Contents

1. The Medical Education System in Pakistan
2. A Personal Observation
3. The Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM-HP)

The Medical Education System of Pakistan

As of February 2008, there are 48 medical colleges in Pakistan recognized by the Pakistan Medical & Dental Council (PM&DC). Of these, 39 are listed in the International Medical Education Directory (IMED) maintained by the Foundation for Advancement of International Medical Education and Research (FAIMER). The remaining eleven recognized medical colleges are pending inclusion in IMED once complete documentation is received by FAIMER.

We will discuss the role of the Pakistan Medical & Dental Council with respect to medical education and licensure in Pakistan. Additionally, we will provide information on the curriculum in the medical schools, including student admission requirements, and the requirements for the Bachelor of Medicine and Bachelor of Surgery medical degree and for a Certificate of Full Registration (license) to practice medicine in Pakistan.

Educational System in Pakistan

The educational system in Pakistan is overseen by the national Ministry of Education. Primary education begins at age 5 and lasts 5 years. Subjects taught include reading, writing, arithmetic, general sciences, social studies, religious studies and physical education.

Secondary education is divided into three stages. The first stage is middle school, which lasts three years, from ages 11-13. At age 14, students enter the second stage, secondary school, choosing a course in either sciences or humanities. Secondary school lasts two years, through age 15. Students may opt instead for vocational-technical education, for either a one-year certificate course or a two-year diploma program. The third stage is higher secondary education, from ages 16 to 18, during which students continue to specialize in either sciences or humanities.

The first level of university higher education is the Bachelor's Pass degree, awarded after a two-year program. The Honor's Bachelor's degree is awarded in arts, humanities, science and commerce after completion of a three-year program. The Bachelor's degree in engineering, pharmacy and computer sciences requires a four-year program, while the Bachelor's degree in medicine, the Bachelor of Medicine & Bachelor of Surgery (MBBS) is a five-year program.

Pakistan Medical and Dental Council (PM&DC)

Medical and dental education in Pakistan is regulated by the Pakistan Medical and Dental Council. The Council was instituted in 1947 by adopting the Indian Medical Council Act 1933. Originally, members of the Council were nominated by the federal government of Pakistan, with recommendations from universities and provincial governments. In 1951, the composition of the Council was changed by the Pakistan Medical Council Act of 1951 to include representatives from medical colleges, registered medical practitioners, provincial health authorities and the Ministry of Health. At that time, three provincial medical councils were also created, in Punjab, Sindh and East Bengal. These provincial councils were disbanded under the provisions of the Pakistan Medical Council Ordinance in 1962. The Ordinance was further revised in 1972, at which time the Council's name was changed to Pakistan Medical and Dental Council, familiarly known as the PM&DC.

The functions of the PM&DC are as follows:

• To set minimum standards for the Bachelor of Medicine, Bachelor of Surgery (MBBS), Master of Science (MS) and Doctor of Medicine (MD) degrees
• To set requirements for qualifications of teachers in medical colleges
• To inspect medical colleges for provisional and full recognition
• To set the Code of Medical Ethics for Registered Medical Practitioners
• To set regulations for formation of new public and private medical colleges

The PM&DC is an autonomous organization, financially independent of the government of Pakistan. The Council is supported by registration and renewal of registration fees, and inspection fees from private medical colleges.

Composition of the Council

The Council consists of one medical member elected by the National Assembly, one medical member from each province, one member of the medical faculty and one member of the dental faculty of each Pakistani university, four registered Medical Practitioners, four members nominated by the Central Government, of whom at least one is a member of the Armed Forces Medical Services, two registered dentists, one member elected by the teaching staff of each recognized medical and dental college from amongst the professors on its staff, and one member belonging to the legal profession. The number of Council members varies, dependant on the number of approved medical colleges.

The President and Vice President are elected by the members of the Council from amongst its members. The Secretary is appointed by the council.

Committees of the PM&DC

The PM&DC is made up of eight committees. These committees are:

The Executive Committee: responsible for administrative and financial matters.

Recognition Committee: evaluates and recognizes degrees not specified in the PM&DC regulations, including degrees awarded outside Pakistan. The committee also evaluates the qualifications of teachers from outside Pakistan for appointment to the faculty of a Pakistani medical college.

Curriculum Committee: meets periodically to determine if the curriculum offered by Pakistani medical colleges is in accordance with current trends.

Disciplinary Committee: initiates action against doctors when complaints of professional negligence or misconduct are filed.

