Foreign medical practitioners: requirements for medical practice and postgraduate training in Thailand under ASEAN Economic Community liberalization in 2015

Open access

Abstract

Background

The ten member states that currently comprise the Association of Southeast Asian Nations (ASEAN) agreed to cooperate to become the ASEAN Economic Community (AEC). The first targets of the AEC are free flow of goods, services, investment, capital, and skilled labor. The eventual goal is “a single market and production base”. The ASEAN Mutual Recognition Arrangement (MRA) for medical practitioners has been formulated to facilitate cooperation and the mobility of medical practitioners within the AEC.

Method

We reviewed the requirements of the Medical Council of Thailand (TMC) and the Thai Ministry of Public Health for medical practice and postgraduate training of foreign medical practitioners.

Result

In Thailand a foreign medical practitioner (FMP), holding a valid medical license from their country of graduation, will be recognized as a legal medical practitioner only after obtaining either a temporary or permanent medical licensure from TMC. To acquire a permanent Thai medical license, the FMP needs to register as a member of the TMC, have graduated from a TMC recognized medical school, but also having passed all 3 parts of the National Licensing Examination of Thailand. A Thai medical license is also required for clinical postgraduate medical training. Thai language proficiency is mandatory for registration. There is now only one formal international postgraduate medical training program in Thailand. Participants as observers may be exempted from some or all of these regulations.

Conclusion

The current status of medical licensure in the Kingdom of Thailand presents hurdles that may have to be surmounted.

Abstract

Background

The ten member states that currently comprise the Association of Southeast Asian Nations (ASEAN) agreed to cooperate to become the ASEAN Economic Community (AEC). The first targets of the AEC are free flow of goods, services, investment, capital, and skilled labor. The eventual goal is “a single market and production base”. The ASEAN Mutual Recognition Arrangement (MRA) for medical practitioners has been formulated to facilitate cooperation and the mobility of medical practitioners within the AEC.

Method

We reviewed the requirements of the Medical Council of Thailand (TMC) and the Thai Ministry of Public Health for medical practice and postgraduate training of foreign medical practitioners.

Result

In Thailand a foreign medical practitioner (FMP), holding a valid medical license from their country of graduation, will be recognized as a legal medical practitioner only after obtaining either a temporary or permanent medical licensure from TMC. To acquire a permanent Thai medical license, the FMP needs to register as a member of the TMC, have graduated from a TMC recognized medical school, but also having passed all 3 parts of the National Licensing Examination of Thailand. A Thai medical license is also required for clinical postgraduate medical training. Thai language proficiency is mandatory for registration. There is now only one formal international postgraduate medical training program in Thailand. Participants as observers may be exempted from some or all of these regulations.

Conclusion

The current status of medical licensure in the Kingdom of Thailand presents hurdles that may have to be surmounted.

The Association of Southeast Asian Nations (ASEAN) was established by 5 leading countries: Indonesia, Malaysia, Philippines, Singapore, and Thailand. Subsequently, the ASEAN Declaration was signed on 8 August 1967 [1]. Brunei Darussalam, Vietnam, Lao PDR, Myanmar, and Cambodia joined later [1-3]. At the 9th ASEAN summit at Bali, Indonesia in 2003, all members of ASEAN agreed with the Declaration of Concord II to develop the ASEAN Community by the year 2020. In 2007, the Declaration on the Acceleration of the Establishment of the ASEAN Community by 2015 was announced at the 12th ASEAN summit in Cebu, Philippines.

One year later, the ASEAN Charter has taken effect and is the constitution of the community since 15 December 2008. The 3 main pillars of the ASEAN Community consist of the ASEAN Political-Security Community, ASEAN Economic Community (AEC), and ASEAN Socio-Cultural Community. The AEC aims to achieve 4 main conditions: (1) a single market and production base, (2) a highly competitive economic region, (3) a region of equitable economic development, and (4) a region that is fully integrated into the global economy [4].

To become a single market and production base with free flow of goods, services, investment, capital, and skilled labor is part of the AEC Blueprint [5]. Healthcare services are among the sectors to become coordinated. To facilitate cooperation and mobility of medical practitioners within the AEC, an ASEAN Joint Coordinating Committee on Medical Practitioners (AJCCM) has been created [6]. A medical practitioner (MP) holding a valid medical license of his/her country of origin, can apply for registration to practice medicine in other countries within the community and will be known as a Foreign Medical Practitioner (FMP). However, such a FMP will be still subject to all local domestic regulations set forth by the professional medical regulatory authority of the host country [6]. In Thailand, the professional medical regulatory authorities are the Medical Council of Thailand (TMC) and Ministry of Public Health [6]. For registration to practice medicine, both Thai MPs and FMPs need to fulfill all the requirements determined by the TMC. For Thai MPs, this information can be easily accessed through the TMC’s website in Thai language [7]. However, information in other languages, including English, for FMPs is limited. Although some information is translated and already presented on the TMC’s English website, it does not contain all necessary requirements to pursue a medical career in Thailand, which currently include a work permit for other than Thai citizens. For the benefit of FMPs, the authors have reviewed current domestic regulations and procedures, which may undergo significant changes in the future.

Medical practice in Thailand

Legal medical practitioners, Thai MPs and FMPs, are required to perform their work under laws and regulations determined by the TMC [7] formulated as the Medical Profession Act Buddhist Era (B.E.) 2525 (1982), Professional Standards for Medical Practitioners 2012, The Medical Council Regulations on Medical Ethics B.E. 2549 (2006) and other official announcements by the TMC. According to the AJCCM 2015 Goals and the objectives of the ASEAN Mutual Recognition Arrangement (MRA), Member States of ASEAN have agreed on a policy for temporary licensing and registration for FMPs in 5 designated categories. These include limited practice, expert visits, education and training, humanitarian missions, and research [8]. In Thailand, the temporary license is valid for 1 year, but renewable and granted only for practice under supervision of a fully-licensed Thai MP. Interested FMPs in these categories can apply directly to the respective healthcare institution where they plan to work. The institution will establish contact with the TMC for endorsement and clearance of documents needed for a temporary license [8]. FMPs who wish to practice independently, have to apply for a permanent Thai medical license. Since 1946, only 220 FMPs, from 22 countries, have been registered and granted a permanent medical license by the TMC [9].

There are 3 principle requirements for obtaining a permanent Thai medical license. (1) Admission to membership in the TMC. (2) A certificate from the university where he or she has graduated along with a valid medical license from the country of graduation. (3) Successful passing of all 3 parts of the National Licensing Examination of Thailand [10].

To register as a member of TMC, an applicant must attain the age of 20 years, obtain a medical degree from a list of medical institutions accredited by the TMC, and have no record of misconduct, unlawful acts or imprisonment that would bring dishonor to the profession. The applicant must not have any mental disorders, chronic alcoholism, drug addiction, and other diseases that may interfere with professional practice. The registration and membership fee is 4,500 Thai baht [10]. At present, there are 111 curricula of foreign medical schools, distributed in 28 countries, recognized by the TMC. They appear on the TMC website [9]. If the name of the medical school is not present on this list, the applicant needs to request the TMC to review the medical curriculum, and obtain its approval before the application process can begin. This process may take time and there will be a processing fee of 10,100 Thai baht for each applicant [10].

Finally, applicants are required to pass all 3 parts of the National Medical License Examination of Thailand (NL). The NL is conducted by the Center for Medical Competency Assessment and Accreditation (CMA), under Medical Competency Assessment Criteria for National Licensure B.E. 2555 (2012) announced by TMC [11, 12]. The NL consists of Part-1: 300multiple choice questions (MCQ) in basic medical sciences, Part-2: 300 MCQs in clinical sciences, and Part-3 in 20 stations of objective structured clinical examination (OSCE). The NL Part-1 and Part-2 are separately scheduled for 1-day, twice yearly, and offered at several testing locations in Bangkok and other provinces. Since 2015, almost all questions in NL Part-1 and Part-2 will be in English, except for the questions associated with Thai law or forensic medicine, which appear in Thai. The Table of Specification for the NL Part-1 and Part-2 can be downloaded from the CMA’s website [13, 14]. Only FMPs graduated from medical schools previously approved by TMC are eligible to apply. There is an examination fee of 3,015 Thai baht for each part, and there is no limit in attempts for taking these examinations. The NL Part-3 OSCE is a half-day examination given 3 times a year, and is conducted only in Thai. This examination is offered mainly in Bangkok, and in one of the following provinces: Chiang Mai, Khon Kaen, or Songkhla. FMPs who wish to apply must have a valid foreign medical license and pass both the NL Part-1 and Part-2 within 7 years. For Thai-national FMPs only, the foreign medical license from country where graduated may not be required if they participate in the skills enhancement internship program at a designated hospital arranged by TMC [15]. An examination fee of 5,015 Thai baht will be applied, and there is no limit of attempts for taking this examination. In addition, FMPs are also required to take 2 more examinations, which are considered part of the NL Part-3. They consist of modified essay questions (MEQ) and long case examinations. Completion of all examinations, including NL Part-1 (MCQ), NL Part-2 (MCQ), NL Part-3 (OSCE), MEQ, and the Long case, are the same requirement for both Thai national MPs and FMPs [16].

