“Steps by the PMC will revamp the healthcare delivery system of Pakistan.”
Dr. Arshad Taqi, an anaesthesiologist has been at the helm of the Pakistan Medical Commission since the regulatory health body’s establishment in October 2019. As president of the Pakistan Medical Commission, he oversees the organization’s role in regulating healthcare education in the country.
A graduate of the Allama Iqbal Medical College and a Fellow of the College of Physicians and Surgeons (FCPS) in Anaesthesiology, Dr. Taqi also has contributed to critical care and teaching training as a founding member of the faculty of critical care medicine. He specializes in preoperative care, developing comprehensive aesthetic plans, and administering anaesthetics. During the course of his career that spans over four decades, he has been instrumental in training new graduates and creating opportunities for learning for consultants in the field of anaesthesia in Pakistan.
He is a member of the Faculty of Critical Care Medicine, College of Physicians and Surgeons Pakistan. As the Course Director for CEEA (Committee for European Education in Anaesthesiology), Dr. Taqi is running the programme for continuing medical education for anaesthesiologists. He has conducted supervisor training workshops as a member of the faculty of Health Professional Education, College of Physicians and Surgeon Pakistan.
Dr. Taqi is also the course director for BASIC ICU courses in Lahore, In collaboration with Health Services Academy, these courses were conducted throughout the country to train and certify more than 5000 doctors and nurses in managing critically ill patients during the 2020 COVID-19 epidemic.
Following are the edited excerpts of a recent conversation BR Research had with Dr. Taqi:
BR Research: Let us begin with why the Pakistan Medical and Dental Council (PMDC) was dissolved, and why the Pakistan Medical Commission (PMC) was formed. Can you walk us through the mandate and objectives of PMC?
Dr. Arshad Taqi: PMDC was formed in 1962 under a philosophy that the people of the profession shall regulate the profession. That’s the way a lot of organizations are being regulated in various parts of the world. Under PMDC were six to seven medical colleges with a small number of students and faculty.
Over the years, two major changes have taken place. First is the exponential increase in the number of institutions delivering the service and the healthcare needs. Second is the way in which learning is taking place and the way in which healthcare services are being delivered all over the world. Initially, healthcare was mostly in the public sector. Public hospitals like Civil Hospital were where the big specialists were, and most of the people would go to the family physicians. The concept of specialist did not really exist. But times have changed; healthcare has become a lot more specialized, and a lot more expensive in the process, and so have the challenges. It is not limited to diagnosing and treating diseases. There are economic challenges and societal challenges. This has changed the way we need to think about healthcare and its impact on society. The way it needs to be taught and the way it has to be delivered has changed.
Moreover, the need to have more doctors gave rise to a number of institutions in the private sector. The First Amendment in 1962 encouraged the formation of private-sector medical colleges that caused an exponential growth in the number of dental and medical colleges. In 2014 the government introduced an ordinance to bring an amendment into the PMDC 1962 Act, and try to regulate this profession. A footnote by the then health minister on the amendment said that the regulation of healthcare has gone into the hands of people who are not keeping the interests of the public in mind; so the profession needs to be regulated.
In 2020 this law brought the major fundamental shift from a regulator that was previously regulated by the people of the profession to a more hybrid fashion wherein an executive committee was formed, and the state had taken over to regulate the profession with its own appointed structure. The structure consists of a 9 member council: three lay members and five members from the profession. Of the nine members, two are ex officio. Others are three doctors, one dental surgeon, and three members from the civic society. This is also the kind of arrangement that happens all over the world and society becomes one of the major stakeholders.
The other component of the PMC is the academic board. There are three main tasks assigned in the law. The first is to grant a practising license to all the practitioners that specify their area of expertise. The second is to regulate medical education through forming standards of both undergraduate and postgraduate medical education and the curriculum. Note that education is actually delivered in the colleges which are under the degree-awarding universities; the latter is part of the Higher Education Commission. Once the student gets a degree then they come to PMC for a license for which they have to sit for a central licensing exam.
The third task is recognition of a foreign undergraduate, that is, to equate and recognize the various qualifications that are obtained from other countries to ensure they are of the same or a better standard.
Then there is the executive part which is the medical authority. It is a seven-member medical authority that executes all the decisions of the council. These are people on a contract while the council and the academic board are all honorary positions.
BRR: One of the policies states the introduction of computer-based testing. While it is a brilliant idea, there is a lot of resistance by the students and other bodies. There are also reservations about the MDCAT. How are you resolving it?
