17-7-2024 (KUALA LUMPUR) Thousands of patients in Malaysia are languishing on lengthy waiting lists for life-saving heart surgery, a concerning situation that has brought to light the critical shortage of cardiothoracic surgeons in the country’s public healthcare system.
At the Sultan Idris Shah Serdang Hospital in Selangor, an estimated 1,000 patients are awaiting urgent heart surgery, while at the Penang General Hospital, the waiting list has swelled to about 850 people. In Kuching General Hospital, the wait for the same procedure stretches beyond a year.
“All these patients urgently need heart surgery. Heart conditions are unpredictable, and surgery should be done as soon as possible, but there is a shortage of cardiothoracic surgeons in public hospitals,” said Dr John Chan Kok Meng, honorary secretary of the Malaysian Association for Thoracic and Cardiovascular Surgery (MATCVS), in an interview.
The shortage is stark: only 14 cardiothoracic surgeons are currently serving in the seven public hospitals where heart surgery is performed across Malaysia. Three of these hospitals – in Kota Bharu, Kuantan, and Kota Kinabalu – have a single surgeon each, compounding the issue.
Dr Chan noted that these overworked surgeons often must attend to emergency cases beyond their regular working hours, further exacerbating the strain on an already overburdened system.
The lack of cardiothoracic surgeons has made headlines after four graduates of a “parallel pathway” training programme with the Royal College of Surgeons Edinburgh filed a legal challenge against the Malaysian Medical Council’s (MMC) refusal to recognise their qualifications and register them on the National Specialist Register (NSR).
The MMC, a statutory body overseeing medical policies in the country, said it does not recognise the qualification from the Royal College of Surgeons of Edinburgh, despite it being recognised in Singapore, Hong Kong, and other countries.
Healthcare experts warn that this issue merely scratches the surface of a much broader problem – the lack of medical specialists in Malaysia, which could worsen as the country faces an ageing population. They caution that the shortage will also impact the quality of care received by patients in the public healthcare system who cannot afford private institutions.
The Academy of Medicine Malaysia (AMM), a body representing specialists, has sounded the alarm on the urgent need to increase the number of specialists in the country. Its president, Dr Rosmawati Mohamed, said that the population-to-specialist ratio in Malaysia stands at 10,000 to four, far below the Organisation for Economic Cooperation Development’s (OECD) “ideal ratio” of 10,000 to 14.3.
According to Health Minister Dr Dzulkefly Ahmad, there are currently 8,397 specialists serving in 29 specialty areas at public healthcare facilities. However, the Ministry of Health estimates that Malaysia will need between 18,912 and 23,979 specialists by 2025 and 2030, respectively.
Dr Rosmawati of AMM warned that Malaysia faces numerous challenges, including an ageing population, a high burden of non-communicable diseases such as diabetes, and an under-resourced healthcare delivery system. The lack of medical specialists in the public sector only compounds these issues.
“There is a very big gap that Malaysia needs to catch up,” Dr Rosmawati stressed, referring to the “ideal ratio” recommended by the OECD. “This gap will not even be attained in the next 10 years, but the good news is there are attempts to make sure that specialist training is enhanced.”
She cited the increased training specialist study slots for Master’s Programmes in the country, from 1,500 to 1,650 slots each year, as a positive step.
Dr Hirman Ismail of the Health Ministry’s Medical Development Division wrote in a paper published last year that only about 15.7 per cent of doctors in the public sector were specialists. In contrast, in developed countries such as Singapore, Japan, Canada, the United States, Australia, and the United Kingdom, the proportion of specialist doctors compared to non-specialists ranged from 41 per cent to 60 per cent.
“These advanced countries have a considerably high proportion of specialists among general physicians, and these include family physicians in primary care who are also regarded as specialist physicians in those countries,” he wrote, proposing that at least 30 per cent of the total number of doctors in the public sector should be specialist doctors.
Universiti Kebangsaan Malaysia public health medicine specialist Prof Dr Sharifa Ezat Wan Puteh said that the public healthcare sector was underserved, with severe shortages not just in cardiothoracic surgery but also in fields such as forensic pathology, family medicine, urology, oncology, general surgery, paediatric surgery, plastic surgery, neurosurgery, and psychiatry, among others.
Prof Dr Sharifa shared an anecdote about a recently-diagnosed lung cancer patient from Johor Bahru who had to wait two months to receive the results of an investigation into their condition. The test was conducted in Johor Bahru but had to be sent to Kuala Lumpur for assessment due to a lack of specialists in the area.
“There are also children who have cancer but there are no paediatric oncologists in many areas,” she said.
The Malaysia Oncology Society reportedly stated last year that there were only 130 oncologists in the country, while they needed 300 oncologists as cancer cases continued to rise.
Prof Dr Sharifa acknowledged that those who could afford it had the option of seeking treatment at private hospitals, but many from lower-income groups or without medical insurance coverage were unable to do so.
“The majority of patients go to the public sector, but it is hard to manage because there are just not enough specialists,” she said.
She also believed that one of the issues faced by the government was that many specialists had chosen to work in the private sector or overseas, where the remuneration was much higher. A check on the NSR website showed that almost two-thirds of cardiothoracic surgeons in the country were in the private sector.
While there are no official numbers, doctors said that those working in public hospitals had a heavier workload for much less pay. A doctor undergoing a parallel pathway training programme in obstetrics and gynaecology, waiting to be registered on the NSR, said the lack of manpower in public hospitals caused frustration among many in the field.
“There is only so much one can take in a system that is failing. I earn about RM10,000 (US$2,140) now, but if I can get into the private sector, I could easily earn at least three times that, and for a lesser workload. Of course, you need to have the proper qualifications and experience,” the doctor said.
