Introduction
The Ministry of Health has embarked on training of subspecialists in the last 10 years or so. As of 1998-99, various subspecialties have defined the training curriculum, entry criteria, duration of training (total of 3 years), progress assessment, list of trainers and training centres. None of the subspecialty training programme, however, has formal exit certification. Supervisors are expected to evaluate candidates on a regular basis e.g. 6 monthly. On satisfactorily completing 2 years of local training, candidates are sent on scholarship to approved centres overseas for another year. Some candidates may prefer to spend all three years locally.

To be eligible for medical subspecialty training, candidate must have a recognized postgraduate qualification in Internal Medicine, viz Master in Internal Medicine from local universities or MRCP (UK or Ireland) or equivalent. For candidates with the MRCP, he / she must have a total of 4 years of supervised training in Internal Medicine, both before and after obtaining MRCP. Serving 12 months in designated hospitals as a general physician is also an entry requirement for training in medical subspecialties.

There are 11 ongoing medical subspecialty training programmes viz. Cardiology, Dermatology, Endocrinology, Gastroenterology, Haematology, Hepatology, Infectious Diseases, Nephrology, Neurology, Respiratory Medicine and Rheumatology. Advanced training in General Internal Medicine is now offered as a subspecialty in its own right.

From 2001 , this training in subspecialty has been renamed Fellowship training, differentiating it from the four-year basic physician training of the local Master programme.

Organizational Structure in the Ministry of Health
Since July 2001, a three-tier structure has been put in place. The highest tier is the Main Fellowship Training Committee in the Ministry of Health. This committee has the following membership:

• Deputy Director-General of Health (Medical) - Chairman
• Director, Medical Development Division - Secretariat
• Appointed representative/s of Medical Discipline
• Appointed representative/s of Surgical Discipline
• Appointed heads of subspecialty (2 medical & 2 surgical)
• Appointed representative from other disciplines (Anaesthesiology, Ophthalmology, ENT, Radiology, Pathology, Orthopaedic, Psychiatry, O&G)

Terms of reference of this committee include:

• Overall planning of subspecialty training, including appropriate number and distribution in various medical/surgical subspecialties, availability of training posts
• Accreditation of training centres and trainers
• Policy on selection and placement of candidates
• Review of training program
• Transfer policy vis-a-vis placement of candidates in various training centres
• Policy on exit certification and gazettement

This committee will meet twice a year, after the meeting of individual fellowship training subcommittees.

The second tier. The Medical Fellowship Training Committee coordinates training in medical subspecialties. This committee has the following membership:

• Chairman: elected by consensus amongst the heads of medical subspecialties
• Members: all heads of medical subspecialties (Cardiology, Dermatology, Endocrinology, Gastroenterology, General Internal Medicine, Haematology, Hepatology, Infectious Diseases, Nephrology, Neurology, Respiratory Medicine, Rheumatology)

The terms of reference of this committee include:

• Coordinate all medical fellowship training programmes
• Standardize criteria for accreditation of training centres, trainers, selection of candidates, exit certification etc
• Organize common training seminars for medical fellowship trainees

The third tier. The individual medical subspecialty is to form individual Subspecialty Fellowship Training Subcommittee. Head of that subspecialty will chair the subcommittee. Membership includes 2-3 other senior members of that subspecialty (from other training centres), and a representative each from the relevant specialty society and university. Committee members will be appointed for a term of 2 years, which will be renewable.

Terms of reference of this subcommittee include:

• Recommend candidates for selection into training program
• Review accreditation status of training centres and trainers
• Review programme contents and mode of training
• Plan training schedule of individual trainees
• Review progress of trainees
• Exit evaluation

Individual subspecialty fellowship training subcommittee will meet twice a year, before the MOH main committee meeting.

Gastroenterology Fellowship Training
The Objective of this training programme is to produce gastroenterologists who are clinically skilled and sufficiently competent to provide general gastroenterological and hepatological services.

As a guide, the Training Programme has the flexibility to encourage a degree of specialization and choice to suit career aims and service needs. The training will also encourage a critical and analytical approach to effective clinical management and a positive approach to health service management, teaching and research.

The Gastroenterology Fellowship Training Subcommittee has been in place since the late 1990's. This committee meets regularly every 6 months to discuss and decide on various issues pertaining to training. Input from this subcommittee has been instrumental in implementing various training activities in Gastroenterology.

Duration: Just as other Fellowship Training, Gastroenterology training programme runs for a period of at least 3 years. Trainees have the option of completing the entire 3 years of training in accredited centre(s) locally or spend the final year of training in specialised area of gastroenterology in approved centre(s) overseas.

Training Components: Trainee will be under direct supervision of an accredited consultant, who will be responsible for monitoring and evaluating the progress of the candidate.

Components of training include:
1) ward work
2) outpatient work
3) endoscopic procedures
4) other specialized gastroenterological procedures (e.g. manometry & pH study)
5) tutorials, seminars and clinical meetings
b) research
7) teaching

The trainee will be a member of the team in the Department and will share in the clinical work. The time spent in General Medicine will not exceed 40% of the total time. The other 60% of the time will be spent in clinical gastroenterology. The trainee will participate in the daily management of a wide variety of digestive disorders, and will have the responsibility for the care of individual patients on a continuing basis with appropriate guidance from the supervisor/s. The importance of follow-up medical care and preventive care will be emphasized.

