M. H. Shiwani ( Barnsley General Hospital and University of Sheffield, U.K. )
Today medicine and medical education have become a huge business, which is growing very rapidly. The cost of medical care is increasing. The investigation tools and machinery is imported in most developing countries and feasibility of starting a new department runs around the economics of the services provided. The philosophy of the corporate world might not be compatible with the health profession in these countries, whether it is a pathological laboratory or a radiology institution or a fully equipped medical college university hospital. Government spends a meager amount of the budget on health care of the nation in Pakistan. However, it allows and encourages the businessmen and voluntary organizations to run medical facilities, which provides substantive and world-class services. The difference in the quality of health care in public funded hospitals and private hospitals is phenomenal. In this scenario the role of charitable organizations is commendable.
Inequities in access to care, avoidable mortality and poor quality services are recognized even in developed countries like USA.1 Medical errors happen worldwide. Inadequate preoperative work-up, incorrect diagnoses, wrong operations, poor communication, not dealing with the complications at the right time are well-recognized events in developed countries. Who is held responsible for the medical errors and medical liabilities? In developed countries there are systems of compensation after medical errors are in place. There are processes of investigations, assessment of liability and remedy for the complainant. The remedy might include an apology, explanation or award of financial compensation. The system of compensation for medical errors could be complex, slow and costly, both in terms of legal fees and time of clinical staff and can be criticized, even in developed countries.2
Public demands a safe and high quality care, which is their right. Traditionally, this has been addressed by continued medical education, self-assessment, peer review, and credentialing. In our society and culture the poor performers are rejected by the words of mouth.3 There is no system of objective assessment available in the country. There is no league system of the doctors or hospitals to identify the excellent performers. There are no insurance companies who can check and balance the adverse outcome of a physician's wrong practice, as happens in United States. There is no system of incident reporting. The radical reforms in the health care system in United Kingdom after the highly publicized scandal of case of "Harold Shipman" are an example to learn lessons in last few years. This case refers to a single doctor's malpractice and killing of few patients which has resulted in radical reforms in the health care proviso of the country.4 Under the reforms, which builds on "Good Doctors, Safer Patients", doctors will have their skills and competence checked every five years. Doctors who fail the revalidation process will be expected to take further training.5
Who protects the public if they suffer from unsafe or dangerous practices in Pakistan? Apparently medical council in any country is in-between the public and medical professionals. The statutory purpose of the council is to protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine and to ensure that patients have confidence in doctors.6
Accordingly it is the responsibility of the Pakistan Medical and Dental Council to regulate doctors' fitness to practice. The PMDC is a statutory autonomous organization constituted under the Pakistan Medical and Dental Council Ordinance, 1962. The objective is to establish a uniform minimum standard of the basic and higher education in medicine. It's not the prime objective of the Council to ensure good medical practice by the health care professionals. However, there is a Disciplinary Committee. The nominee of the Chief Justice of Pakistan who is generally a Judge or eligible to be a Judge of the High Court heads the Disciplinary Committee. The Committee is responsible to initiate disciplinary action against doctors as and when a complaint is received for professional negligence or misconduct. The Professional experts assist the Legal Member. The complainants and doctors are given full opportunity to present their cases either personally or through a lawyer. Under the Medical and Dental Degrees Ordinance, 1982, the Secretary, PMDC or any person authorized by the Secretary is authorized to file a complaint against any un-authorized medical practitioner. In exercise of the powers conferred under this Ordinance, the Secretary PMDC is authorized in consultation with the various Provincial Government officers, to take cognizance of the offences under the Medical and Dental Degrees Ordinance, 1982 and file a complaint in the court of competent Jurisdiction.7 Medical Council in Pakistan has failed to show any effective influence on the government authorities to take actions against "quacks". The actions taken by PMDC against malpracticing doctors and non-bonafied specialists are not commonly heard compared to the common observation of such practice in the community. It could be because that Council does not receive enough complaints or public has got no confidence in the medical litigation system in the country.
Majority of the doctors would be in favour of self regulation through the council or a similar professional organization. A medical majority and representation from the undergraduate and post graduate medical institutions within the PMDC would promote greater confidence within the medical community for the functioning of the Council. The appropriately qualified and experienced medical professionals, both with local and foreign postgraduate qualifications and experience can assist the Council in fulfilling its obligations.
