Amin A. Muhammad Gadit ( Memorial University of Newfoundland, Canada. )
There are a number of reports about medical malpractice in Pakistan. Every now and again media would report negligence by doctors leading to deaths or complications. The regulatory bodies elsewhere are now taking the matter of periodic competence assessment of doctors in order to ensure safety of patients. It is high time when Pakistan Medical and Dental Council (PMDC) should take this matter on board. The total number of registered medical practitioners is 119083 and the specialists are 23709, totaling 142, 792 doctors excluding the registered dentists.1
It is largely unknown about the quality of medical practitioners being produced every year since the mushrooming of the medical colleges in the country. The quality of medical training is not being monitored effectively and hence only a small number of doctors appear to have adequate training that reflects in their ultimate practice and they find the way to go to developed countries in order to brighten their academic as well as economic future. For the safety of patients, it is absolutely necessary to monitor the ongoing competence of doctors and to put in perspective a programme for continuous learning and developing skills. This is being done in Pakistan at a very small scale and that too is not a mandatory requirement by the PMDC. One can argue about the existence of the examination system at graduation level and certifying exams by the College of Physicians and Surgeons (CPSP), but would this be sufficient? A number of factors cause the knowledge and skills to decay with the passage of time and there is a likely possibility of harm to the patients. Some examples from developed countries can assist the PMDC and provide a general insight on this serious situation.
The General Medical Council (GMC) of UK has initiated the process for revalidation and recertification of doctors. Once effective, every registered doctor will undergo periodic review and assessment by a variety of methods. The respective Royal Colleges will advice the GMC about the state of recertification of the individual specialists.2
Recently, the Irish Minister has signed a bill related to mandatory assessment of professional competence of doctors in order to ensure safe medical practice. Now for the first time, doctors working in Ireland will be required to participate in Continuous professional Development and demonstrate to the Council that they are maintaining their standards of professional competence in their practice. These schemes would include Continuous Professional Development and Multi-Source Feedback. This will incorporate \'systematic peer review\' and \'clinical audit\' which is a systematic review and evaluation of current practice with reference to research based standards to improve patient care. The Medical Council is in the process of developing an official format and is seeking help from professional postgraduate bodies.3
In the United States, it is not only \'certification\' but \'recertification\' is essential for professional competence. As both these processes are rigorous and now often a requirement for practice, it holds out considerable promise as a methodology for the continued assessment of competence. "Recertification is required every 7-10 years. The recertification procedure encourages the doctors to continue learning and remain updated with medical knowledge in order to safeguard the interests of patients. Most of the boards use a snapshot assessment of knowledge, skills and performance. Witten examinations are in the form of multiple choice questions, some boards also require 50 hours a year of CME in the three years before recertification. Performance is measured by licensure status, recommendation letters from healthcare authorities, CME attendance and independent assessment by peers. There are a number of other methods used by different regulatory boards in the United States for assessment of competence. Generally, four main frames of competence assessment have been identified: 1) achievement tests and simulation, including practice under supervision 2) inference of competence in practice from participation in continuing medical education and training programmess 3) peer reviews of medical records, surveys of coworkers and colleagues about physician\'s communication skills and collaborative practices etc. 4) Assessment of the outcome of doctors\' work that includes patient satisfaction surveys, complaints or malpractice claims data on mortality and morbidity etc."4
The Canadian system is based upon "The CANMEDS Roles Framework" For adequate competence, the physicians are judged against a number of criteria with central feature of being a \'Medical Expert\' along with the qualities of being a \'communicator\', \'professional\', \'scholar\', \'health advocate\', \'manager\' and \'collaborator\'. These seven \'pillars\' are being used to assess competence of doctors by a number of methods and tools. Certification is the essential first step for competence and the maintenance of certification is the second step in order to maintain the competence. MOCOMP is a voluntary continuing education programme by the Royal College of Physicians and Surgeons of Canada to help specialists manage their continuing education themselves.5
The Federation of Medical Regulatory Authorities of Canada (FMRAC) has issued a Position Statement "All licensed physicians in Canada must participate in a recognized revalidation process in which they demonstrate their commitment to continued competent performance in a framework that is fair, relevant, inclusive, transferable and formative. "The Royal College of Physicians and Surgeons of Canada is advocating for the creation of a learning culture characterized by practice reflection, inquiry, peer review and rigorous formative assessments of knowledge (through self-assessment programs), competence (through simulations) and performance (through practice reviews) that reflect the entire spectrum of roles and competencies associated with CanMEDS framework."6
Reverting back to the scenario in Pakistan, there are a number of options that can be adopted. To initiate the process, first of all, the PMDC should publish the names of all the registered practitioners on their website (under review by PMDC) which should have all credentials and specialty status appended and be accessible to the general public. This is the essential step as anybody can check the practitioners\' authenticity with the click of a finger on computer. Introduction of Continuous Professional Development (CPD) programme that can be jointly monitored by the PMDC and CPSP. This should be made mandatory with yearly requirements for x number of hours spent in continuing education. There should be credit points for attending conferences, courses, workshops, reading journals, research and group learning activities. Peer review can be initiated at institutional levels to start with assessment of practice. The matter of re-certification can be considered at some stage by the CPSP or an alternate plan be suggested. Would it not be a step towards improvement of healthcare in Pakistan?
1.Pakistan Medical and Dental Council (PMDC). Statistics. 2010. (Online) (Cited 2010 June 30) Available from URL: http://www.pmdc.org.pk/Statistics/TABID/103/Default.aspx.
2.General Medical Council (GMC). Licensing and Revalidation. 2010 (Online) (Cited 2010 June 30) Available from URL: http://www.gmc-uk.org/doctors/licensing.asp.
3.Medical Council. Professional Competence. 2010. (Online) (Cited 2010 June 30) Available from URL: http://www.medicalcouncil.ie/Professional-development/Professional-Competence/
4.Irish Medical Times. The different hues of professional competence. Muhammad, AA 2010. (Online) (Cited 2010 June 30) Available from URL: http://www.imt.ie/opinion/2010/06/the_different_hues_of_professi.html.
5.Royal College of Physicians and Surgeons of Canada. \'The CanMEDS Physician Competency Framework (Online) (Cited 2008 January 9) Available from URL: http://rcpsc.medical.org/canmeds/index.php.
6.Federation of Medical Regulatory Authorities of Canada (FMRAC). Agreement on National Standards for Medical Registration in Canada, 2009; p: 1-9.(Online) (Cited 2010 July 2) Available from URL: http://www.quadrant.net/cpss/pdf/CPSS_National_Standards.pdf.