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May 2007, Volume 57, Issue 5

Opinion and Debate

Psychiatric training: a comparison between Canada and Pakistan.Is there a common ground?

Sujay Patel  ( University of Newfoundland, Discipline of Psychiatry, St. John's, NL, Canada, A1B 3V6. )
Amin Muhammad  ( Gadit Memorial University of Newfoundland, Discipline of Psychiatry, St. John's, NL, Canada, A1B 3V6. )

Training system in medical sciences is modelled on the base of the British system in Pakistan. Many changes were brought in the British system during the years but Pakistan has not made a headway at a required pace. Among the medical disciplines, psychiatry as discipline has remained in debate for one or other reasons but the aspect of training has not been touched with force and enthusiasm. Of late, Britain has revamped its training structure and requirements and the sad point is the bleak future for Pakistani doctors wishing to access training slots in UK because of the new visa/permit requirements.1 CPSP has made great efforts in bringing the FCPS diploma at par with MRCP in disciplines like general medicine and paediatrics but no success in getting it at par with MRCPsych, even to the extent that full FCPS cannot get exemption from part I of MRCPsych. Having said this, FCPS has importance in article 14 application for entry into specialist register of general medical Council of UK.2 Many developing countries have their own systems of training in psychiatry, for example, training in Malaysia is well respected in the western world and despite low number of psychiatrists and required emphasis on mental health, the progress is visible in terms of its impact. India has a national system for selecting prospective trainees and providing structured training leading to M.S. and D.P.M. Indian trained psychiatrists have done wonderfully well in the western world based on their Indian training and qualifications. In order to assess the ground realities in Pakistan, we need to look at the current scenario in terms of psychiatric training. In Pakistan, an autonomous body with a close liaison of PMDC and the Government of Pakistan regulates the postgraduate education and training in medical profession. This body is the College of Physicians and Surgeons Pakistan (CPSP) with its main office in Karachi and regional offices in almost all the big cities of Pakistan. The college offers Diploma (DCPS) and Fellowship (FCPS) exams in various disciplines of Medicine including Psychiatry. The CPSP is also responsible for accrediting academic and clinical institutes for postgraduate training and education in the various fields of Medicine across the country. The CPSP with the help of subject experts prescribes a training curriculum that is structured, competence-based and time-framed. In addition, it also acts as a resource and guidance center for postgraduate research and continued medical education for health professionals in the form of training workshops and seminars. In the context of opportunities for postgraduation, the College at present is offering only FCPS in Psychiatry and has stopped awarding memberships (MCPS). The FCPS programme is conducted in two steps, Part-I and Part-II. The eligibility for FCPS-I is one-year internship after graduation (with or without an exposure in Psychiatry) and is mainly based on assessment of clinical applications of basic science knowledge relevant to psychiatry. Both the written papers comprise multiple-choice questions of one best type. Those declared successful in FCPS-I undergo at least four years of training in the relevant discipline at CPSP-recognized institutions under the supervision of CPSP-approved supervisors.3

The candidates have to submit a dissertation, before taking the FCPS-II exam. The dissertation has to be written under the supervision of the immediate supervisor. Recently, the College has given a choice to the candidates to publish two research papers as the first or second author in the Journal of the College of Physicians and Surgeons, Pakistan, or in journals listed in the MEDLINE in lieu of submission of dissertation. The college recognizes only a very few institutions for postgraduate training in Psychiatry. Most of these institutions are in public sector with just a few in military and the private sector. The total number of recognized slots for FCPS training is 17 and 12 for DCPS. DCPS is a new exam instead of MCPS, which has been withdrawn. The requirements for DCPS is MBBS, a candidate must have completed one year of recognized training, out of which six months should be in the chosen specialty. Deficiency of house job in chosen specialty is made up by equal period of residency. (i.e. extra six months' postgraduate training). Training Program comprises of two years' structured training in a CPSP accredited training institution under CPSP approved supervisor after registration.3

In order to meet the needs of the country, some institutes have tried to provide postgraduate training opportunities.4. One such endeavor in the public sector is Diploma in Psychological Medicine (DPM) in affiliation with Punjab University; Diploma in Psychiatric Practice (DPP) that is initiated in collaboration with institutes in Egypt and London under the supervision of renowned psychiatrists from Fountain House, Lahore. The DPP is now being withdrawn.

Similarly, the postgraduate education programs are offered by many public sector universities - under their respective Faculty of Medicine - in the form of Doctor of Medicine in Psychiatry (MD Psychiatry). It is a two-year research-based educational program, completed under the supervision of qualified supervisors, and has an extensive examination of academic, clinical and research skills at the end.4

Therefore, despite hopes and assumptions of provision of high quality postgraduate education in Psychiatry, there lingers the question about its feasibility. The existing ground reality of having very few training slots, a large number of trainees, dearth of trained teachers and varying standards of different qualifications make it difficult to get standardized quality training.

