Healthcare Quality is defined as the "highest standards of healthcare and patient safety". Patient care and patient safety should be the focal points of quality improvement in any health care system. The purpose of the healthcare professional licensure process in any system is to ensure that individuals have the required education, training, credentials and experience to obtain a license that allows them to practice their designated profession within that country.

There are a large number of specialty career paths in medicine - with over 50 career options available, a doctor is assured of finding a suitable career. The options include becoming a surgeon, a general practitioner, a geneticist, a psychiatrist, a medical lecturer at medical school, a medical researcher, or a public health physician, to name a few. On successful completion of postgraduate training in a chosen speciality one becomes a consultant or a GP principal. Whilst these are viewed as career pinnacles, all doctors are expected to continually demonstrate their fitness to practice medicine, and so learning continues throughout a doctor's career. Competence, integrity, confidentiality, caring, compassion, commitment, and responsibility remain to be the core values of a doctor irrespective of being a generalist or specialist.1

Due to rapidly growing medical specialities and variable training structures worldwide licensing authorities in many countries are producing guidelines, requirements and restrictions for individual professionals to provide documentation of appropriate recognized qualification and training.

A formal structured training programme for the postgraduate specialization has been well known for United States and many European countries. In the past, the postgraduate qualification was the most important criterion considered for a doctor to be a specialist in many countries like UK and Pakistan. Recent changes in the training programme in UK and Ireland has made post graduate medical education more structured and focusing on the training along with post graduate qualifying exam from the specialist royal colleges.
Postgraduate Medical Education and Training Board is an independent body set up in 2003 to supervise postgraduate medical education and training in the UK. It ultimately replaced the Specialist Training Authority [STA] and Joint Committee for Postgraduate Training in General Practice [JCPTGP]. It defines a " specialist qualification" as a diploma, certificate, accreditation, or other written evidence of success in a programme or programmes of postgraduate education or training in any medical specialty including general practice. This shall have been awarded by an approved university, college, training body or institute as a result of success in an examination or formal assessment against defined standards For the purpose of interpretation of this definition, 'approved' shall mean recognised by the official system in the jurisdiction where the qualification was awarded 2

By definition "specialist training" means medical training that comprises of theoretical and practical instructions in a post specifically designated as a training post, it should take place in a university centre, a teaching hospital or other health establishment, should be supervised by an appropriate authority or other body; and involves the personal participation of the person training to be a specialist in the activity and in the responsibilities of the establishment concerned.

Hence the role of different authorities responsible to provide a specialist qualification and specialist training is absolutely important in making and recognising of a specialist.

A "specialist" is a doctor who has completed his/her training and requires no further training or supervision to practice independently in the discipline of his/her choice. Specialists may hold posts such as General Medical Service's principals, consultants in public hospitals or other independent practice posts.3

Many developed countries have an established system of maintaining specialist registers. In these countries doctors cannot work as a specialist unless their name is on specialist register. This list is available for public access, which makes it transparent and receives public's confidence on the medical council of the respective country.4

In UK and Ireland a specialist is one whose name is in the specialist register of the respected medical councils. Thus a consultant or a professor may be a specialist but a specialist does not necessarily be a consultant or professor. However, there are other names that have been evolving in medical profession throughout the world are "super-specialist", "sub-specialist" and "generalist specialist". For example, a paediatrician could be a generalist paediatrician, but he could obtain more specialized training in paediatric gastroenterology and be called a paediatric gastroenterologist. His knowledge and skills of paediatric nephrology might not be as good as paediatric nephrologists and both are super-specialist.

There is always a need of independent statutory body that should be responsible to establish standards and requirements for postgraduate medical education and training for all specialities including general practice. The role of this body should be independent of the medical council and should incorporate the entire postgraduate training authorities with an equal recognition of both public and private postgraduate medical institutions. This body, which can be like PMETB of U K, will make sure that all the set standards are met. The medical council should be an implementing authority rather than a setting authority.

The requirements for the speciality medical license can not be same as for general medical practice, hence there is increasing need to maintain a register of specialist.

Pakistan Medical and Dental Council is the Regulating Authority for Health Professionals of Pakistan. Without PMDC registration, no Health Professional is allowed to practice. The certificates by the training authorities, colleges and universities in the country and certificates of foreign specialist qualifications are considered by the PMDC before these doctors are registered as specialist. Until May 2006, there are 101803 doctors registered with PMDC with their primary qualification as MBBS (Male: 61982, Female: 39821) and 18242 doctors as specialist (Male: 14509, Female: 3733).5

Neither the list of registered medical practioners or specialists nor the rules and regulations for the recognition of a specialist are available openly to public or on the website. Therefore, public cannot have any access to a minimum information about a doctor whether he is qualified not to mention about any doctor's claim to be a specialist. Maintaining a register of qualified doctors and specialists and keeping it open for public would not only help public' confidence on PMDC but also build council's power and authority.

Since the development of private medical colleges in early eighties and falling standard of medical colleges in public sector in Pakistan there is a growing concern on the performance of PMDC as a regulatory body. As it has been previously suggested that governance is a serious issue in the health care system in Pakistan there is a desperate need of an authority that can maintain the standard of medical education and postgraduate training.6

An autonomous body should have the representation from the public and private postgraduate training institution. This body should be responsible for the accreditation of the postgraduate training achieved in Pakistan and abroad. After a thorough scrutiny of the training and experience, recommendation should be forwarded to the medical council for their registration.

Specialist registration is the best assurance to the public of the ability of a doctor to practise without supervision. In Pakistan there is no strict governance on the "general" medical register and about 600,000 non-qualified practioners are flourishing in the system, providing their "services" to the masses in a "cost effective" manner.

It is high time when Pakistan Medical Council should seriously consider the establishment of specialists' register. It will be a nightmare when it will come to choosing members for the board when majority of the doctors are not specialists trained in accordance with the rules set by authority like PMETB. We will have to consider setting our own rules to meet the local demand and considering the constraint of level of governance exist in general in the country. When it comes to an agreement, will it open tussle and debates between doctors, department of health and PMDC as these three bodies are to date not unified on any issue pertaining to eventual population welfare. Shall we involve public who is the ultimate receiver to make a decision? Should we demand our parliamentarians to make legislation to develop a specialist register and standardize the health care system? Are we too ambitious in asking for the best level of care for our patient population or do we have to wage war?

1. Becoming a doctor: Entry in 2006. www.bma.org.uk. Date accessed: 25th June, 2006.

2. Postgraduate Medical Education Training Board, www.pmetb.org.uk. Date accessed: 24th June, 2006.

3. Medical Council, Ireland. 2006. www.medicalcouncil.ie Date accessed: 24th June, 2006.

4. General Medical Council; 2006. http://www.gmc-uk.org/doctors/how_to_ register/registration/specialist.

5. Pakistan Medical and Dental Council, Statistics, May 2006. www. pmdc.org.pk

6. Shiwani M H. Clinical governance in Pakistan: myth or reality? J Pak Med Assoc. 2006; 56: 94-5.