Postgraduate Medical Education Regulations 2023: A Critical Review

Introduction

The National Medical Commission (NMC) Gazette notified the “Postgraduate Medical Education Regulations, 2023” (PGMER-23) on December 29, 2023, which were released on the NMC website on January 4, 2024.[1] These regulations are going to replace the PGMER-2020, first time released on October 7, 2000, and amended up to May 2018.[2] Thus, new regulations for postgraduate medical training in India have been released after a gap of 23 years. For the last 3–4 years, the system has been made to run through an ad hoc mechanism of releasing circulars every now and then. During the intervening period, from May 2018 (the time when PGMER-2000 was last amended) to September 25, 2020 (the time when the NMC was established), most notifications were published for the addition of qualification as a prior requirement for different super-specialty courses. However, some major decisions were also taken by the Board of Governors in the Supersession of the Medical Council of India during this intervening period, thus bringing about a paradigm shift in postgraduate medical training in India [Box 1].

Box 1.

Major decisions taken by the Board of Governors in the Supersession of the Medical Council of India

Issuing Gazette notification to provide 5% reservation for the candidates with benchmark disabilities in accordance with the provisions of the Rights of Persons with Disabilities Act, 2016[3]

Issuing Gazette notification to redefine the teacher-to-student ratio for various postgraduate and super-specialty courses in government and nongovernment institutes[4]

Issuing Gazette notification for mandatory training in online research methodology courses for postgraduate students[5]

Issuing Gazette notification for mandatory training of postgraduate students at the district hospital for 3 months as DRP[6]

DRP: District residency program

As one can well gauge from Box 1, these decisions scripted some of the defining moments in the history of postgraduate medical training in India. Since the inception of the NMC, many advisories and public notices have been issued. Most of these were related to providing relaxation to different postgraduate batches in qualification criteria for final university examinations in the form of – relaxation in presenting paper or poster, thesis submission date or committed sample size in thesis synopsis, online research methodology course, or relaxation in the criteria for appointment of external examiners, in the wake of prevalent COVID conditions.

Draft Regulations – Chronology

After the setting up of the NMC on September 25, 2020, the release of such a consolidated document in the form of PGMER-23 was much awaited, particularly when the draft of PGMER had been placed in the public domain for scrutiny, comments, and feedback of the public on more than one occasion. A brief chronology of the issuing of drafts of PGMER and related notices from September 2020 onward is depicted in Box 2.

Box 2.

Chronology of issuing of drafts of the Postgraduate Medical Education Regulations and related notices

The first draft was posted on the NMC website as “Draft Postgraduate Medical Education Regulations, 2021” on July 29, 2021, and comments were asked on this draft from the general public till August 30, 2021[7,8]

Another document, with few changes marked in red font, was posted on the NMC website on October 5, 2021, as the “Postgraduate Medical Education Regulations, 2021.”[9] This document was peculiar in the sense that the word “draft” was not used anywhere in the title of this document (thus giving an impression as if these are PGMER-2021), but the word “draft” was present in the whole document as “watermark.” However, no notice was issued asking for comments of the general public on this document

After a gap of 2 years, the third draft in the form of the “Postgraduate Medical Education Regulations, 2023” was released on September 6, 2023, asking for comments of the general public within 10 days of publication of the draft (till September 16, 2023).[10] The last date for seeking comments was further extended to October 5, 2023[11]

NMC: National Medical Commission; PGMER-2023: Postgraduate Medical Education Regulations, 2023

As is evident from Box 2, a huge amount of labor, efforts, and time has been put-in for accurate drafting, and finally, to notify such a mammoth document, as per the aspirations of different stakeholders. The NMC and particularly, the Postgraduate Medical Education Board (PGMEB) deserve thunderous applause for the same.

Amendments

Whenever new regulations are notified, all stakeholders, including students, faculty, and administrators, are curious to know the changes being implemented through the new regulations. In the following sections, major changes in the chapter of ‘postgraduate training’ as cited in the PGMER-23 compared to PGMER-2000 have been discussed.