Once certified, there is no provision of higher specialist training for a period of at least three years on the pattern of UK with evaluation of practice-based efficiency, infact the UK model is worth adopting.5 There is no trend for CME credit maintenance and hence no programme specifically designed for psychiatrists, though there are many such programmes for the general practitioners of course, with no condition of maintaining credit certification, this is mostly prompted by the pharmaceutical companies with a view of improving sale as evidence has shown that the knowledge of even the most common disorder depression was not adequate among general practitioners.6 It appears that we are still far behind in achieving the required standards and in order to improve the existing scenario, some drastic steps are essential.

Under the circumstances, it is difficult to keep pace with the UK model since many changes are now being made, hence, it is worthwhile exploring the Canadian model which has a flavour of both US and UK systems of training and moreover, it can obviate the need for higher specialty training with its design and structure. A glimpse of Canadian training is being described hereunder:

Psychiatric Training in Canada
Upon the completion of a medical degree (MD), or its equivalent, medical graduates must complete the requirements set by the Royal College of Physicians and Surgeons of Canada (RCPSC) in order to be certified as a psychiatric fellow of the college. These requirements broadly include postgraduate training in an accredited psychiatric "residency" program followed by a passing grade in the RCPSC national board exam in psychiatry.

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Canadian and American medical graduates may pursue one of the 136 positions offered by the sixteen accredited postgraduate psychiatric residency training programs in Canada (Table 1).7 International medical graduates (IMGs) are limited to apply to only 1 of 9 positions but will have the opportunity to vie for positions that may be "left over" from the aforementioned 136 positions.7 Candidates are selected based on fulfilling the necessary requirements as well as by merit.

The Canadian Resident Matching Service (CaRMS) works in close cooperation with medical schools and students to provide an electronic application service and a computer match for interviews and subsequent entry into any of the aforementioned psychiatry programmes.
All psychiatric programmes in Canada are five years in duration, referred to as postgraduate year 1 (PGY-1) to PGY-5. Most psychiatry residents will commence the first day of their training on July 1, and complete it on June 30 of their final year.

Each psychiatric training programme offers postgraduate medical training in hospital and ambulatory settings with direct supervision by more senior physicians. The specific objectives of the training scheme are determined by the RCPSC. Because there is some flexibility in this scheme, the sixteen psychiatry programmes vary slightly.

According to the RCPSC, the purpose of the first year of residency (PGY-1) is to allow the psychiatric resident to further their interactional skills, to provide greater independence in clinical decision making and to consolidate competence in primary clinical and technical skills across a broad range of medical practice.8 Usually, this will involve a period of rotating training that will include internal and family medicine, paediatrics and psychiatry.

PGY-2 and PGY-3 in psychiatry include a one year period in adult general psychiatry (divided equally between inpatient and ambulatory settings), six months of chronic care psychiatry and six months of child and adolescent psychiatry.

PGY-4 in psychiatry requires a one year period of training in a psychiatric subspeciality or other area that is relevant to the objectives of psychiatry.
PGY-5 in psychiatry is an "elective year" where the resident may choose to pursue any medical training of their choice.

Throughout the course of psychiatric residency the RCPSC requires that the resident receives at least two years of adult psychiatry training. Also, the resident should receive two years of one hour weekly supervision in various psychotherapy modalities. Finally, the RCPSC also requires training in geriatrics, consultation liaison and substance abuse disorders.

Interestingly, the RCPSC recently adopted the "CanMEDS" (Canadian Medical Education Directives for Specialists) framework to describe the required competencies that physicians should have for optimal patient care. The CanMEDS framework is organized around seven roles: Medical Expert (the central role), Communicator, Collaborator, Health Advocate, Manager, Scholar and Professional.8 These competencies have been integrated into the RCPSC's accreditation standards, training objectives, in-training evaluation reports (ITERs) and examinations.8

Aside from the aforementioned rotations most programs will have weekly didactic sessions, periodic case presentations, psychotherapy supervision, on-call responsibilities and research supervision.9

Each residency program will have their own mechanism to train and evaluate their residents. There are two formal methods of evaluating residents. One method is via formal ITERs which are completed by a supervisor upon the completion of a specific rotation. Secondly, residents are usually required to pass two long-case psychiatric interviews in their final year. Residents may also be informally evaluated via written or oral exams. Near the completion of residency training, the program director reviews the overall performance of each resident prior to sending a final in-training evaluation report (FITER) to the RCPSC. This report will determine the resident's candidacy for the national psychiatry board exam.

