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Surgical competence and mutual recognition in ASEAN countries

The article by SK Lum in this issue of the Journal highlights important and imminent challenges for surgical care of the hundreds of millions of people in the Southeast Asian region. A Mutual Recognition Agreement (MRA) will govern the movement of medical practitioners between the 10 member countries of the Association of Southeast Asian Nations (ASEAN) from 2015. These nations, in order of population, are Indonesia, Philippines, Vietnam, Thailand, Myanmar, Malaysia, Cambodia, Laos, Singapore and Brunei. Australia and New Zealand are not part of ASEAN but have a very close interest in the activities of our regional neighbours. It is highly relevant that the MRA was an agreement between the Ministers of Trade and Industry, rather than the Ministers of Health, of the ASEAN counties. The motivation was mostly political and economic, and health care appears to be regarded as a commodity. This concern is reinforced by the commentary on medical tourism which flourishes in Southeast Asia and provides temptation to place profits ahead of patient’s best interests. It is clear that there are enormous disparities in populations, cultures, economies and health systems between the ASEAN countries. The education of medical practitioners and specialists is designed to meet the needs of individual countries and these vary greatly. The common language of the region is English but there are a few English language or bilingual medical schools and the majority of patients and other health-care workers speak only the language of their own country. Effective communication is always a challenge and the mutual recognition process will need to consider a policy to manage communication issues. A strong case may be made for promoting improvement in the fundamental health care of the majority of patients and a minimum standard of acceptability of medical practitioner competence. For surgery, this would mean a common curriculum including the agreed elements of general surgery and an assessment process linked to the curriculum and administered by a regional ASEAN Board of Surgery. In assessment of competence, consideration would be given to recognition of prior learning and experience, review of logbook data and other audits of performance, referee reports and interviews as well as examinations. In addition to the basic common standard, there will also be a need to recognize specialists with higher skills and experience in particular areas of surgery. There are many such surgeons in Southeast Asia, and if they wish to move between countries, a standardized process of competency recognition would be desirable. Australia and New Zealand have long experience in the complex issues of assessment of competence of international medical graduates and the RACS has expertise that could be of benefit to an ASEAN Board of Surgery. The challenges for our ASEAN surgical colleagues are considerable as they develop systems to assess competence and suitability for transfer between their countries. They are correct to aim to develop robust processes where they, and not government, have control of surgical standards. Quality of patient care and the professional competence of surgeons should be the guiding principles.