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PMDC — RIP

With the devolution of healthcare to the provinces, PMDC is no longer capable of performing all the functions it is supposed to

PMDC — RIP

Pakistan Medical and Dental Council (PMDC) is in what former United States President George H W Bush might have called deep doo doo. Recently it has been placed under ‘retired’ martial law. The reasons for such a drastic action was of course the commonest given reason for such things in Pakistan: corruption. The important question at this time is whether the PMDC should be fixed with a more restricted mandate or should it just be abolished. My personal opinion is that after health as an issue was devolved to the provinces; there is no need for a central organisation with such a large mandate. I have given below the functions and duties of the PMDC as taken from their website.

Functions and duties of PM&DC:

For uniform application across Pakistan, PM&DC has been given a mandate to:

— prescribe a uniform minimum standard of courses of training for obtaining graduate and post graduate medical and dental qualifications.

— prescribe minimum requirements for the content and duration of graduate and post graduate medical and dental courses of study.

— prescribe the conditions for admission of courses of training as aforesaid.

— prescribe minimum qualification and experience required of teachers for appointment in medical and dental institutions.

— prescribe the standards of examinations, methods of conducting the examinations.

— prescribe the qualifications, and experience required of examiners for professional examinations.

— Register Faculty and Students of Medical & Dental Institutions.

— Maintains the Register of Medical & Dental Practitioners.

— Inspect and formulate recommendations regarding recognition of Medical & Dental Institutions for training of undergraduate & postgraduate qualification.

— Inspect undergraduate & postgraduate examination for standardisation.

— Decide cases against registered practitioners for infamous conduct and professional negligence.

— Inspect and approve of Hospitals for House Job.

— Prescribe guidelines for Medical & Dental Journals.

— Issue experience certificates to faculty

— Set up of schemes of reciprocity with other countries and medical regulatory authorities.

If we look at all the functions ascribed to the PMDC above, other than number one and ten, all other functions can and probably should be devolved to provincial medical and dental councils. Clearly there is a need for national standards for medical education and training. Besides the devolution of healthcare to the provinces there are other important reasons why PMDC is no longer capable of performing all the functions it is supposed to.

First, we should realise that the PMDC was set up in its existing form at a time when there were barely six or seven medical and dental colleges in all of Pakistan and there were no ‘private’ medical colleges at all. Today, the city of Lahore alone probably has more than 20 public and private medical and dental colleges, and the number easily approaches a hundred if we consider the entire country. Besides the colleges and medical universities, we also have a large number of teaching hospitals that are also within the ambit of PMDC regulations and inspection. The number of post graduate teaching positions has also mushroomed tremendously. Here I want to iterate that we definitely need supervision as well as oversight over all these situations but in my opinion, the PMDC sitting in Islamabad is clearly not capable of performing all these functions by itself.

One of the recent initiatives taken by the now ‘defunct’ PMDC was to ask for evidence of continuous medical education (CME) from medical practitioners before renewal of registration. The fact that the ‘new’ PMDC management has cancelled this requirement is sad to say the least. Whether it was politically motivated or not is an important question. CME is one of the primary requirements for recertification or relicensing by all modern healthcare systems. In my previous articles in this newspaper, I have often stressed the importance of CME to assure adequate medical care. If getting rid of the CME requirement for re-registration of physicians and dentists is how the new and improved PMDC is supposed to work then that does not auger well for the future of medical practice in Pakistan.

As far as registration of medical faculties including private medical colleges, and students as well as practicing physicians is concerned, this again is clearly a provincial matter. After all it is the provinces that are responsible for determining the number of physicians and dentists that they need to fill available positions in the private as well as the public sector hospitals and rural healthcare centers. More importantly, for many public institutions in the provinces interference from Islamabad might be considered as politically motivated. For an Islamabad based organisation to take any form of ‘disciplinary’ action against a major teaching hospital or medical university in Sindh might be opposed and even rejected for political reasons.