Once all these 3 principle requirements are fulfilled, FMPs will be granted a life-long, permanent Thai medical license, which is valid for practice throughout the country. For personal identification, the registered medical practitioner may request an MD Card authorized by the TMC [7]. Currently, FMPs who are not Thai citizens, must also obtain a work permit.

Postgraduate medical training in Thailand

Postgraduate medical training in Thailand (PGMT) refers to residency or fellowship programs in various specialties. Many organizations are involved in the arrangement of PGMT programs, including medical teaching centers, Royal Colleges of Medical Specialties, Ministry of Public Health, and TMC. Currently, there are 50 recognized training institutions, offering PGMT programs in 80 specialties and subspecialties [17]. Each year, the numbers of position opening for PGMT are announced by the TMC. For example, in 2015 there are totally 2,363 positions available for enrollment [18]. A valid permanent Thai medical license is required for all applicants, including FMPs [19]. Most of the programs require working clinical experience in a hospital after graduation. For Thai MPs, they normally participate in the skill enhancement internship program, arranged by TMC and other accredited governmental hospitals. In 2014, there were 2,835 internship positions available in 126 hospitals throughout the country [15]. During the 1-year internship program, an intern will practice medical skills and rotate in different medical specialties, mostly in internal medicine, obstetrics and gynecology, surgery, and pediatrics. A certificate of completion of the internship program is required for most PGMT programs. FMPs with a Thai medical license can also participate. The PGMT programs can be classified into 3 major categories [17, 19].

Category-1 (Encouraged specialties)

Because of the shortage of medical specialists in some fields, TMC encourages applications for PGMT programs in (1) psychiatry, (2) child and adolescent psychiatry, (3) forensic medicine, (4) anatomical pathology, (5) clinical pathology, (6) general pathology, (7) therapeutic radiology and oncology, (8) family medicine, (9) emergency medicine, (10) nuclear medicine, (11) oncology, and (12) hematology. Internship experience is not required for application in these fields and applicants in this category can begin their training as early as the year following graduation. The duration of training is normally 3 years, except for 4-year training programs in child and adolescent psychiatry, and oncology.

Category-2 (Main specialties)

There are presently 26 specialties in this category considered to be the main specialties of the PGMT programs. They are anesthesiology, internal medicine, obstetrics and gynecology, ophthalmology, orthopedics, otorhinolaryngology, pediatrics, preventive medicine, diagnostic radiology, rehabilitation medicine, and surgery. The certificate of completion of a 1-year internship program is necessary for the application in these fields. Some programs require 2, 3, or more years of internship before applying, to ophthalmology, dermatology, and plastic surgery programs. Furthermore, an applicant who has received a government training scholarships may be considered as a priority. The duration of training is 3-5 years depending on specialty.

Category-3 (Subspecialties)

This category consists of 43 subspecialties, referring to as advanced PGMT or fellowship. Applicants considered final-year residents, certified medical specialist or as Diplomats of Thai Board of Medical Specialties, are eligible to apply for such subspecialty fellowships. FMPs who are medical specialists must have a Thai permanent medical licensure in order to apply. The usual duration of training programs in this category is 2 years.

The process of application regularly begins by the end of the year before closure of applications through the website of TMC [7, 19]. However, the applicant should contact the director of programs of interest as early as possible because some programs may start the selection process before the official application process begins. There are 2 rounds of application by the TMC. For the first round, the applicants can choose more than one program in order of interest. If accepted by any program in the first round, TMC will announce names as having been filled. The second round begins only for applicants left from the first round. Now, they can apply for only unfilled programs left from the first round.

The final result will be announced by the TMC. For 2015 enrollment, the numbers of position for the first and second rounds of application were 2,363 and 572 respectively. There were 1,981 applicants in the first round, and only 182 applicants in the second round. In conclusion, there are 1,951 filled positions (66.47%), and 456 positions remain open [18].