Majority of the doctors would agree that medical knowledge is growing exponentially. Medical specialities are rapidly increasing and the concept of generalist is evaporating throughout the world. Even the general practioners are developing a special interest to provide a better service to the patients and public. Creating a "specialist's register" and introducing system of appraisal and revalidation is a way forward. Specialist Register will ensure the highest standards of patient safety. It is essential that patients should be able to quickly and easily ascertain the level of training and competence of the doctor treating them.8
In Pakistan, at present, a doctor with a postgraduate qualification is considered as a specialist by the PMDC. The Council has got a postgraduate committee which is responsible to set the standards of postgraduate qualifications. In the last decade, it has become very clear that a postgraduate qualification on its own right does not make a doctor a specialist. Proper recognized training is essential to call a doctor a specialist in developed countries like USA, UK and Ireland. Achieving a complete training and a certificate of completion of training (CCT) or certificate of completion of specialist training (CCST) is not considered sufficient now. In UK, reforms are underway where recertification and revalidation process would be necessary. All these issues are based on the generic standards of Good Medical Practice.9 However, PMDC has got no means or policy to revalidate a doctor's fitness to work in Pakistan. Concept of relicensing and revalidation is far from thoughts.
Not many physicians and hospitals keep track of the outcomes of procedures performed by them and not many health care professionals maintain a portfolio of their CME. There is no formal audit of mistake and adverse outcome of their treatment presented by any government or private institute available to public. Incident reporting in health care system should ideally communicate all information relevant to patient safety. There should be a system in place at each and every hospital locally and also at a large scale, such as that of UK National Patient Safety Agency (www.nspa.nhs.uk), which allows a wider dissemination of lessons learnt and emphasize the need for parallel analysis and development of a solution.10
Generating a new breed of medical workforce in the era of "specialized" and "privatized" health care, which is an effluent and corporate system, we must emphasize professionalism in our undergraduate medical curriculum and maintain the high degree of professional behaviour and good medical practice at post graduate level. The medical and dental professionals, teaching and training institutes and PMDC need to understand the importance of medical professionalism in the "changing" medical practices. The need for the continuous formal assessment of good medical practice and professionalism cannot be emphasized more to be incorporated in the undergraduate and postgraduate curriculum. The training structure in the current climate of health care delivery should adopt the regular in-training assessment of professional behaviour in the country.
PMDC needs to update its policies in the light of recent significant changes all around the world. The undergraduate and postgraduate curricula need to be standardized according to the recent advances in the field of medical education. The council requires ascertaining their supreme authority to implement the newer methods of assessment to be introduced at both undergraduate and postgraduate education levels. The concepts like "Good Medical Practice" and "Good doctor, Safer practice" of General Medical Council of UK should be considered to be adopted and modified according to local needs.4,7 The criterion of eligibility and medical licensing requires updating to make sure that knowledge and skills learnt once have been maintained. The definition of a specialist needs redefining and the recognized experience of the health care professionals should be incorporated in this equation. The information regarding doctors should be made public to earn their confidence. If required, the matter should be taken to the national parliament for an open discussion and wider public involvement, to which the council is accountable.
Our country needs a system which should be compatible with the modern delivery of a safe health care where patients and public can have confidence on the professionals and also on their regulators. The regulators like medical council should ensure that doctors are objectively validated throughout their career and fit to deliver a safe and quality medical care.
A safe and high-quality medical care is a basic human right. The health care professionals should be accountable for its delivery within the available resources. There is a need for a National Quality Assessment and Maintenance of Heath Care Delivery, which should incorporate clinical governance and national health care audit to provide quality health care to the nation.
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6. The GMC's Proposals on Healthcare Professional Regulation. November 2006. GMC.
7. PMDC. http://www.pmdc.org.pk/what_it_is.htm (accessed March 4, 2007).
8. Shiwani M H. Need for the specialist register in Pakistan. JPMA 2006; 56: 564-5.
9.General Medical Council. Good Medical practice.Londn:GMC,2006 www.gmc-uk.org/guidance/good_medical_practice/index.asp (accessed March 5 2007).
10. Vincent C. Incident reporting and patient safety. BMJ 2007; 334:51.