About disciplining errant physicians, the PMDC has no punitive authority besides cancelling a physician or a dentist’s registration. In a country where thousands of untrained individuals practice medicine without caring about the PMDC, and where many regular physicians continue to practice even when their registrations with the PMDC have expired, making it the PMDC’s responsibility to discipline medical malpractice is at best impractical. I have also written in the past that what assures a relatively proper medical environment is enforceable legal requirements for a minimally accepted level of care at a local level. This has to be fortified by a legal system that allows patients to sue medical practitioners that have performed inadequately or caused harm to their patients.

The Punjab Healthcare Commission (PHC) has taken over many of the PMDC functions in terms of licensing medical facilities especially outside the ‘teaching hospital’ environment. However, the PHC is not a government run organisation and such does not have the sort of punitive capabilities that are needed to assure proper medical care and punish malpractice or fraudulent practitioners. Most importantly the PHC has little power to influence teaching hospitals. PHC is a good initiative but it does need to be strengthened. And it does provide an interesting and viable alternative to the PMDC function of inspection of hospitals and assuring some action against medical malpractice.

Licensing of medical practitioners after their initial registration with the PMDC should be a provincial function. As a matter of fact it might even be devolved further down to the divisional level to assure that all practicing physicians and dentists in a particular geographical area are actually licensed to practice medicine or dentistry. This perhaps is one of the areas where the PMDC is least effective. And yes, CME must be a part of the recertification process.

University based post graduate training as well as ‘house physician’ training should remain the responsibility of the medical institution providing such training. However, most post graduate medical training in Pakistan has now been taken over by the College of Physician and Surgeons of Pakistan (CPSP). It is the CPSP’s responsibility to oversee medical and dental training programmes and to then conduct appropriate membership and fellowship examinations. The PMDC should have no role in this. As said above, the PMDC should only be restricted to number one and ten of its functions. Anything more than that is inappropriate. Concerning corruption, for that we in Pakistan badly need an effective vaccine.

Syed Mansoor Hussain

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The author has served as Professor and Chairman, Department of Cardiac Surgery, King Edward Medical University.

One comment

  • While I support a larger role of the College of Physicians and surgeons in post graduate education as recommended by the senior surgeon but the suggestion of breaking PMDC into provincial and even district level organization and his suggestion of virtually little third party control on house job quality is totally frightening and a recipe for disintegration of a once effective central organization recognized abroad. Breaking of PMDC will create many problems for overseas Pakistani doctors.

    There was a time there were provincial medical councils like say Punjab medical council but at that time there was a unified commonwealth medical register as well.

    CME is usually not primarily a medical council function but that of local deaneries under Royal colleges in the UK. Besides PMDC conducted CME were not specialty assessments as they should have been. As a common practice , as doctors become senior they tend to do certain pet but fewer procedures and do them well, there is no point in offering and testing them in generalities or knowledges which they might not apply again.

    One apprehension is however shared by me with the author is that PMDC did not function effectively for some time.

    The basic unsolved problem in PMDC is that even now there is no balance envisaged between provinces or between different groups of doctors , i.e firstly executive committee is not according to either respective provincial doctors strength or else according to their national population quota on one hand and all provinces are strangely represented evenly, second issue is that though the the new system is not well announced but seems to tilt heavily in favour of medical college associated doctors which is not good as backbone of health care is GP and private medical specialist.

    Is PMDC, in this interim period of post presidential ordinance and before its elections in competent hands is another question raised by the author indirectly ? but here my view is that interim executive committee membership is too small and narrow based and not even people from all subspecialities are adequately represented for advanced thinking.

    PMDC should remain as federal structure and watch undergraduate education, house jobs , and main doctor’s register and recognize overseas and local post graduate degrees and training . But For overseas and local post graduate degree recognition CPSP advise should be binding on PMDC . CPSP and PMDC decisions should be challengeable in the proposed newly created Medical ombudsman court which should act a supreme court of medical matters in the country .

    I see no merit in either the amendments which have splintered medical profession or in the demand for provincial councils. Solution lies is strong centralized PMDC and strong CPSP manned by local and overseas qualified experts and creation of medical ombudsman office.

    Dr.Mansoor Elahi
    General and Geriatric medical specialist and author of books on medical law and medical diagnosis.

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