AT: Initially the criteria for entry into medical colleges was the marks scored in FSc. But with time, the various boards started competing with each other by awarding higher marks to get more of their students into the medical colleges. To tackle this, the government decided to hold a standardized entry test. The first and second years of introduction of the MDCAT was mayhem but due to the lack of media platforms back then, the news did not spread as much. After that, the provinces held their own exams, but what happened instead was that a lot of preparatory academies popped as the universities that held these exams had a limited question bank. With time the academies started getting hold of these questions, and only prepared the students for those; this defied the purpose of gauging the student’s capacity, hence the decision for a central admission test was taken.
After forming PMC in early October 2020, the test was held in November. To ensure transparency, a carbon copy of the exam was given to the students, and the exam key was later revealed to the students so they could check their own papers. But once they enter the medical college, nearly half of the scores are based on vivas, and one cannot possibly have a recording of it. They appeared for the tests again and went through three months of protest, litigation, and law courts. Each time, we were able to prove the transparency of the test to the courts.
Coming to computer-based testing, computer-based testing will give you the kind of data that you require in your system. Firstly, it's important to realize that this is not FSc. We are selecting students who can enter into a medical college and it is an extensive course. But we did not make an immediate shift; we gradually made the shift to computer-based which is going to give us information that is quite critical in giving feedback to all the educators. The group at a loss with this is the academies because now they are clueless about the kind of questions that would appear in the exam.
Logistically it was impossible to conduct the test on a single day for logistic reasons. So what we had was this large pool of questions developed by a team of experts who then assigned them a topic and the level of difficulty. Then two different sets of reviewers checked them.
Now when the student comes into an examination hall, he gets a set of tokens. The students pick his/her own token. Because of that random token, he/she is given a tablet with different questions. However, every day students get a test that has the same level of difficulty and the same topics and the same ratio as described in the syllabus. This was bound to have consequences. In the previous years, no matter how many students passed, only 20,000 applicants were going to get admitted.
When you pass too many, you are making way for students who have lower scores yet they get into medical colleges. However, the students who scored higher but did not have the resources could not secure a seat.
Now the ratio between the number of candidates who have passed and the number of seats would be reason enough for the institutions to not give them the freedom to pick students from the bottom of the list.
The case being made is that some of the bright students have failed. But on the other hand, we have to look at all sides of the argument. First thing, we need to find out if any one of the question items were flawed. The results we are declaring are provisional and we have initiated a complete analysis of the entire exam by bringing in experts. If that question had a wrong key, as they claim, then most of the students would have done it wrong. If the question is wrong, the bright student would be getting it wrong. There are various ways to look at it. All over the world, SAT, ECFMG, even the high school exams are computer-based and are using the same tools as we are.
With regards to the National Licensing Examination (NLE), the exam is designed to ensure that the doctor has the capability and knowledge to treat patients and be a safe doctor. A doctor who has the ability to diagnose and treat patients safely and not take any steps that may cause harm to the patients. Furthermore, have the know-how to understand when to refer them to a specialist if the need is.
BRR: How is the standardization that you are trying to achieve, work around the world?
AT: In the US and some parts of Europe it has always been there but several countries are gradually making the shift. For example, India and the UK are shifting to licensing exams in 2023. The objection we are facing is why we are shifting now, and not three years later. Firstly, we had to do what the law says.
Secondly, looking at the various aspects of the exam, we felt this filter needs to be applied now because unless people understand that they are going to have to take a licensing exam, they take it easy. This exam needs to be introduced now; they are gradually phasing it in which makes it easier in the beginning with limited scope and then gradually as universities start aligning their teaching and the doctors (students) begin to understand what is required, then start raising the bar and bring it to the level the top countries are at.
PMC has taken measures to standardise the healthcare education of Pakistan in line with global best practices. The steps being taken today by the Pakistan Medical Commission will revamp the healthcare delivery system of Pakistan and foster an environment in our nation that promotes meritocracy and produces competent, compassionate, and skilled doctors.
BRR: What kind of facilitation are you giving to foreign graduates?
AT: Our only objective is to ensure that our license gets the value that it should. Foreign regulators should be respecting our Pakistani license so they become more competitive. But the challenge is that we have tightened the admission process, and private sector medical education is very expensive. So students move abroad instead. Now some of those programs are very sound and have produced good doctors. But some have started offshore degree programs where the focus is only on preparing them for the licensing exam without having exposure to patient management; whereas students after the first two years are made to work in hospitals and deal with patients directly.