[OPINION] The role of accreditation in the registration of medical practitioners

Knowing my interest in medical education he urged me to develop an accreditation system for the medical and health sciences. He secured World Health Organisation (WHO) Fellowships for me to study accreditation systems and to visit several institutions in the USA, United Kingdom and Australia.

Seminars and workshops were held with the assistance of the late Dr Nancy Gary who was President of the Educational Commission for Foreign Medical Graduates (ECFMG). Tan Sri Abu Bakar was able to get representatives from universities, MoH and specialty societies to work together to develop accreditation standards and procedures using the American accreditation system as a guide. In trying out the system, visits were made to 4 training institutions and reports were submitted to the respective Councils and Board.

During his tenure as Director-General, Tan Sri Abu Bakar was also invited as an expert by the World Federation for Medical Education (WFME) to set standards for undergraduate, postgraduate and continuing medical education. It was also during his time that findings from my MD thesis could be used to help develop the CME credit system for renewing the Annual Practicing Certificate (APC) and to start the Open Learning in Family Medicine as a collaborative venture between Universiti Kebangsaan Malaysia, the MoH and the College of General Practitioners (now known as Academy of Family Physicians).

These experiences with the MMC and MoH had profound influence when I was developing the Malaysian Qualifications Agency (MQA) Bill in early 2004 together with Dato Jagjit Singh who was in the Drafting Division of the Attorney-General’s Chambers and who had prior to that served as the Legal Advisor to MoH. It can be said that the procedures and standards used by the MQA were modelled on the accreditation system earlier developed and used by the MMC. In fact, the MQA Act was developed to ensure that professional bodies such as the MMC had absolute power in selecting accreditation panels and making decisions about approving programmes and giving the final accreditation. The MQA was a secretariat for handling logistics and to ensure that rules and ethics of accreditation were followed.

The MQA system of accreditation worked well from 2007. However when the Medical (Amendment) Act 2012 was enforced in July 2017, the MMC could not register graduates of the “parallel programme" into the National Specialist Register (NSR). There are many solutions to this legal problem. The Government chose to hastily amend the Medical Act by way of Medical (Amendment) Bill 2024 (“2024 Amendments”).

It would appear that the word “accreditation” is a problem because it has disappeared in the 2024 Amendments. This is disappointing because the MMC DNA is in the accreditation system of the country. MMC must be proud in pioneering the accreditation system. It is important to emphasise that any amendments to the Medical Act 1971 must enshrine accreditation at the heart of regulating the profession through a register (Medical Register and NSR) which will ensure that all practicing doctors have appropriate education and training, and that they abide by recognized standards of professional conduct while serving their patients.

We can learn from systems in other countries. The Medical Board of Australia is responsible for regulating medical practitioners practising in Australia through 6 types of registrations. It specifically states that accreditation of programs of study and education providers is the primary way of ensuring that Australia's medical practitioners are suitably trained, qualified and safe to practise. Public safety is the priority. The responsibility of accrediting education providers and their programs of study is given to the Australian Medical Council (AMC), a company limited by guarantee and a registered charity or non-profit entity.

The AMC assesses providers and their programmes of study against the approved accreditation standards published on the Medical Board of Australia’s website. The providers are medical schools and specialist colleges such as the Australian College of Dermatologists, Royal Australasian College of Surgeons and so on. The AMC provides accreditation reports to the Board which may approve, or refuse to approve, the accredited program of study as providing a qualification for the purposes of general or specialist registration. An approval may be granted subject to conditions. This process is similar to the MQA practice. The AMC also conducts the AMC CAT MCQ Examination for three pathways for international Medical Graduates who wish to practice in Australia.

In the USA licensing is done by state medical boards and Interstate Medical Licensure Compact, a legal agreement which offers a new, expedited pathway to licensure for qualified physicians who wish to practice in multiple states, expedited by telemedicine.

The license that the physician eventually receives from a state medical board is for the general, undifferentiated practice of medicine. Physicians in the United States are not licensed based upon their specialty or practice focus. Certification in a medical specialty, such as by a member board of the American Board of Medical Specialties (ABMS) is not required to obtain a medical license. However, other practical considerations — such as obtaining hospital privileges — lead most physicians to obtain specialty certification. The majority of physicians in the United States hold specialty certification through the ABMS.

To be fully licensed a physician must meet predetermined qualifications that include graduation from a medical school accredited by the Liaison Committee on Medical Education (LCME), completed at least 1-3 years postgraduate or residency training which is accredited by the Accreditation Council for Graduate Medical Education (ACGME), and passage of the United States Medical Licensing Examinations or USMLE, taken at various points in a prospective physician’s career that tests their knowledge of health and disease management, clinical and communication skills and effective patient care.

Students in U.S. medical schools routinely take the first two steps of the licensing examination prior to graduation. The final step of the examination sequence is usually taken during residency training. International Medical Graduates must be certified by the Educational Commission for Foreign Medical Graduates (ECFMG). This entails a verification of their degrees and successful completion of USMLE Step 1 and 2 before entering an ACGME-accredited residency training program and fulfilling its requirements.

In the United Kingdom (UK) the General Medical Council (GMC) maintains the official register of medical practitioners within the UK to "protect, promote and maintain the health and safety of the public". It regulates and sets standards for medical schools and postgraduate deaneries (since 2010) in the UK though 'quality assurance' to ensure that the necessary standards and outcomes are achieved. It includes all the policies, standards, systems and processes that are in place to maintain and improve the quality of training. The GMC liaises with other nations' medical and university regulatory bodies over medical schools overseas, leading to some qualifications being mutually recognised. The GMC is also responsible for a licensing and revalidation system for all practising doctors in the UK, separate from the registration system. The GMC is a registered charity (non-profit) since 2001, composing of not only doctors but also lay persons. It is subject to the Medical Act 1983 and has statutory duty to cooperate with the Council for Healthcare Regulatory Excellence (GHRE).

The 2024 Amendments appear to concentrate powers of recognising providers and programmes as well as qualifications in the MMC without statutory oversight as in the case of GMC. The quality assurance system in the process of recognition is not explicit. Since the MMC membership is not composed like the GMC, it will give great comfort and confidence to the public if the quality assurance is independent of the Council that also makes decision on approving providers and programmes.

This is because the Council is made up of doctors representing the providers - universities, Ministry of Health and professional societies. Regulations may be made under the Medical Act to appoint and entrust the MQA to carry out this function, similar to the Australian model. The provisions for MQA to collaborate with all professional bodies which include the medical and health bodies in approving programmes and providers and giving the final accreditation are found in the MQA Act. Regulations can also be made to cater for international medical graduates in consistent with the Australian system of establishing pathways and conducting examinations or the American ECFMG system.

It will also be comforting if the new schedules (4 and 5) introduced in the 2024 Amendments will only contain qualifications that have been in the administrative list approved by the MMC and that new ones are incorporated only after the proposed regulations have been made. If schedules 4 and 5 contain qualifications that have not been quality assured, I humbly urge the Cabinet to reconsider the amendments with a view to remove the schedules which are not really necessary because the MMC can keep an administrative list which it should update from time to time.

The public holds high regards for the medical profession. The public also understand the need for more specialists. All that they ask is for the registration of the medical practitioners and specialists to be done with integrity in an objective, fair and transparent manner that inspires confidence that all medical practitioners are suitably trained, qualified and safe to practise.

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* Prof Emerita Tan Sri Dato Seri Dr Sharifah Hapsah, Former Vice Chancellor of UKM, President of NCWO and developer of the Malaysian Qualifications Agency (MQA) Act. ** The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the position of Astro AWANI.