of reasons. MMC’s obligation is to maintain on its website the information as provided at the time of gazetting the university as recognised.
It is the responsibility of graduating students to monitor and inform the university concerned to officially notify MMC of any changes.
Unrecognised foreign degrees
Students also go to universities not included in the recognised list. The Medical Act provides that registration may also be granted to graduates from universities not on the recognised list deemed suitable for registration by the minister after consulting MMC.
What is the basis of determining which graduate qualifies under this provision? The DG’s statement suggests that all graduates from unrecognised medical schools sit for a qualifying examination and thus become eligible for registration.
Malaysians are not unaware that a mangled set of policies and implementation inconsistencies is fertile ground for rent-seeking opportunities and this has led to the current glut of medical graduates.
A glut of graduates is not to suggest that they are all incompetent. It is outrageous to refer to the “poor standard of our recent medical graduates” because doing so is to lump together the brightest, indeed the crème a la crème of our students, with the mediocre.
It is incumbent on those who refer to poor quality medical graduates to specify who they are.
A matter of honour
The DG and MMC are certainly culpable for the sorry state of affairs with regard to contract doctors in the country.
As explained by former health minister Datuk Seri Dr S. Subramaniam, as a short-term measure, new graduates have since 2016 been offered contract posts with assurances of equal treatment in remuneration, and on appointment as medical officers the opportunity for postgraduate training.
Wage disparity, ineligibility for local postgraduate training programmes, and an opaque hiring process were not the intention of the system’s architects.
MoH is honour-bound to not renege on its commitments. The government has to increase the number of permanent medical officer positions and implement a transparent hiring process.
Need for more doctors
In the immediate term, we need more doctors in our public hospitals. The 2018 Auditor-General’s Report noted that the emergency and trauma departments at Malaysian hospitals are understaffed and overcrowded.
At the larger hospitals reviewed, the number of patients exceeded the level of care by between 5.7% and 95.6%, causing congestion; only 58.7% to 74.5% of patients were treated within four to six hours.
Way forward
It is obvious that there cannot be a continued increase in posts to accommodate all future graduates.
The way forward is to have a standardised Malaysian examination a la the three-step United States Medical Licensing Examination (USMLE) to serve as the single path to medical practice, regardless of the medical school or country in which a student pursues their medical degree.
In the United States, it matters not if you are from the top medical schools, be they Harvard, Johns Hopkins, Stanford, California, Washington, Pennsylvania, or Duke (the top seven rated for 2021) or a lower-rated institution from elsewhere in the world. All medical graduates who wish to practise medicine in the US have to pass USMLE.
The UK also conducts a standard examination known as the Professional and Linguistic Assessments Board (PLAB) test. As the name indicates, the two-part test assesses proficiency in medical knowledge and skills and the English language. It is only for foreign graduates, not for those graduating from UK medical schools.
There will be much resistance from vested interests and even demands for an ethnicity-based dual system, but it is degrading to seek, and an insult to be granted, affirmative action privileges when one is already a medical graduate.
It calls for confidence in a medical school to have its students also take an external examination, albeit not requiring a pass in it for graduation. International Medical University has blended into its curriculum all steps of the USMLE without payment of any additional fees and advertised this move.
A number of other local universities now also do so. Such a move will attract foreign students and provide Malaysian students an opportunity to do their residency overseas.
It is time for MMC to give up its charade of selecting foreign universities for recognition and to simply specify that foreign graduates must either have also passed the USMLE or PLAB to be eligible for appointment to available posts in the MoH health service. And if MMC has the gumption, to also require this from local medical graduates.
A lesson from the nursing school debacle
The contract doctor debacle is a repeat of what happened earlier to the nursing profession. Beginning in 2000, MoHE, in its sustained accommodation of cronies, approved a glut of nursing schools, some of which operated in shophouses.
When former higher education minister Datuk Seri Mohamed Khaled Nordin imposed a moratorium in 2010, there already were 106 institutions offering nursing diploma programmes: 66 private providers, 11 public institutions, and 29 by MoH itself.
Diploma holders unable to obtain immediate employment took on jobs such as salesmen and telemarketers. Poor enrolment led to the closure of many nursing schools.
Today there are 71; MoH maintains 21, and another 50 are at public and private institutions.
The Nursing Board conducts a common examination for all nursing students including those at programmes offered by MoH, and this helps maintain a minimum exit-level competence.
A large number of Malaysian nurses seek employment overseas because of the credibility that the Nursing Board examination has built up over the years.
Local medical schools, both public and private, will be well advised to integrate the USMLE or PLAB into their medical programmes. – The Vibes, September 10, 2021
Datuk Dr Sothi Rachagan is an emeritus professor. He is a former dean of the faculty of law, University Malaya; vice-chancellor of Perdana University and Nilai University, and president of the International Association of Consumer Law. He serves on numerous international consumer protection bodies