Post-graduate Medical Education Committee: sets standards and requirements for programs of graduate medical education and regulates the system of post-graduate qualifications in various specialties.

Staffing Committee: sets qualifications and requirements for teachers and examiners in medical colleges.

Dental Education Committee: sets standards for dental education, staff and all other functions related to dental education in Pakistan.

Examination Board: conducts biannual examinations for medical graduates from outside Pakistan seeking licensure.

The Secretariat

The Secretariat is an independent body headed by the Secretary and charged with implementing the decisions of the Council and its committees. The Secretariat is made up of six sections:

• Administrative and Council Section: for administrative responsibilities.
• Recognition Section: recognition of qualifications and experience not specified in the PM&DC regulations.
• Registration Section: issues Registration Certificates to medical practitioners.
• Inspection Section: performs inspections of public and private medical schools seeking recognition.
• Computer Section: responsible for computer functions for all sections.
• Accounts Section: deals with accounts and budgets.

Establishment and Recognition of Medical Colleges

Prior to advertising for students, a new medical college must submit a comprehensive feasibility report to the PM&DC and request an inspection visit by the Council. The current criteria for establishment and recognition of both public medical colleges (those administered by the national or provincial government) and private medical colleges was adopted in December 2001.

The criteria are:

• Space: ownership, possession and plan of academic blocks.
• Infrastructure: adequate physical facilities for academic blocks, dissection halls, laboratories, libraries.
• Financial resources: resources should be clearly indicated according to level, size and type of institution, sufficient to not only establish but run a progressive medical college.
• Fulfillment of all legal requirements.
• Organizational structure/faculty: faculty should be employed full-time and fulfill qualification requirements of the PM&DC.
• Transport facilities: adequate transportation facilities for students, teachers and staff, based on location of institution, number of students etc.
• Library: should have sufficient number of books, including latest editions of reference works.
• Attached teaching hospital.
• Affiliation: with a university with an existing medical faculty in the same province as the medical college seeking recognition

Inspection Schedule

New medical schools are inspected by the PM&DC prior to the granting of full or provisional recognition. The Pakistan Medical & Dental Council Inspection Team consists of five to seven members, including two senior professors in basic sciences, five senior professors in medicine, surgery, obstetrics & gynecology, ophthalmology, pediatrics and otorhinolaryngology, and the Secretary of the PM&DC or his representative.

The inspection schedule for new medical schools is:

Visit 1: first Comprehensive Inspection, prior to first admission of students

Visit 2: at the time of the First Professional Examination, at the end of the second academic year

Visit 3: at the beginning of the third academic year

Visit 4: at the time of the Second Professional Examination (at the end of the third academic year)

Visit 5: Comprehensive Inspection, at the beginning of the fourth academic year

Visit 6: at the time of the Third Professional Examination (at the end of the fourth academic year

Visit 7: at the time of the Final Professional Examination (at the end of the fifth academic year)

In addition, the Council conducts surprise inspections. After the final inspection, a medical college is granted either provisional or full recognition.

Provisional recognition is granted for a specified period of time, with conditions set for rectifying deficiencies. The medical college is again inspected after the provisional period to determine if the deficiencies have been corrected.

Fully recognized medical colleges are re-inspected every five years.

The system of recognition/accreditation of the PM&DC had been determined by the National Committee on Foreign Medical Education & Accreditation (NCFMEA) of U.S. Department of Education to be comparable to the standards used to accredit medical schools in the United States.

Admission Requirements to a Medical College

A standardized medical college entry test is required for admission to public sector medical colleges and is conducted by the provincial governments. Medical colleges in the private sector conduct their own entry tests.

The requirements for admission to the public sector medical college entry test are:

Priority 1:
The candidate should have passed the Intermediate Science (F. Sc.) Examination (Medical Group) with at least 60 % aggregate marks, from a Pakistani university or an equivalent examination of a Board of Secondary education in Pakistan or any foreign examination found to be equivalent to the Intermediate Science (F. Sc.) Examination (Medical Group) of a Pakistani university or Board of Secondary Education

Priority 2:
The candidate should have passed a higher examination of a Pakistani university with Biological Sciences provided he/she has passed the Intermediate Science (F. Sc.) Examination (Medical Group) with at least 60 % aggregate marks, from a Pakistani university or an equivalent examination of a Board of Secondary education in Pakistan

A minimum age of 17 and a maximum age of 25

Adequate mental and physical health to obtain medical education and to practice as a general duty doctor

The MBBS curriculum

An optimum admission rate of 100 students per year has been established by the PM&DC. The maximum teacher-student ratio in clinical subjects is 1:5; for basic subjects, the ratio is 1:10. The hospital bed-student ratio of 1:5 should be maintained. If a public medical college has sufficient teacher-student ratio and other facilities, total admissions may be raised to a maximum of 250 per year, but private medical colleges are limited to 100 admissions per year.