Training Environment: As clinical care of patients with digestive disorders often require collaboration with other disciplines, this training programme will involve regular interaction between trainees and other specialists like surgeon, radiologist, pathologist, oncologist, infectious disease specialist etc, so that the trainees will become appropriately knowledgeable in these other areas.

Direct involvement of trainees in at least two research projects is required, and one of which should be of sufficient standard for publication in a local or international journal or for presentation in local or internationa! gastroenterology meeting.

The trainees will participate in the teaching of house officers and medical officers, as well as paramedical personnel.

The Training Curriculum aims to provide:

Scientific Basis: sound scientific and theoretical knowledge of the normal structure and function of the gastrointestinal tract as well as knowledge of the aetiology, pathogenesis, natural history, clinical presentation, investigation, treatment and prognosis of diseases of the gastrointestinal tract, including the hepato-biliary system and pancreas. Such knowledge includes histopathology, microbiology, parasitology, chemical pathology, immunology, genetics, molecular biology, pharmacology, oncology, epidemiology and statistics. An understanding of medical demography and health care economics is also required.

Clinical knowledge: Knowledge of the indications, contraindications and the complications of various endoscopic, imaging, investigational and surgical procedures together with the understanding of their limitations will be essential in a variety of clinical settings.

Core gastroenterology
1. Oesophageal and gastroduodenal disease
2. Hepatobiliary disease (acute and chronic liver disease, jaundice and alcohol related disorders)
3. Gastrointestinal emergencies (acute abdomen, acute Gl bleeding, removal of foreign bodies from the GI tract, fulminant colitis, cholangitis, liver failure)
4. Functional bowel disorders
5. Gastrointestinal infections and AIDS
6. Oncology (oesophageal, gastric, pancreatic, colon cancer and hepatoma)
7. Inflammatory bowel disease
8. Malabsorption and pancreatic disease
9. Organ transplantation
10. Nutritional support
11. Gastroenterological manifestations of systemic disease

Clinical care and expertise
Trainees should have supervised practical experience in the clinical care of patients, both as in-patients and out-patients. The clinical management of patients in the primary care setting and at home should be understood. Clinical experience must be gained mainly in the substantive posts with appropriate development of clinical responsibility. Teaching by direct supervision of clinical work and attendance at multi-disciplinary meetings must be an integral part of the training programme.

Competence and skills required
Training will be required in the following skills:

1 . Diagnosis, treatment and management of conditions listed in core gastroenterology

2. Basic diagnostic endoscopy
These should include oesophago-gastro-duodenoscopy, sigmoidoscopy and colonoscopy, and exposure to endoscopic retrograde cholangio-pancreatography. Principles of disinfection, safety and sedation should be understood.

3. Basic endoscopic therapeutic techniques
These should include endoscopic haemostatic techniques e.g. endoscopic variceal ligation, injection techniques, polypectorny, insertion of PEG tube, stricture dilatation etc.

4. Non-endoscopic techniques
These should include liver biopsy, abdominal paracentesis and other investigative techniques used in gastroenterology and hepatology.

5. Basic abdominal and endoscopic ultrasonography.

6. Communication skills
Trainees should acquire attitude, knowledge and skills in doctor / patient communication, in communication within a multidisciplinary team, in communication within hospital and beyond.

Management training
Include experience of audit and quality assurance, information technology and health services management.

Option Modules
The trainee will be encouraged to undertake a variety of advanced option modules:
• Advanced hepatology (in recognized hepatology centre)

• Physiological measurement (oesophageal manometry and pH measurements, gastric and pancreatic function testing, ano-rectal physiological studies)

• Nutrition (assessment of requirements, catheter placement, nutrition team service management)

• Advanced therapeutic endoscopy (ERCP, laser therapy, photodynamic therapy, management of strictures and fistulae, enteroscopy)

• Imaging (ultrasound, endoscopic ultrasound, CT, MRI, MRCP, nuclear medicine)

• Cancer care (drug therapeutic regimens, radiotherapy, combined modality treatment and brachytherapy of all common gastrointestinal and hepatic malignancies)

• Palliative care (pain relief, hospice care, terminal care, palliative endoscopic techniques)

• Communicable disease (advanced AIDS, intestinal infection, hepatitis, tropical disease, parasitology, special experience with Heticohacter pylon)

Teaching Modalities
Much of the training will be on the basis of apprenticeship:

Case Presentation
Presentation of complex and interesting cases by trainees. Discussion to focus on differential diagnoses, choice of procedures in work-up and therapy, and review of literature.

Gastroenterology Grand Rounds
Weekly presentation of problematic gastroenterology / hepatology cases requiring discussion and consensus in management.

Journal Club
Weekly conference in which pertinent studies from the major GI, liver and internal medicine journals are discussed. Trainees learn to critically appraise and evaluate scientific publications in the field of gastroenterology.

