The Grandfather Clause

Introduction

Mersing. That’s the rural town I grew up in the 60’s and 70’s, and I recall the only dentist in town was a man who learnt his profession from his ancestors. He did not have a professional certified degree. The community accepted him as a dentist and he practiced his skills.

In the late 80’s, I worked as a medical officer in the department of dermatology where the head of department only possessed a diploma in dermatology. Everyone accepted him as a dermatologist even though by current  criteria, he did not have all the necessary certifications of a dermatologist. This system also worked in other departments like ophthalmology where some one with only a diploma in ophthalmology was accepted as an eye specialist.  These doctors were accepted as specialists in their fields under the  “grandfather clause”.

What is “The Grandfather Clause?

A grandfather clause is a provision whereby an old rule continues to apply to some existing situations while a new rule applies to all future cases.

The Webster medical dictionary states that a grandfather clause is any policy or rule that exempts a group of individuals, organizations, or drugs from meeting new standards or regulations—e.g., when a new subspecialty board in internal medicine is created, the physicians practising in that area may be ‘grandfathered’ into the subspecialty and not required to meet residency or other educational requirements.

One example of how the grandfather clause is used in the United Kingdom is the usage of new drugs or technology.  Sometimes a new drug is approved for usage for a particular disease. Later, if the National Institute for Care and Health Institute (NICE) comes out with a guideline that the new drug is not effective or not cost effective for the particular disease, the grandfather clause is used to allow continuation of the usage of the drug for patients who have already started   treatment with the drug. This has led to some ethical problems that have been described in a paper entitled “ The ethics of grandfather clauses in healthcare resource allocation”, published in the journal Bioethics 2021;35:151-160.

The Law

How does the grandfather clause affect us as doctors in Malaysia? The Medical (Amendment 2012) Act 1971 came into force on 1st July 2017 when the Medical Regulation 2017 was adopted. The amended Act requires that for a doctor to practice as a specialist, he must be registered under this Act. For this purpose, the Malaysian Medical Council has established the National Specialist Register (NSR), the database of Specialist Medical Practitioners in the country. The register contains information about medical specialists, their discipline/speciality qualifications and places of practice. Only medical practitioners on the Specialist Register can practice in their registered disciplines/specialties.

Before 2017 most private hospitals encouraged their specialists to register with the NSR but after 2017 almost all private hospitals insisted that their specialists  register with the NSR. This may be a requirement to please hospital accreditation societies like the Malaysian Society of Quality of Health and Joint Commision Internation (JCI). I am unsure whether the Ministry of Health is also insisting all their specialist to be registered with the NSR. 

There are 29 specialities listed in the NSR. In some of the categories there are further subspecialty categories. An Evaluation Committee for Specialist Medical Qualifications assists the Malaysian Medical Council. Subcommittees for each speciality further assist this committee with 4 to 6 doctors in each speciality. I am sure that many doctors, who did not have the sufficient paper qualifications to be a specialist or subspecialist, were grandfathered into this register. Usually a certain cut off period is given to doctors without sufficient paper qualifications to write to this committee to provide evidence of their work to prove that they can come under the grandfather clause to be included as a specialist in the register.

Problems with “The Grandfather Clause”

I have seen the effect of this clause in some hospitals. Before the establishment of subspecialties, general physicians who were interested in nephrology were performing dialysis. However, when the subspecialty of nephrology was established they were not allowed to perform this procedure anymore. Similarly, general surgeons have been performing surgery for colorectal cancers for a long time. Now that there is this subspecialty called “Colorectal surgery” are hospitals going to prevent their general surgeons from performing this surgery?

What are some of the problems with the grandfather clause? It can sometimes be risky because it doesn’t mean that someone who has been doing something for a long time without any formal training is really qualified to perform the procedure.  The question then is when and who decides that the grandfather clause is applicable. I presume that when a new subspecialty is established in a country certain doctors who have obtained qualifications in that subspecialty will gather and be the decision makers as to who will or will not be considered part of the subspecialty, under the grandfather clause. These are man made rules and they can be subjected to abuse.

Example of The Grandfather Clause at work

Let me illustrate this in my profession, Obstetrics and Gynaecology.  I started performing in vitro fertilization (IVF) in 1997. At that time there were very few IVF specialists in Malaysia. There was no law or regulation as to who was to be called an IVF specialist. I just went ahead and started an IVF Lab and provided IVF services. Although I attended numerous workshops and spent a few months at the IVF centre at King’s College (London), acquiring skills to perform IVF, I did not have any paper qualification. In order to overcome this problem, I enrolled in a Master of Reproductive Medicine, online course with the University of Western Sydney. It took me 3 years to get this Master’s Degree in 2005. I also kept records of every IVF case I performed in my centre.

I was hoping that when the laws were enacted, with my experience performing IVF for decades and with this degree I would be accepted as a Reproductive Medicine Specialist. When the NSR started its subspecialty register, I applied and the accreditation committee found my qualifications sufficient to include me as a subspecialist in Reproductive Medicine.  Although currently you don’t need to be in a subspecialist register to perform a particular procedure designated under that subspecialty, one day that rule might apply. This will probably hold true for IVF. Since IVF centres are mushrooming in Malaysia and almost anyone who has attended some workshop and is performing IVF, is designated an IVF specialist, someone will have to decide whether all these practicing IVF specialists will come under the grandfather clause.

So what advice can I give doctors

  1. If you are practicing a field of interest which is currently not a speciality or a subspecialty yet and may become one in the future, make sure that you try to get as much paper qualification as you can in that particular field so that when it ultimately becomes one, you can show your qualifications to enable you to be included under the grandfather clause.
  2. Keep a detail log of all work you are doing. This will assist you in proving to a committee of peers that you qualify to be in that particular speciality.
  3. Try to publish in that field as well, and again this will make you an expert in that field and this will be recognition.
  4. Be so good in that field that it will be difficult to ignore you as a specialist in that field

Selva
22/2/22

I would like to thank :
My wife Sarojini for editing this post
Dr. J. Ravichandran and Dr Gunasegaran for giving me some good suggestions

Share:

Share on facebook
Facebook
Share on twitter
Twitter
Share on pinterest
Pinterest
Share on linkedin
LinkedIn
Dr. Selva

Dr. Selva

Dr S. Selva (Sevellaraja Supermaniam) is a Consultant Obstetrician and Gynaecologist and a subspecialist in Reproductive Medicine at a private hospital in Melaka, Malaysia. He heads the O&G unit and the IVF Centre at the hospital.

More About Dr. Selva

Leave a Comment

Your email address will not be published.

Related Posts

Copyrights © 2022 Selva’s Fertility, Obsterics & Gynaecology Clinic. All Rights Reserved.