“As an individual who has needs and is being offered a better package, wouldn’t you take that? It doesn’t make you a lesser doctor.”
The lawsuit involving the cardiothoracic surgeons against the MMC has also highlighted the pathways to becoming a specialist doctor in Malaysia. There are two main routes: a Master’s programme run by a local university or the parallel pathway programme initiative conducted by the health ministry since 2014, allowing Malaysian healthcare professionals to seek specialist training through overseas qualifications.
Health Minister Dr Dzulkefly Ahmad told parliament on June 27 that there were 120 local Master’s programmes in medicine offered by nine universities and 14 specialties for parallel pathway programmes. To date, he said, 6,933 medical officers had received government scholarships for specialist training – 6,142 for local Master’s programmes and 791 for the parallel pathway programme. An additional 2,622 medical officers were undergoing the parallel pathway programme without a scholarship.
Dr Rosmawati, the AMM president, said that before 1973, almost all specialists obtained their training overseas or trained in Malaysia while attaining international qualifications by attempting international examinations to be recognised as specialists.
“It is an important part of the development of specialists in the country. Without it, there would be a lot less specialists,” adding that the parallel pathway programme currently represents a form of on-the-job structured training provided by the Ministry of Health for trainees who have opted to sit for international examinations conducted by overseas Royal Colleges.
Former MMC member Dr Milton Lum said that local universities, which started the specialist Master’s programmes since the 1980s, have not produced sufficient specialists for the country’s needs.
“The gap has been filled somewhat by the Royal Colleges. The local universities’ performance is reflected in the National Specialist Register, in which 47 per cent have Master’s and 53 per cent have Royal Colleges qualifications, respectively,” adding that Malaysia has had a shortage of specialists for more than six decades, though there have been improvements since 2000.
Currently, the only specialist training programme for cardiothoracic surgery in Malaysia is a joint venture by Universiti Teknologi Mara (UiTM) and the National Heart Institute, but it is open only to Bumiputeras – an official term for Malays, the Orang Asli of Peninsular Malaysia, and various indigenous peoples of East Malaysia.
For non-Bumiputeras, the only option is to take the parallel pathway option, such as the one offered by the Royal College of Surgeons of Edinburgh, which costs RM250,000 according to the Ministry of Health for its entire duration.
The six-year programme includes five years of local training in cardiac centres under the Ministry of Health and the National Heart Institute (IJN), as well as one year of training in the United Kingdom.
While the NSR shows that Malaysian specialists holding this certification were registered in the past, MMC president Dr Radzi Abu Hassan, who is also Malaysia’s health director-general, said in March that the council had never recognised cardiothoracic surgeons from the college.
In a statement on March 26, Dr Radzi said the MMC was not against any of the parallel pathway programmes nor were they being discontinued. He said the council’s interest was to ensure that the training programmes conducted in the country fulfilled the relevant legal and statutory requirements.
Former Health Minister Dr S Subramaniam claimed there had been a growing sentiment among a group of medical professionals in recent years that the local Master’s programmes should be strengthened while the parallel pathway programme should be phased out, as the Master’s programme was unable to provide enough places to train the required number of specialists.
In response, the “Group of Professors of Health and Medicine” claimed that the parallel pathway programmes had been running for years without complying with local standards and laws, and that the quality of these programmes was unknown due to a lack of regular third-party audits.
“In summary, we want to ensure that all medical specialist programmes follow the same procedures for accreditation and comply with existing local laws to preserve their quality,” said the group’s head, Prof Dr Noor Hassim Ismail, a lecturer at Universiti Kebangsaan Malaysia (UKM). “We are concerned about the competency of graduates, and the safety of patients and the public. Not everyone can become a specialist; only those with capability and capacity can be trained as a specialist.”
Meanwhile, a doctor undergoing specialist training under the parallel pathway programme at a hospital in the Klang Valley said that he was worried about not being recognised as a specialist upon completing his examinations. He said there had been a growing fear in recent years that the parallel pathway programme was being sidelined, not just for cardiothoracic surgery but also in other specialties.
“I am worried that I will not be recognised as a specialist. I have put in a lot of time and effort, and I don’t want to see it being wasted,” the doctor said, requesting anonymity.
Health Minister Dr Dzulkefly said amendments would be made to the Medical Act to streamline irregularities linked to the specialist training programmes involving parallel pathways and local Master’s degrees.
“Engagements have been made with different stakeholders; we have engaged with everyone worth the salt,” he told parliament on June 27.
He pointed out that 35 cardiothoracic surgeons – in both the private and public sectors – had received their qualifications from the Royal College of Surgeons Edinburgh.
“Suddenly, we are questioning their safety, quality, and their ability. I think it is not responsible to make innuendos and insinuations,” he said.
The proposed amendments were tabled in Parliament on July 15, with Dr Dzulkefly stating that they aimed to enhance the quality of medical specialists produced through the two pathways to specialisation.
The Malaysian Medical Association (MMA) supported the amendments in a statement on the same day, saying they were essential for ensuring every Malaysian had access to high-quality, specialised medical care.
“By streamlining processes and maintaining professional oversight, we can create a more robust and flexible system for specialist training and recognition. These amendments will benefit both the parallel pathway and Master’s programs, ensuring that graduates from both routes have clear paths to specialist registration,” said MMA president Dr Azizan Ismail.
“The MMA hopes that with the passage of these amendments, more doctors will take up specialisation, which is critically needed by the country.”
However, there is opposition to any amendments, with UKM lecturer Prof Dr Noor Hassim claiming that amending the Medical Act would affect the future of local programmes.
“We will be at higher risk of opening the floodgates to foreign programmes and specialists, even as other countries have tightened control over the influx of such programmes and specialists,” he said.