Recognition of New Programs

For the first time, the existence of Postdoctoral Certificate Courses (PDCC) and Postdoctoral Fellowship (PDF) courses has been accepted, and the duration of such courses has been documented. Furthermore, in Annexure-4 of the PGMER-23, the list of recognized PDCCs has been mentioned; however, Annexure-5, which was supposed to delineate the list of recognized PDF qualifications has been left blank. Moreover, the document is silent about the ways and means by which a super-specialist can seek admission in PDCC and PDF courses, although the admission procedure for broad-specialty and super-specialty has been documented in detail. Hopefully, more details, including the procedure and requirements, to start PDCC and PDF courses by medical institutes, will be notified in the near future.

Recognition of Mental Health of Postgraduate Students

It is heartening to note that the ongoing debate over the mental health of postgraduate students has been recognized by the NMC and the same has been reflected in the form of acceptance of reasonable working hours in a day for postgraduate students. Although the working hours have not been fixed, it has been very clearly expressed in the PGMER-23 that the postgraduate students will work for reasonable working hours and will be provided a reasonable time for rest in a day.

Academic Cell

In PGMER-2000, there was a provision for the establishment of an academic cell or curriculum committee (CC) in an institute, so as to implement the training program across all specialties. The same CC constituted for the undergraduate course under the curriculum implementation support program was doubling up the role for postgraduate courses also, in most of the institutes. Now, in PGMER-23, setting up of an academic cell has been made mandatory.

E-logbooks

Logbooks have been used historically for maintaining records and proof of learning/training in postgraduate training. PGMER-2000 mandated the use of logbooks which needed to be checked by the faculty members imparting the training (not fixed) periodically (periodicity not defined). However, PGMER-23 has mandated to maintain a dynamic e-logbook by PG students, which should be updated on a weekly basis and must be assessed and authenticated on a monthly basis by the PG guide imparting the training. Fixing the responsibility of guides to assess the logbooks and fixing the periodicity of such assessments are welcome steps, and at the same time, the introduction of dynamic e-logbooks is going to revolutionize PG medical training in this digital era.

Poster Presentation/Paper Presentation/Research Paper

In terms of the Gazette Notification dated December 9, 2009, clause 13.9 A was added in PGMER-2000, thus requiring a PG student to present one poster, to read one paper at a national/state conference, and to present one research paper that should be published/accepted for publication/sent for publication during the period of training, to be eligible for final university examination. This means that a student has to do three research-cum-publications-oriented activities. It is a known fact that PG students mostly conduct one research-related activity – their PG thesis work, and in most of the cases, thesis work gets completed only 8–9 months before final examinations, and it is only after the completion of thesis work that students use to present posters/papers. Now, presenting the same research work as a poster and a research paper at a state/national conference (even if on different occasions) looks preposterous. Moreover, expecting a PG student to write a thesis, present a poster, present a paper, and send a paper to a journal during the last 7–8 months of the training program is like asking for a moon. Accordingly, under prevalent conditions, this whole exercise is undertaken as an eyewash, without contributing substantially to the scientific evidence. In the recently released PGMER-23, these requirements have been marked as below:

A postgraduate student of a degree course in broad specialty/super-specialty will do at least one of the following to make him/her eligible to appear in his/her final examination:

1. Poster presentation at a national/zonal/state conference of his/her specialty

2. Podium presentation at a national/zonal/state conference of his/her specialty

3. Have one research paper published/accepted for publication in the journal of his/her specialty as the first author.

These changes will have both pros and cons. It will be advantageous for PG students as they will now need to undertake any one of the three activities – either present a poster or a paper at a conference or publish a paper in a journal, and not all three activities. Moreover, now, PG students will be designated as the “first author” in the paper originating from their own research work and will not be at the mercy of the supervisor for the same. However, PG students have to present a paper or poster now in the conference of their own specialty. Furthermore, the research paper needs to be at least accepted for publication in the journal of their specialty. This will be a bit tricky – finding a specialty journal for so many PG students across India from one specialty will be difficult. However, at the same time, this condition is not mandatory now, and this will also enforce students and supervisors to undertake good thesis research to get the paper accepted in the specialty journal.