Current international postgraduate medical training programs

In addition to the conventional PGMT programs, FMPs who wish to continue their medical education in Thailand without registering for a permanent medical license, may consider applying for international PGMT programs of the Faculty of Medicine of Siriraj Hospital, Mahidol University [20]. Accepted residents will be granted a temporary medical license from the TMC, which is valid for 1 year, but renewable. Currently, there are 8 residency and 28 fellowship international PGMT programs offered in various departments. These include Anesthesiology, Dermatology, Emergency Medicine, Obstetrics and Gynecology, Ophthalmology, Orthopedic surgery, Otorhinolaryngology, Pediatrics, Surgery, and Internal Medicine. These programs are mainly conducted in English. However, Thai language skills are still required for communication with patients. Admission requirements, courses of training, criteria for assessment, and available positions are varied among programs. Prospective FMPs should contact the program director for further information [20].

Discussion and conclusion

The start of the ASEAN Economic Community (AEC) is a historical event. All ten ASEAN member states are preparing for challenging new conditions. For healthcare services and the medical profession, we have agreed to cooperate and develop ASEAN Mutual Recognition arrangements (MRA). We should anticipate that an increasing number of qualified FMPs will desire further study and wish to practice in Thailand. These FMPs will have to fulfill all domestic Thai regulations set forth by the local professional medical regulatory authority. These requirements are accessible through the TMC’s website in Thai and in English. However, some detailed information is only briefly stated and was omitted in the English website. FMPs who cannot read Thai, will not yet be able to obtain all of the needed information from the website alone. To provide comprehensive information regarding this matter for interested FMPs and others, the authors have attempted to summarize relevant regulations formulated by the TMC.

We emphasize that the FMP’s proficiency in Thai language is important. Currently, there is no requirement for FMPs to demonstrate their Thai language skills in an official test. FMPs may have little difficulty in the NL Part-1 and Part-2, because most of the questions are in English. However, the NL Part-3 is only conducted in Thai. Language requirements vary among the medical licensing examinations (MLE) offered by the ten different member states. English questions are used or used in part in the MLE in most of these counties. However, the MLE in Vietnam and Indonesia are conducted only in Vietnamese and Bahasa Indonesia respectively [21].

The European Economic Area (EEA), established on 1 January 1994, is a single market that provides free movement of persons, goods, services and capital between the EEA member states, which now include 28 countries as the European Union (EU) and 3 countries in the European Free Trade Association (EFTA) [22]. According to EU legislation, free movement with full registration in any EEA should become available provided that the physicians are citizens of a member state and have completed primary training in a member state’s medical college and hold a valid license to practice there [22, 23]. Currently, major destination countries for such migration of EEA physicians are Germany, France, Italy, UK and Spain. Factors influencing the mobility of physicians include financial motivation, better working conditions, desire for more training, and better career opportunities. Migration also reflects fundamental health care systems problems in different EEA counties from where most physicians tend to depart. It may also deprive these countries of doctors who will be difficult to replace [24]. Regulation and licensing criteria for physicians in the European countries have been published [25]. It is important to note that many EEA member states still maintain their own and differing national regulations for work application requirements and for full unlimited physician registration. For example, The UK General Medical Council (GMC) remains the responsible authority for recognition of doctors in the UK. Virtually all EEA countries require some evidence of proficiency in the local language before approving medical registration for migrant physicians [25-27]. A new Directive (2013/55/EU) will take effect in January 2016. It is an update of Directive 2005/36/EC regarding the recognition of professional qualifications. Discussions concerning need for a valid European professional identification card, mandatory continuing professional education, common postgraduate training frameworks and recognition of migrating medical specialist’s qualifications are also on the list. There are several additional issues and debates concerning the competence of migratory physicians and patient safety. These are mostly found in the public media. They include problems with communication and language proficiency, cultural and attitudinal differences, and a better warning systems for safety problems. In other words, current rules are not immutable or “carved in stone” [28].

In conclusion, FMPs with valid foreign medical license will be recognized as legal medical practitioners in Thailand only after either temporary or permanent Thai medical license has been granted by the TMC. FMPs with Thai medical license can continue postgraduate medical training within Thailand. However, to truly liberalize rules for physician migration among AEC countries, they will have to consider further the differing educational, economic, political, linguistic, and cultural factors. A survey of medical school accreditation systems in different ASEAN countries would be a basic step towards such a liberalization.

Acknowledgements

This article was generated from the student-centered, self-directed learning process in the course of 499722 Foreign Language for Communication in Medicine, which is an elective course for medical students at the Faculty of Medicine of Naresuan University [29]. The authors wish to thank The Medical Council of Thailand (TMC) and Center for Medical Competency Assessment and Accreditation (CMA) for also providing information via phone and email.

Conflict of interest statement The authors have no conflicts of interest to declare.

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