A curricular strategy approved by the PM&DC should be adopted by each medical college. General guidelines are:

• Students should be able to recognize and manage common health problems and make appropriate referrals. The curriculum should not be overloaded with details about uncommon conditions.


• Lectures should be given less than one third of the time allotted to a subject; more emphasis should be given to tutorials, seminars, workshops, practical work and clinical training, particularly in the final year.


• Clinical training should be conducted in teaching hospitals and at the community level in Primary Health Centers.


• Students should learn to perform simple basic clinical procedures required in all disciplines.


• The duration of the MBBS course is five years, followed by a one-year pre-registration house job. The house job should be six months in medicine and allied specialties, and six months in surgery and allied specialties. The academic session should not be less than nine months in one year.


• Integration should be promoted between basic and clinical subjects and between different clinical subjects. Basic scientists and clinicians should take part in teaching both basic and clinical sciences.

Specific guidelines for basic and clinical subjects can be found on the PM&DC website at http://www.pmdc.org.pk/regulation_mbbs.htm.

Examinations

General Information:

The PM&DC mandates regular internal evaluations as part of the education process. The purposes of the evaluations are to give students feedback about their understanding of course materials, to certify that students have successfully completed the training and have achieved the objectives of the educational program and to determine the success of the teaching program.

There are four Professional MBBS Examinations administered during the MBBS course. Students must pass the First Professional MBBS, Part I and Part 2 University Examination in Anatomy, Physiology and Biochemistry before promotion to the 3rd year MBBS class. A student who does not pass the First Professional MBBS Part I and Part II in three chances, or who does not sit for an examination for which he/she is eligible is not permitted to continue the MBBS course.

A minimum of three academic years must pass between the dates of passing the First Professional MBBS Examination and the final Professional MBBS examination. The final MBBS examination may not be taken before completion of the fifth academic year.

The Professional MBBS Examinations:

The First Professional MBBS Examination, Part I is held at the end of the first year. The examination consists of one paper and a practical and oral examination in each of the following subjects: Anatomy & Histology, Physiology and Biochemistry.

The First Professional MBBS Examination, Part II is held at the end of the second year. The examination consists of one paper and a practical and oral examination in each of the following subjects: Anatomy & Histology, Physiology and Biochemistry.

The Second Professional MBBS Examination is held at the end of the third year. The examination consists of one paper and a practical and oral examination in each of the following subjects: Pharmacology & Therapeutics, Pathology General & Microbiology and Forensic Medicine.

Clinical skills are taught and evaluated in the third year. The method of evaluation is determined by the individual medical college.

The Third Professional MBBS Examination is held at the end of the fourth year. The examination consists of one paper and a practical and oral examination in each of the following subjects: Community Medicine and Special Pathology.

The Final Professional MBBS Examination is held at the end of the fifth year, after completion of the entire MBBS course. The examination consists of two papers and a practical and oral examination in Medicine, including Psychiatry and Dermatology, Surgery, including Orthopedics and Anesthesia and Obstetrics & Gynecology, and one paper and a practical and oral examination in Pediatrics, including Neonatology, Otorhinolaryngology and Ophthalmology.

Medical Education Credentials Awarded

After completion of the medical curriculum and all parts of the Professional Examinations, the Bachelor of Medicine, Bachelor of Surgery (MBBS) degree is awarded by the affiliated university. Graduates must then complete a one-year house job to qualify for the Certificate of Full Registration to practice medicine in Pakistan. The house job consists of six months training in medicine and allied disciplines and six months training in surgery and allied disciplines.

The Bachelor of Medicine, Bachelor of Surgery (MBBS) diploma is the medical diploma that ECFMG requires graduates of medical schools in Pakistan to submit for the purpose of ECFMG certification and is the diploma that ECFMG must verify directly with the medical school.