The RCPSC board exam consists of a written and oral component. The written component consists of two three-hour papers which are administered annually at several centers across the country. Paper one is multiple choice consisting of 175 questions. Paper two consists of fifteen short-answer questions. Candidates may expect questions sampling all areas of clinical psychiatry, selected basic science areas, ethics and biostatistics.

The oral component is held annually in one center. This portion of the exam consists of several short clinical encounters dealing with the phenomenology, diagnosis and management (PDM) in psychiatry. These PDM stations are approximately twenty minutes in duration. They may entail questions from watching a video, interpretation of investigations and role playing with other health professionals, patients or family members. The stations are designed to evaluate multiple CanMEDS roles across the life span.

Upon obtaining membership to the RCPSC as a psychiatric fellow, the psychiatrist must fulfil provincial licensing requirements which includes registration in the Canadian Medical Register.10 Registration in the Canadian Medical Register is done via the Medical Council of Canada (MCC). The MCC issues physicians the Licentiate of the Medical Council of Canada (LMCC), which is recognized by the thirteen provincial medical regulatory authorities in Canada, and is one of the requirements for the issuance of a license to practice medicine in any province of Canada.11 In order to be awarded the LMCC and be registered in the Canadian Medical Register one must complete the Qualifying Examination Part I (QE Part I) and the Qualifying Examination Part II (QE Part II) which is administered by the MCC. These are one-day multiple choice questions exams (MCQ) and an objective structured clinical exam (OSCE), respectively. IMGs must also pass the Medical Council of Canada Evaluating Examination (MCCEE), a one-day MCQ exam prior to writing the Qualifying Examinations.

Finally, upon completing residency there are two primary methods in which psychiatrists obtain further training. Firstly, psychiatrists are required to provide evidence of having undertaken at least 250 hours of CME every 5 years.12 This allows psychiatrists to maintain or improve on their existing skills and knowledge. Secondly, psychiatrists have the option to sought higher training in a subspecialty of psychiatry.

Having reviewed post graduate psychiatric training in Pakistan and Canada, one can use the above table (Table 2) which compares each model side by side. This differential picture allows one to understand Pakistan's training dilemmas and provides solutions that are drawn from the Canadian model of psychiatric training. It is apparent from this comparision that Pakistan could adopt the Canadian psychiatric training model with obvious benefits.

Utilizing the blueprint of well-established psychiatric training models, such as the Canadian model, ultimately reflects in a strong training system that yields well-trained psychiatrists, which in turn results in improved mental health within nations.

Rather than comparing psychiatric training models of developing nations with each other, it may be more worthwhile for developing countries to making comparisons with the well-established and advanced psychiatric training models of developed countries such as Canada.

The question now remains whether or not the psychiatric training bodies in Pakistan will have the open-mindedness and foresight to consider the implementation of a Canadian training model. After all, psychiatric training in Canadian has established itself to be amongst the best in the world. Furthermore, the road to transition will be much smoother for Pakistan since Canada has a few common characteristics with the British training model-the same model currently followed in Pakistan.

References

1. Gadit, AM, Dilemma facing IMGs from Pakistan, BMJ Career Focus 2006,333:179.

2. www.pmetb.org.uk "Certification" Postgraduate Medical and Training Board, UK - date accessed: 29/01/2007.

3. www.cpsp.edu.pk "CPSP Training Program" College of Physicians and Surgeons, Pakistan-date accessed: 29/01/2006.

4. Gadit, A., Khalid N, "State of Mental Health in Pakistan - Education, Service and Research", 2002, Ed-1, Corporate Printers, Karachi Pakistan. P: 38-40.

5. Royal College of Psychiatrists. Higher Specialist Training Handbook.1998, review 2001 p: 1-56.

7. www.carms.ca "Main Residency Match" Canadian Residency Matching Services- date accessed: 9/1/2007.

8. www.medical.org "The Royal College News" The Royal College of Physicians and Surgeons of Canada- date accessed:
8/1/2007.

9. www.med.mun.ca/psychiatry "Mission Statement" Memorial University of Newfoundland- date accessed: 15/1/2007.

10. www.nmb.ca "Registration and Licensure" College of Physicians and Surgeons of Newfoundland and Labrador- date accessed: 15/1/2007.

11. www.mcc.ca "Statement of Registration" Medical Council of Canada. Date accessed: 10/1/2007.

12-. www.mainport.org "Continuous Professional Development" The Royal College of Physicians and Surgeons of Canada- date accessed: 29/1/2007.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: