This article first appeared in Forum, The Edge Malaysia Weekly on April 8, 2024 - April 14, 2024

We believe that Malaysia needs doctors with high professional, ethical and personal standards to properly care for the health of the rakyat. Therefore, we are writing to discuss three recent healthcare issues that are directly related to the doctors that Malaysians deserve.

The first issue is the announcement on March 26 by the Malaysian Medical Council that the MMC has never recognised the parallel pathway training programme for cardiothoracic surgeons with the Royal College of Surgeons of Edinburgh. (It’s called the “parallel pathway” because the “main pathway” is the master’s training programmes offered by local universities.) Other parallel pathways include neurosurgery training under the Royal College of Surgeons of the United Kingdom and family physician training under the Royal Australasian College of General Practitioners. We would like to emphasise several fundamental points for current decision-makers.

One, the problems are clear. Malaysia has too few specialists compared with peer countries. Too many specialists leave the public sector for the private sector too quickly, and too many specialists leave Malaysia for other countries such as Singapore or Australia. The master’s pathway to train specialists is robust but cannot train enough specialists quickly enough. These problems are complex, and the parallel pathway is only one solution in a set of solutions for complex problems.

Two, the overall national objective for specialist training is for Malaysia to have “adequate numbers of well-trained specialists”, not “choose between main, parallel or both training pathways”. Systematic efforts to harmonise and increase quality are more important than blunt statements like “one pathway is better than the other”. There is a role for the MMC, Ministry of Health (MoH), Academy of Medicine of Malaysia (AMM), professional bodies, the Malaysian Qualifications Agency (MQA), entry and exit exams, and “final common pathways” of standardised gazettement periods.

Three, Malaysia needs to change the governance and administration of our health system to improve the way we plan for human resources for health (HRH). The fourth pillar of the health white paper (passed by parliament in June 2023) encompasses a restructuring of MoH, including removing any duplicate roles or conflicts of interest. Ideally, MoH plans HRH needs for Malaysia; MMC sets the minimum training standards for doctors; the universities, MoH, AMM and professional bodies are stakeholders in specialist training; and MQA accredits the training where required. That ideal scenario is very realistic, with many checks and balances that are currently absent.

On Feb 23, the Federal Court ruled that a private hospital has a “non-delegable duty of care” and is “liable personally” for medical negligence of individual doctors working in its facility. We welcome this landmark decision, because while the duty of care of individual doctors to their patients is very clear, the duty of care of private hospitals to their patients has not been fully addressed in Malaysia.

We would like to emphasise several fundamental points for every Malaysian, not just decision-makers. These points are important to every Malaysian because at some point in our lives, we are all patients requiring healthcare from doctors in clinics or hospitals.

First, we all want safe doctors who are kind, smart, well trained, updated on the latest science, make good decisions, have good clinical judgement and many other relevant attributes. And we want the ability to appropriately hold doctors accountable for their actions and decisions. And yet doctors are only human, capable of error. These three points can be reconciled: it is realistic and reasonable to hold doctors to high standards. However, it is not realistic or reasonable to hold doctors to perfect standards, 100% of the time in their entire 40-year careers as doctors.

Today, Malaysia has several ways to hold doctors accountable. Patients can complain to the hospital (or to MoH via SISPAA in the Public Complaints Bureau), to MMC for professional standards, to the Tribunal for Consumer Claims under the Ministry of Domestic Trade and Consumer Affairs, or to the courts via litigation. We believe these ways can be strengthened to be faster and more transparent for all parties, which will reduce anxiety and increase trust and standards.

Other accountability measures can be implemented over time, including no-fault compensation (as in New Zealand and Scandinavia), alternative dispute resolution such as mediation or arbitration (as in Singapore), and building a larger network of independent expert witnesses.

Second, having expressed the importance of accountability, we now stress that the issue of accountability is complex. It requires a delicate balance between “the rights of patients” and “the reasonable duties and constraints of doctors”. Indeed, it is reasonable to state that patients have duties and doctors have rights too, because rights and duties are two sides of the same coin.

We caution against a damaging scenario where patients think it is easy, desirable or even financially rewarding to sue doctors and hospitals for the slightest of reasons. Such a scenario benefits no one: medical costs will increase because doctors must pay higher premiums for medico-legal or indemnity insurance; doctors in high-risk specialisations (such as surgery, obstetrics or anaesthesia) will refuse high-risk patients; more high-risk patients will go to public hospitals because they are turned away by private hospitals; and there is less trust between doctors and patients who become suspicious of one another.

Third, the Patient Safety Council of Malaysia (PSCM) was established in 2003 by a cabinet directive, with many clinical governance recommendations to protect patient safety and deliver quality improvement efforts (as opposed to fault-finding or finger-pointing). Doctors and hospitals need to work collaboratively to improve patient safety, rather than any adversarial relationship. Over time, there can be a regular review of credentials and privileges of doctors, monitoring and reporting of clinical quality metrics and strong continuous professional development, all intended to improve patient safety. (Disclosure: Abu Bakar Suleiman is chair of Medical Defence Malaysia, a non-profit medical indemnity non-governmental organisation).

We support strong accountability for doctors and hospitals, holding them to high and realistic standards. We do not support unnecessary or inappropriate litigation that holds doctors and hospitals to perfect and unrealistic standards as this will increase costs, impair trust between doctors and patients and damage the health system.

There are many doctors who no longer practise medicine. Some are political leaders, researchers or businesspeople, all contributing to Malaysia outside of medicine. We call on all doctors, including non-practising doctors, to remember the first principle of medicine: First, Do No Harm.

For political leaders who happen to be doctors, they have an even greater duty to not do harm and to protect public health, given their influence and reach.

In taking stands on political issues, doctors who are in politics have the added duty and privilege to ensure that their stand helps to heal and repair the fractures in society. Their medical training should direct their political process to be inclusive and non-combative, and attempt to seek solutions that will not inflict any social wounds on the delicate fabric of society while ensuring the physical, mental and social well-being of citizens.

Doctors enjoy privilege, status and respect from society, which come with a duty of care and accountability. We raise these three issues out of a desire to improve the health of Malaysians and to remind everyone of the needs of our nation and the medical profession beyond individual egos and petty politics.

Tan Sri Dr S Subramaniam is a former health minister. Tan Sri Dr Abu Bakar Suleiman is a former director-general of health. Prof Dr Rosmawati Mohamed is the master of the Academy of Medicine of Malaysia. Dr Azizan Abdul Aziz is president of the Malaysian Medical Association. Dr Khor Swee Kheng is CEO of Angsana Health.

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