New Courses/Changes in Existing Courses

In addition to the ongoing “Online Course on Research Methodology” and “District Residency Program,” now, PG students are required to complete a “Course in Ethics,” including “Good Clinical Practices” and “Good Laboratory Practices” (whichever relevant), and a course in “Basic Cardiac Life Support (BCLS)” and “Advanced Cardiac Life Support (ACLS)” skills. These new courses will be conducted by the institutions, and students need to complete them during the 1^st year of training.

In the original guidelines published for the “District Residency Program” in September 2020,[10] it was the responsibility of the “Board of Governors in Supersession of Medical Council of India” to develop a transparent electronic platform to facilitate and ensure rule-based placement of PG residents to various institutions under the District Residency Program. However, in the PGMER-23,[1] no such responsibility has been owned by the NMC. Though the PGMER-23 talks about tracking the attendance and performance of District Residents by the District Residency Program Coordinator (DRPC) of the district concerned, as well as the parent Medical College through an appropriate electronic/digital or mobile-enabled system and making such monitoring systems accessible to the State/Union Territory Steering Committee and the National Coordination Cell. Moreover, it will now be mandatory for all medical institutions to submit the DRP posting details of the students to PGMEB of the NMC within 1 week of completion of the DRP. This is, again, a welcome step as it will ensure accountability and quality maintenance. However, the document is silent about the course of action to be followed in case the duty performed during DRP is marked as unsatisfactory by the DRPC – remedial measures, repeat posting, or extension of tenure – nothing is mentioned in the document.

Leaves Rules and Attendance Criteria

In PGMER-2000, no fixed number of leaves for PG students was defined. It was documented to be as per the concerned state/union territory rules and regulations. In PGMER-23, the leave period has been fixed. Now, PG students will be entitled to 20 paid casual leaves per year, five paid academic leaves per year, and one weekly holiday, along with maternity/paternity leaves as per existing government rules. This translates to the effect that every PG student is entitled to a minimum of 77 leaves/holidays in a year. Tenure is to be extended by the same number of days in case the leaves availed are in excess of the above-permitted number of leave days. Going by the wording of the document, it means that the period of training will not be extended, even if maternity/paternity leave is availed, as these are permitted leaves. In many states, maternity leave is for 6 months and can be availed for two times. Now, in a hypothetical situation, female PG students can avail 1 year of leave (over and above 77 leaves/holidays per year) without any extension in the tenure! A clarification from the NMC is certainly required. It is worth mentioning here that as per the “NMC (Compulsory Rotating Medical Internship) Regulations, 2021,” female intern students are also entitled to maternity leave as per prevailing government rules; however, in those regulations, it is specifically mentioned that the internship shall be extended if the leave of absence of any kind exceeds beyond permissible 15 days of leave (casual leaves to be specific).[12] It means that for female interns, availing any maternity leave will extend the tenure, but not for PG students.

PGMER-2000 very vaguely defined the attendance criteria. It was stipulated that PG residents shall attend not <80% of the imparted training during each academic term of 6 months. However, PGMER-23 very specifically mentioned that even in case of an extension of tenure by some days, a student shall be allowed to appear in the examination if he/she has 80% of the attendance. This means that now, cumulative attendance in the full course will be considered and not the attendance in every 6-month term. Hence, if a student avails more leaves in one term, it can be compensated by 100% attendance in the next term, and again, such a clause is beneficial for the students. However, one query will need explanation – for calculating 80% attendance, what will be the denominator used - if it will be total days of tenure of 3 years (365 × 3 = 1095 days) or days after deducting permitted leaves and holidays (77 × 3 = 231 days), that is 864 days (1095–231 = 864 days)? If total tenure is counted as a denominator, then permissible leaves and holidays of 231 days will result in attendance of <80%, rendering a student ineligible to appear in the final year examination. If a denominator of 864 days is considered, it will mean that a student will become eligible to appear in the PG final examination after attending around a total of 690 days of training (average 230 days per year). Hopefully, the NMC will issue an explanation shortly.

