Postgraduate medical education in South Asia

Undergraduate and postgraduate education increased rapidly in the post-independence era in South Asia—except for Bhutan and the Maldives, which do not have medical schools. Now in India alone, 136 medical schools admit more than 6000 trainees into postgraduate programmes.¹

Satisfaction over the numbers who have completed postgraduate education conceals the challenges facing the region. Specialist training is in the traditional apprenticeship style rather than an appraisal based approach. Selection of assessment tools is not governed by modern educational theory. Some postgraduate examinations rely on outmoded assessments, such as essays and long cases. Training in research, ethical issues, concepts of team work, and management is variable. Standards for accreditation are ill defined and not uniformly applied. Training programmes are rarely subjected to external review or internal quality control. National medical councils, expected to set and maintain standards, have failed to introduce quality assurance measures on a par with the UK's General Medical Council or the Liaison Commission on Medical Education in the United States.

Some countries and institutes, however, have initiatives to meet these challenges. The Postgraduate Institute of Medicine of Sri Lanka and the College of Physicians and Surgeons of Pakistan invite external examiners for their final examinations, mostly from UK royal colleges but also from Australia, India, Singapore, and New Zealand. External examiners also review study programmes, and provide training to local educators. Trainees at the specialist registrar level at the Sri Lankan institute must complete a year of training in an approved centre in the United Kingdom, Australia, New Zealand or Singapore. These measures have helped challenge and maintain standards. In Bangladesh all postgraduate courses at state medical schools are subject to quality control.

India is reaping the benefits of the foresight of leaders such as Pundit Jawaharlal Nehru, who made considerable investments in developing science and technology—after independence—albeit from a meagre budget. Subsequent government policies have ensured that India is studded with centrally supported—and regulated—institutes of postgraduate excellence in medicine, science, and information technology. Bangladesh, India, and Pakistan also boast numerous centres of excellence devoted to single specialties such as cardiovascular disease, endocrinology, ophthalmology, neuroscience, and mental health. What is missing is a system of accreditation for these centres.

In most countries in South Asia, professional colleges and associations supervise a variety of continuing medical education programmes but there is no revalidation process and no system of awarding credits for educational activities. The College of Physicians and Surgeons Pakistan has initiated a dialogue among stakeholders, however, to introduce revalidation, and the Medical Council of India awards grants for such activities.² The Sri Lankan experience is that revalidation is not acceptable to all stakeholders. A plan has emerged to set up a national council and district committees for continuing professional development by January 2005, and a detailed points scheme is being drawn up.³,⁴

Every country in the region has a core of medical academics and specialists with a vision of a better system. A region wide group devoted to improving postgraduate education could drive quality improvement. Professional colleges and associations in the region can play an important part through advocacy and raising debate and awareness about issues relating to postgraduate education. And lastly, policy makers at the highest level such as government ministers must be lobbied to encourage policies that will drive change. Otherwise, any optimism about medical education in the region will remain unfulfilled.