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Sources
Pakistan Medical & Dental Council website (www.pmdc.org.pk)
ECFMG medical education credentials reference library
World Education News and Reviews, November/December 2007

A Personal Observation by Stephen S. Seeling, JD, Vice President for Operations, ECFMG

The disciplinary hearing was chaired by a lay person who happened to be an attorney. The other committee members were a diverse group of physicians and non-physicians, men and women, older and younger. Each of the committee members had stacks of medical records. There was a table for the accused physician and one for the complainant. Several of the accused were represented by counsel. In each of the cases, there were tough questions asked by committee members, often citing specific entries in the medical record.

A typical disciplinary hearing taking place in Harrisburg or Raleigh? No. I am describing a hearing before the Pakistan Medical and Dental Council. I was visiting a number of medical schools in Pakistan and meeting with their students/graduates in December 2006 when I received a telephone call from the Executive Secretary of the Pakistan Medical and Dental Council. He invited me to observe hearings before the Disciplinary Committee of the Pakistan Medical and Dental Council. Having served in a previous life as both a prosecutor and Executive Director of a licensing board in the U.S., I jumped at the opportunity.

Frankly, I had no idea what to expect but came away very impressed with both the rigor and fairness of the disciplinary proceedings that I witnessed in Islamabad. In each case, the accused was given notice of the offense and an opportunity to be heard. The Chair conducted the proceedings impeccably, and the committee members actively engaged both the complainant and the accused. Fourteen months later, I still recall an extended exchange between a younger woman physician on the committee and an older male physician which ended with the committee member stating, "I am concerned about your professionalism." Several of the hearings involved quality of care cases; one of the accused happened to be a physician trained in the U.S. who had obtained Board certification here.

If I had closed my eyes and ignored the occasional lapse into Urdu, this could have been a disciplinary hearing in Raleigh or Harrisburg. Instead, it was an impressive display in Islamabad.

The Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM-HP)

Introduction

The 2004 report of the Federation of State Medical Boards (FSMB) Special Committee on the Evaluation of Undergraduate Medical Education contained a recommendation that,

"The FSMB should monitor closely efforts underway in various quarters to establish approval or accreditation mechanisms for international medical schools and provide support for these initiatives if appropriate.[1]"

One of these “accreditation mechanisms” is the Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM-HP). CAAM-HP was established in 2004 as an independent regional accreditation authority for medical education programs located in countries that are members of the Caribbean Community (CARICOM)[2]. CARICOM is a political and economic affiliation of 15 member states, and includes most English speaking islands and some Central and South American nations. Member countries are Antigua & Barbuda, The Bahamas, Barbados, Belize, Dominica, Grenada, Guyana, Haiti, Jamaica, Montserrat, Saint Lucia, Saint Kitts & Nevis, Saint Vincent & The Grenadines, Suriname and Trinidad & Tobago. Associate members of CARICOM include Anguilla, Bermuda, British Virgin Islands, Cayman Islands, and Turks & Caicos Islands.

Background

Fifty years ago there were only a small number of medical schools in the Caribbean region, including the University of the West Indies (UWI) in Jamaica, then part of the University of London. The following decades saw a slow but steady increase in the creation of medical education institutions in the region. The growth rate has increased more recently, with almost 20 new institutions opening their doors since the year 2000 [3]. This increase in the number of medical schools in the Caribbean region is expected to continue. The University of Medicine and Health Sciences, St. Kitts, has announced its medical school will open in May 2008 [4]. Currently there are more than 60 medical schools listed in the International Medical Education Directory (IMED) in the region, of which approximately half are located in countries under the jurisdiction of the CAAM-HP.

In the past, oversight of the educational quality of medical programs in the Caribbean region was conducted by various organizations, depending on the country and the affiliations of the medical school programs. Until recently, the UWI and its associated campuses in Jamaica, Barbados and Trinidad and Tobago were accredited by the General Medical Council (GMC) in the United Kingdom. As of 2003, the European Union requirements dictated that the UK comply with new regulations regarding academic and professional training programs. In fulfillment of these policies, the GMC sent notice of its intention to abolish the concept of accrediting overseas institutions. This change meant that the GMC would no longer have a role in accreditation of medical education programs located outside of the UK, including those of the UWI. This left a void in organizations qualified to evaluate medical training programs in the region. Consequently, on the initiative of UWI and with backing and collaboration from the member states of CARICOM, CAAM-HP was established in 2004 to fulfill this need.