Role of Universities

A new chapter – Role of Universities – has been added to the PGMER. The universities, along with the medical institutes under them, have been asked to join hands with the NMC to implement appropriate curriculum, encourage self-directed learning, maintain proper records, and make efforts to maximize the use of digital technology for conducting examinations and issuance of Degrees/Diploma and other certificates in digital mode.

Examination and Evaluation Rules

Now, there can be a maximum gap of 8 months between two postgraduate final university examinations compared to 6 months as per 2000 regulations. The minimum gap of 4 months between two examinations remains the same. Although the number of examiners for the examination is the same as earlier, i.e. four – two internals and two externals, now, only one external examiner is required to be out of state. The criteria for the appointment of postgraduate examiners have also been changed. Now, to be appointed as an examiner (both internal and external), a faculty member must possess 3 years of experience as a recognized Postgraduate Guide in the concerned subject. This is in contrast to the PGMER-2000, where the internal examiner needed 3 years of experience as a PG teacher, while the external examiner needed 6 years of experience as a PG teacher. There are two changes – one, for external examiners, the criteria have been changed from 6 to 3 months; second, for both examiners, the criteria have been changed from PG teacher to PG guide. This means that even if one is a recognized PG teacher for 3 years as the PG course in the concerned department is being conducted for the last 3–4 years, but he/she is not having PG guide experience of 3 years (may be less number of PG students in the department/unit, so no PG student allotted), he/she cannot be appointed as a PG examiner (both internal and external). Hence, universities will need to be more vigilant in asking for the experience of potential external examiners, and the external examiner list will be required to be updated by the universities.

It will be interesting to check here the difference between the requirements to become a PG teacher and a PG guide. As per regulations prevalent at the time of the MCI and the Board of Governors, like – ”Minimum Qualifications for Teachers in Medical Institutions (Amendment) Regulations, 2018” and “Minimum Qualifications for Teachers in Medical Institutions (Amendment) Regulations, 2019,” a teacher used to be recognized as PG teacher with 8 years of total experience, out of which minimum 4 years should have been as an Assistant Professor.[13,14] Now, PG guide qualification has been defined, and a teacher can become a PG guide only after 5 years of experience as an Assistant Professor or above, as per the “Teachers Eligibility Qualifications in Medical Institutions, Regulations, 2022.”[15] As per the recently released “Minimum Standard of Requirements for Postgraduate Courses 2023 (PGMSR-2023),” if an Assistant Professor fulfills all the requirements of the PG Guide as per the teachers’ eligibility criteria, he may be allotted one PG student.[16] Hence, now, an Assistant Professor can become a PG guide and, subsequently PG examiner.

As per the PGMER-23, the theory examination (both formative and summative) may be of descriptive answer of a question type, multiple choice question (MCQ) type, or a mix of both types. This literally means that full theory paper(s) can be MCQ type. This is in stark contrast to the PGMER-2000, by which MCQ was not allowed in the postgraduate examinations. Furthermore, the first and the fourth papers have been fixed on basic medical science and recent advances, respectively.

Transparent guidelines have been issued for the evaluation of answer sheets and nothing has been left to ambiguity, as per the PGMER-23. All the answer scripts shall be evaluated by two examiners and the average of the total marks awarded by the two valuators for the paper, rounded off to the nearest whole number, shall be considered for computation of the results. If the difference between the two valuations is 15% and more of the total marks prescribed for the paper, it shall be subjected to a third valuation. The average of the best two total marks, awarded by the three evaluators for the paper, rounded off to the nearest integer (whole number), shall be considered for the final computation of the results. No revaluation is permitted once the result has been declared. All the universities imparting postgraduate courses have been asked to implement digital valuation. For the first time, 20 marks (to be added in the clinical/practical examination) have been assigned to the thesis. An external examiner from outside the state will evaluate the thesis, conduct thesis viva, and allocate marks based on the quality of the thesis and the performance of the student on its viva voce.

