Abstract
Postgraduate Medical Education (PGME) and specialist care made a late beginning in developing countries and has progressed quite slowly, compared to the developed world. Historically, medical graduates in developing countries desiring to pursue PGME had to travel to Western centers to acquire specialist qualifications; and after having spent a significant time period it became difficult for them to return from those settings, resulting in “brain drain” from the developing nations and a loss of national resources. The status of overall medical education in Pakistan was dismal at the time of its independence in 1947. Pakistan inherited only a few undergraduate medical colleges, and none offered any postgraduate qualification. The majority of doctors seeking postgraduate education preferred to go to England and the United States. In this situation, the College of Physicians and Surgeons, Pakistan (CPSP) was established in 1962 as an autonomous corporate body to cater to the needs of PGME and to provide specialists for the health care needs of the country. The college started offering fellowship and membership programs in different fields of medicine and dentistry — a hallmark of the College System of PGME, which focuses primarily upon rigorous clinical training. It has succeeded in achieving high standards in PGME and specialization, making its qualifications at par with the institutions of the developed world. This paper describes the policies and strategies adopted by the College to earn recognition for its qualifications, both within the country and in the international community.
Introduction
The organization of specialist care and postgraduate medical education (PGME) began initially in the developed world as a by-product of the Second World War, which underscored the need for better treatment modalities for surgical and medical ailments. Postgraduate medical institutes and colleges were developed to oversee specialist training and to award postgraduate qualifications after medical students completed their training and passed specialty examinations. PGME and specialist training emerged as two important elements in designing an efficient health care delivery system that provides high quality care.1 On the other hand, many developing countries lagged behind in this field.2 The reputation and high standards of PGME institutions in developed countries not only attracted native graduates but also many others from neighboring nations — mostly the developing countries — for specialization.3 In the recent past, many developing countries have made significant progress in this field of medical education and Pakistan is one such example.
THE STATUS OF MEDICAL EDUCATION IN PAKISTAN WAS DISMAL AT THE TIME OF INDEPENDENCE. PAKISTAN INHERITED ONLY THREE UNDERGRADUATE MEDICAL COLLEGES ... AND NONE OF THEM OFFERED ANY POSTGRADUATE QUALIFICATION.
The status of medical education in Pakistan was dismal at the time of independence. Pakistan inherited only three undergraduate medical colleges at the time of independence and none of them offered any postgraduate qualification.3 The majority of doctors desiring to engage in postgraduate qualification and training preferred to go to England, and later, to the United States. This was harmful, resulting in the loss of trained medical manpower — so called “brain drain” — but also causing a substantial loss to national treasuries.4
The CPSP: Establishment of PGME Institution
The elite of Pakistan's medical profession were not oblivious to the issue and took timely measures to develop an indigenous institution for PGME in the country. The establishment of the College of Physicians and Surgeons of Pakistan (CPSP) was an important step in this direction. The college was established in 1962 through an Act of Parliament, fifteen years after the tumultuous events of Pakistan's independence. In fact, Pakistan was the first among developing countries to establish a high-quality PGME institution, offering membership and fellowship programs in different specialties of medicine and dentistry comparable to those of the developed world.
CPSP Qualifications, Academic Program and Training
The CPSP introduced the academic qualifications of membership (MCPS) and fellowship (FCPS) based on the pattern of the Royal Colleges of the United Kingdom (UK). As an autonomous corporate body, it organized and oversaw the development of an apparatus for introducing “needs based” postgraduate academic programs and a system of governance based on democratic principles and collective wisdom. Financial self-reliance that could keep it free from the clutches of a bureaucratic system was one of the cornerstones that helped ensure its academic autonomy.
The success of CPSP programs has been achieved by the relevance of its programs to the health needs of the country and flexibility in duration of training. The specialist care needs of the country vary with the level of care-delivering facilities. The secondary care hospitals, for example, need specialist coverage that can effectively deal with common and simple ailments, for which CPSP offers two-year MCPS programs. But the tertiary care hospitals require specialists who can manage all sorts of disorders — common or uncommon, simple or complex — and are able to carry out academic work, such as teaching undergraduates and residents and conducting research. The primary — or first fellowship — programs are designed for main specialties with these goals in mind and are of four to five years in duration. The second fellowships are offered in subspecialties and consist of two to three years of training. The roadmap to the award of primary fellowship begins with completion of a one-year mandatory staff position after graduation in Medicine (MBBS) or Dentistry (BDS). A medical/dental graduate desiring to enter into the CPSP residency program has to pass the FCPS Part-I screening examination in one of the relevant groups of 11 allied specialties. Success in the FCPS Part-I examination makes a graduate eligible to undergo residency training in a CPSP-accredited institute under the supervision of approved personnel and to register with the Registration, Training and Monitoring Cell (RTMC) of the college, which oversees the training of the candidate. Following two years of training, the resident becomes eligible to participate in the Intermediate Module (IMM) examination. The seamless training allows the resident to progress to the next phase of training, irrespective of the result of the IMM examination, which, however, must be successfully passed before the FCPS Part-II examination. The successful completion of the entire period of training, completion of research requirements and passing of the FCPS Part-II examination leads to the award of a fellowship diploma by the college (Figure 1).