CAAM- HP Accreditation Process

The CAAM-HP accreditation system is based on the Liaison Committee for Medical Education (LCME) model and functions with a clear authoritative mandate, independent of governments and institutions. The system is transparent, uses preset specific standards, external reviewers and procedures which involve self-evaluation and site visits. The objectives of CAAM-HP are to establish and maintain standards of excellence, to establish an efficient system of regulation in relation to the standards and quality and to secure international recognition for, and maintain confidence in the quality of medical and other health professions training offered in the region.

To date, CAAM-HP has carried out six site visits, three to established medical schools and three to proposed schools. The established medical schools evaluated are those at UWI and its affiliated campuses, the University of Guyana and St. George's University, Grenada. The UWI's MB BS program has been accredited for the period 2006 -2010. St .George's University has been accorded provisional accreditation for its MD education program for the period September 2007-2009. A decision on the University of Guyana's medical education program is pending.

The proposed medical schools visited by the CAAM-HP are the University of Science, Arts and Technology, Montserrat, which was denied provisional accreditation, St. James School of Medicine in Anguilla and the British International University in Montserrat, both of which received provisional accreditation.

As part of CAAM-HP's mission to enhance and strengthen the organization's ability to provide a fair and meaningful system of medical education oversight, partnerships with other international authorities are forged. The World Federation for Medical Education (WFME) is the global organization concerned with education and training of medical doctors[5]. WFME's general goal is to strive for the highest scientific and ethical standards in medical education, taking initiatives with respect to new methods, new tools and management of medical education. WFME and the World Health Organization (WHO) have entered into a Strategic Partnership to assist in the support and development of accreditation systems, such as CAAM-HP.

May 2007 CAAM-HP - WFME Conference

In May 2007, CAAM-HP and WFME hosted the Invitational Conference on Accreditation of Medical Education Programs in the Caribbean in Jamaica. The purpose of the conference was to present and disseminate information regarding CAAM-HP and its activities to a global audience.

Conference participants represented a large number of countries, not only in the Caribbean, but also in North and South America and Europe. Government ministers and officials of CARICOM and several Caribbean nations spoke to the participants. Other presenters included officials of the CAAM-HP, WFME, the Pan American Health Organization, Educational Commission for Foreign Medical Graduates, Medical Council of Canada, General Medical Council, and the Federation of State Medical Boards of the U.S. [6]

The conference was well received, with participants examining the value of accreditation processes and expressing support for the activities of CAAM-HP. This forum presented a unique opportunity for participants from outside the Caribbean to learn about various perspectives and enhance their understanding of the complexity of the issues in the region. The conference stimulated an increased recognition of the value of accreditation for schools in the Caribbean, and in turn, improved quality of medical education across the region.

The WFME partnership provides support, enhances credibility, and gives international exposure for developing organizations such as CAAM-HP. The conference also stimulated thought and discussion from additional interested parties on how they could collaborate with or act as a resource to CAAM-HP in helping it meet its objectives. It was also noted that CAAM-HP can serve as a model for other regional initiatives.

Additional Resources

Overview and Status of the Caribbean Accreditation Authority for Education in Medicine and Other Health Professions,
http://www.caam-hp.org/conference/caam_overview_and_status.pdf

Gift, S., Leo-Rhynie, E., & Moniquette, J. Quality Assurance of Transnational Education in the English-speaking Caribbean (2006). Quality in Higher Education, Vol. 12, No. 2, pp. 125-133.

Bassaw, B. & Pitt-Miller, P. Modernizing Medical Education: Perspectives from a Developing Country (2007). West Indian Medical Journal, Vol. 56, No. 1: pp. 80-85.

Karle, H. Global Standards and Accreditation in Medical Education: A View from the WFME (2006). Academic Medicine, Vol. 81, No. 12/December 2006 Supplement, pp. S43-S48.

1) Report of the Special Committee on the Evaluation of Undergraduate Medical Education, 2006, available at http://www.fsmb.org/grpol_policydocs.html

2) Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM-HP) website http://www.caam-hp.org

3) International Medical Education Directory (IMED), http://imed.ecfmg.org/

4) University of Medicine and Health Sciences, St. Kitts, website http://www.umhs-sk.org/

5) World Federation for Medical Education (WFME), http://www.wfme.org

6) Proceedings of the Invitational Conference on Accreditation of Medical Education Programmers in the Caribbean. Information on the conference, including transcripts of presentations and photos, can be found on the CAAM-HP website at http://www.caam-hp.org/conference/conference0507.html