Requirements for Appearing in Final University Examination

Considering the PGMER-23, a PG student will need to fulfill the following requirements, to be eligible for final university examinations:

1. Minimum 80% attendance

2. Certification in “Online Course on Research Methodology”

3. Certification in “Course in Ethics,” including “Good Clinical Practices” and “Good Laboratory Practices” (whichever is relevant)

4. Certification in courses on “BCLS” and “ACLS” skills

5. Certification of satisfactory completion of the “District Residency Program”

6. Thesis submitted to the University for evaluation, 6 months before the examinations

7. Thesis acceptance as per norms

8. Any one of these research publication activities – either poster presentation or podium paper presentation in a concerned specialty conference or paper publication/acceptance in a concerned specialty journal as the first author

9. Any other course/requirement as mandated by the institute.

What Else Could Have Been Added?

As is evident from the above discussion, the PGMER-23 document has been released after much deliberation and discussion. However, a few more points could have been added or explained, as briefed in Box 3.

Box 3.

A few areas requiring clarification/addition in the Postgraduate Medical Education Regulations-2023

The PGMER-23 are applicable from the date of its Gazette Notification, i.e., December 29, 2023; however, many criteria like – certification in the “Course on Ethics” or certification on BCLS and ACLS skills – cannot be applied for current batches. A footnote could have been added for all such rules, indicating that these will be applicable from admission batch 2023 only (please check special note at the end of this editorial)

What will happen in case of unsatisfactory completion of DRP – consequences and action there-off could have been explained in no uncertain terms

Due consideration could have been given to internal assessment by making it a qualifying criterion for the final university examination (say a minimum of 50% internal assessment mandatory to appear in the final university examination)

As per teachers’ eligibility qualification in vogue, in the departments of anatomy, physiology, and biochemistry, nonmedical graduates having M.Sc. (relevant medical) and PhD qualifications, granted by the recognized medical college/institute as a regular on-campus course in the subject concerned, can be appointed as assistant professors. Moreover, for holders of MD – PhD in medical subjects, the period spent during a PhD is now considered equivalent to a senior residency period, making them eligible for direct appointment as assistant professors in the concerned subject[15] Under these circumstances, it would have been better if M.Sc. and PhD courses in medical colleges had been brought under the purview of NMC (as has been done for PDCC and PDF courses)

DRP: District residency program; NMC: National Medical Commission; BCLS: Basic cardiac life support; PDCC: Postdoctoral certificate courses; PDF: Postdoctoral fellowship; ACLS: Advanced cardiac life support

Wrapping Up

It is reiterated that the PGMER-23 have come into force from the date of their publication in the official gazette, i.e., December 29, 2023, and with the Gazette notification of the “PGMER-23,” the “Postgraduate Medical Education Regulations, 2000,” and “The Opening of a New or Higher Course of Study or Training (including Postgraduate Course of Study or Training) and Increase of Admission Capacity in any course of Study or Training (including a Postgraduate Course of Study or Training) Regulations, 2000,” stand repealed. However, the actions taken before the notification of the PGMER-23 based on the above-mentioned regulations of 2000 shall be protected.

Without a doubt, the PGMER-23 is a consolidated document, reflecting transparency and leaving nothing to ambiguity. Its implementation will definitely improve the standards of postgraduate training with the mandatory introduction of courses in ethics, BCLS, and ACLS, and with continued implementation of online courses in research methodology and DRP. It will also relieve the PG students of the burden of undertaking different research-publication activities in the form of presenting posters and papers and publishing a research paper; now, they can choose any one of these. Fixation of the number of leaves and provision of weekly holidays will definitely prove a step ahead in taking care of PG residents’ mental and physical exhaustion. From the faculty point of view, the experience needed to be appointed as an external examiner has been reduced to 3 years. From the administration point of view, only one external examiner needs to be arranged from outside the state. The introduction of e-logbooks and digital valuation of answer sheets are the steps echoing with the aspirations of the Government of India – for digital India. This document literally has something for everyone. In a nutshell, this document is going to create a tension-free and more productive working environment in all medical institutes for PG medical training.

Special note: During an interactive meet of NMC officials with the Principals and senior faculty members of medical institutes of North India at AIIMS, New Delhi on February 04, 2024; NMC clarified that institutes must train all the postgraduate students of batches 2021 and 2022 also in these required courses. One of the authors personally attended that interactive meet.