Gastrointestinal Imaging Conference
Weekly conference which combines the expertise of GI radiology, invasive radiology and gastroenterology in patient management.

Histopathology Conference
Monthly conference in which the trainees meet with members of the pathology department to review the biopsies from in-patient and out-patients.

Combined Gastro/hepato/surgical meeting
Monthly conference which combines the expertise of the above 3 disciplines in reviewing and discussing interesting or challenging cases.

Training in endoscopic & non-endoscopic procedures
Details are provided in appendix (upon request)

Trainers & Training Centres:
Centres will be accredited for training for the whole period or part of it depending on the availability of supervisors, workload, facilities and other supportive services.

Training can only be done under the supervision of an accredited consultant gastroenterologist either in MOH or non-MOH hospital (university or private). A consultant can be accredited as a trainer if he/she demonstrates an interest in training, and has a minimum of two years of working experience in gastroenterology after completing his/her own training. A trainer can only train 2 trainees at any one
time.

Training in hepatology as an option module will be done under the supervision of an accredited consultant hepatologist.

Review & Evaluation
Appropriate supervision, review and/or audit of all trainees' activities should be documented. There should be regular evaluation and feedback concerning the trainee's knowledge and clinical skills in all the relevant areas. The trainer is expected to submit written report of the trainee's progress to the Gastroenterology Fellowship Training Committee at 6 monthly interval.

Log Book
Trainees are required to maintain a logbook, which will be submitted for certification by the supervisor and reviewed 6 monthly by the Fellowship Training Committee.

The following will be recorded:

1. Endoscopic procedures (observed, performed with supervision/without supervision)
2. Non-endoscopic procedures: e.g. percutaneous liver biopsy
3. Others: e.g. Oesophageal manometry & lower oesophageal sphincter pressure measurement, endoscopic ultrasound
4. CME activities
5.Research projects

Exit Evaluation
The trainee will undergo a half-hour viva voce to assess his / her competence at the end of training, after fulfilling the following criteria:

1. Completed 3 years of supervised training
2. Fulfill log book requirement
3. Satisfactory progress assessment
4. Completed 2 research projects with at least one publication in local or regional journal

The Fellowship Training Committee will appoint two neutral assessors for this purpose. Viva voce will be held twice a year. The Ministry of Health will award Exit Certification to the trainee who has passed the viva voce. If not, the Training Committee will recommend remedial measures.

Formalizing Fellowship Training
National mortality and morbidity data, existing specialist manpower, predicted changes in demography and other relevant data help to project the need for specialist service and to formulate plans (n the development of various specialties and subspecialties in this country.

Increasingly the concept of a comprehensive specialist service per X number of population is used to project the number of specialists needed in a specific specialty. This concept will take into account the whole range of specialists required to provide a specialty service. For example, a gastroenterology service should have 2 gastroenterologists, 2 GI surgeons, a pathologist, an imaging specialist, and other paramedical staff.

Establishment of Fellowship Training Committee at MOH level since early 2001 has formalized subspecialty training within the Ministry. Among the priorities of this committee will be to accredit training centres and trainers, both from the MOH and outside MOH, according to set criteria, on recommendation from the individual fellowship training subcommittee. Once that is done, the number of training posts will be defined, with trainer Lo trainee ratio of not more than 1:2.

The secretariat of this main committee has been working hard. There is a generic application form for potential candidates. The work process for application has also been put in place. Candidates will be given application number upon receipt of their application. Later when the subspecialty committee accepts the candidate, he/she will be given a training number. The secretariat will soon establish a website specific for Fellowship Training. Available training posts will be webposted, as well as entry requirement, criteria for selection, list of designated hospitals where the potential candidates should work as a general physician, application procedure etc.

To ensure fairness and transparency, the Fellowship Training Committee has agreed to the following criteria for selection of trainees viz. seniority, track record (including manifest interest in subspecialty, research conducted and papers published, attendance at subspecialty meetings), and service in designated
hospitals as general physician.

Successful candidates will be placed in suitable training centres under the supervision of accredited trainers. The transfer of these candidates will be effected according to standard practice. In order to minimize disruption to the base hospitals, transfer of candidates for subspecialty training will be effected twice a year, approximately 2-3
months after the meeting of the Fellowship Training Committee.

The individual fellowship training subcommittee is responsible for planning the training schedule of every candidate selected to undergo training. In this schedule, the sequence, duration and modules in each location will be made known at the beginning of the training programme.

Role of Malaysian Society of Gastroenterology and Hepatology
Malaysian Society of Gastroenterology and Hepatology has important roles in Gastroenterology Fellowship Training of the Ministry of Health. A representative of the MSGH sits in the Gastroenterology Fellowship Training Subcommittee. The MOH Castroenterology Training Programme in use at present was drawn up with important input from MSGH. Similarly the MSGH has contributed significantly in setting the criteria for accreditation of gastroenterologists, as well as accreditation of training centres and trainers. MSGH will also be involved in exit evaluation of candidates. MSGH wilt certainly play key roles when the Specialty Board for Castroenterology is eventually set up. This Board will be responsible for all aspects of training in Gastroenterology.