PAKISTAN WAS THE FIRST AMONG DEVELOPING COUNTRIES TO ESTABLISH A HIGH-QUALITY PGME INSTITUTION, OFFERING MEMBERSHIP AND FELLOWSHIP PROGRAMS IN DIFFERENT SPECIALTIES OF MEDICINE AND DENTISTRY.
Roadmap to FCPS
Currently, the college is offering fellowships in 73 specialties and subspecialties, and memberships in 22 disciplines, including Health Professions Education and Healthcare Systems Management. The extensive network of training is spread all over the country and abroad, comprised of accredited institutions imparting training to large numbers of doctors under thousands of approved supervisors (Table 1).
CPSP Network of Training
Data regarding the number of examinees who have participated in the last five years shows a gradual increase in number of female candidates, as indicated in Table 2.
Male/Female Examinees, 2010–2015
Achievements
The college has, to date, produced more than 16,500 fellows and 8,800 members, thereby providing more than 26,000 specialists for Pakistan. In addition, the college has awarded approximately 150 non-clinical diplomas in the fields of healthcare systems management and health professions education. These numbers account for 90% of the specialist manpower of the country. This large number of specialists is due to the joint efforts of the health care system's various departments, faculties, supervisors, examiners and fellows. In this regard, the Examination Department, which presently conducts 184 examinations every year, deserves a special mention. This number is likely to increase in the future as the number of fellowships and accredited institutions are increasing rapidly.
The college is continuing to make steady progress both in Pakistan and abroad. Although it was difficult to establish an institution of PGME in a developing country, it is even more challenging to maintain its standards. The progress of the college and the credibility that it has earned internationally highlight the vision of its founders and dedication of its fellows, as well as its consistent policies, strategies and efforts to constantly review and update its systems with emerging national needs and international trends.
THE COLLEGE HAS, TO DATE, PRODUCED MORE THAN 16,500 FELLOWS AND 8,800 MEMBERS, THEREBY PROVIDING MORE THAN 26,000 SPECIALISTS FOR PAKISTAN. IN ADDITION, THE COLLEGE HAS AWARDED APPROXIMATELY 150 NON-CLINICAL DIPLOMAS.
CPSP Policies
The college, in its journey spread over 50 years, has adopted policies to:
Provide an indigenous, yet credible system of PGME.
Produce competent and caring specialists.
Strive for continuous quality improvement through exchange of knowledge and expertise with other institutions.
Utilize collective decision-making.
Achieve financial self-reliance.
The Strategies: Accreditation, Monitoring and Standardization
The strategies used for implementing its policies include regulation of the accreditation processes, along with monitoring and standardization of training.5,6 The strategies, however, keep evolving as new challenges and needs emerge, knowledge and skills expand and the programs and experiences grow.6–10
The CPSP council, in consultation with the Specialist Faculties (drawn from all over Pakistan), has developed an elaborate system for regulating accreditation and re-accreditation and defining its standards, processes, instruments, and appeal procedures. This system has been documented in its Guide for Accreditation.
The monitoring of training in such an extensive network is not an easy task. The college has experimented with many methods and has found an e-logbook system very practical and useful. The electronic system allows trainees to enter their work in a timely manner, and supervisors to validate it promptly. It also generates electronic reports on the performances of the trainees and their supervisors.
Standardization is an essential element for guaranteeing uniformity and equity in training and examinations. This is achieved for CPSP training programs through the development of and strict adherence to the criteria for accreditation of programs and supervisors, competency-based training and CPSP competency framework, development of a curriculum for each phase of all fellowship programs, competency charts, and uniformity in induction. In addition, the College regularly conducts workshops for trainees and supervisors. The elements used in standardizing examinations include blue-printing, item banking, uniform examination, multiple assessment tools, guidelines for examiners and rubrics for scoring, panels of examiners, foreign examiners, and post hoc analysis.
The CPSP has developed a competency model centered on patient care, which involves professionalism, pedagogy and advocacy on the part of specialists. It requires integration of knowledge with research, critical thinking, teamwork and communication skills to offer the best possible patient care, as shown in Figure 2.
CPSP Competency Model
Conclusion
In conclusion, the establishment and maintenance of an institute of postgraduate medical education in Pakistan represents a role model for other developing countries to emulate. Its continued success speaks of the vision of its founders, dedication of its fellows and efforts to remain abreast of the latest developments in the field both within the country and internationally.
About the Author
↵Zafar Ullah Chaudhry, FRCS, is President of the College of Physicians and Surgeons, Pakistan and Head of the Surgical Division of National Hospital and Medical Care, Lahore.
- Copyright 2015 Federation of State Medical Boards. All Rights Reserved.
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