Ten years of MRCGP International South Asia: a beacon of excellence

BACKGROUND

South Asia is home to a quarter of the world’s population yet the health outcome indicators for the region are in a poor state. A great majority of patients receive care in private community settings from GPs who have not received postgraduate training in family medicine. Quackery,¹ the practice of unqualified practitioners posing as qualified doctors and treating patients, is still prevalent in the poorer areas of cities and villages.

It has been long recognised that, for a great majority of GPs in the South Asia region (India, Pakistan, Bangladesh, Sri Lanka, and Nepal), there are limited opportunities to gain a postgraduate qualification in their chosen specialty of family medicine/general practice. This lack of progress in training GPs has persisted in these countries in spite of gaining independence from colonial rule almost 70 years ago. Many specialists work as GPs in the evening in the private sector without having any training as a generalist. As a result, many GPs, despite the desire to improve their competencies in general practice, start practising in the community after completion of their undergraduate education without any further enhancement of knowledge and skills.

A BRIEF HISTORY

Iona Heath, ex-President of the Royal College of General Practitioners (RCGP), visited the Aga Khan University (AKU), Karachi, in 1997. As a member of a delegation from the College she carried out a review of AKU’s 3-year family medicine structured-training programme for recognition towards the MRCGP UK exam. While being impressed with the standard of the training programme, she agreed with the trainees that they should be examined in the summative assessment by family physicians only and not the specialists of other specialties, as was the practice at the time.

Following this visit, Dr Heath wrote in this publication — the BJGP — in support of an MRCGP International exam in which the examiners are themselves family physicians and the content of the exam also reflects local epidemiology and context.² The late John Howard and his colleagues at the RCGP were instrumental in driving this idea forward. Similar requests were also made by family physicians and medical institutions from other regions in South Asia.

Aware of the lack of trained family medicine examiners in South Asia and the determination to provide better primary health care to the people of this region, family medicine academics at the AKU in Karachi and representatives of family medicine organisations from across South Asia joined hands and requested guidance from the RCGP in training local examiners to establish the MRCGP[INT] South Asia exam. Several training workshops for local examiners were held in the region and Valerie Wass, other colleagues from the RCGP, and the AKU Faculty of Family Medicine were the academic facilitators, while Garth Manning provided the administrative support for the workshops and exam logistics. Waseem Hameed, appointed by the South Asia Board, took over the administrative responsibilities very competently at a later stage. Initial capacity building took place over 4–5 years and the first exam was held towards the end of 2006.

WHERE ARE WE NOW?

In 2016 the programme completed its 10 years of inception. It has received an overwhelmingly positive response from the GPs as well as residency-trained family physicians from South Asia and the Middle East.

The total number of registered candidates of this programme up until March 2017 was 2994 with 1117 graduates (657 of South Asian origin). The exam is held twice a year and, among all the sites of the MRCGP[INT] exams, it attracts the largest number of candidates.

In the South Asia region, most of the examiners of family medicine postgraduate exams have been trained by the MRCGP[INT] South Asia Programme. Instead of being a competitor to the local family medicine exams, the MRCGP[INT] South Asia programme has helped to enhance the capacity and quality of other exams.

CHALLENGES

Some of the challenges faced by the MRCGP[INT] South Asia Board include:

• a lack of governmental support;

• a lack of recognition of the MRCGP[INT] qualification by most of the licensing bodies in the region;

• political conflicts among some of the member countries;

• sustainability and ensuring candidate numbers; and

• training of local examiners, simulated patients, and confidentiality including security of the exam. Auditing of the quality of performance of the examiners takes place on a regular basis and a conflict-of-interest document is strictly implemented to ensure the confidentiality and security of the exam.

MOVING FORWARD

Among such challenges, the main obstacles are the lack of recognition of the MRCGP[INT] qualification by the regional licensing bodies and the political issues resulting in visa problems, which restricts the free movement of examiners and candidates in two of the larger countries (India and Pakistan).

Challenging resistance from the specialists who have influence with the licensing bodies is a priority and, equally, challenging the lack of awareness among governments and the public on the importance of trained and qualified family physicians for the healthcare system requires continued efforts and commitment. What follows are a few examples of the impact of the exam felt by the candidates:

‘I have always felt disadvantaged as I have had no formal training in general practice; going through this exam has increased my knowledge and skills and I feel more confident.’

‘As my general practice communication skills have improved, my popularity among my patients has increased and this has also led to a financial gain for me.’

‘Previously I used to tell patients what to do. Now I share information.’

‘Although I failed in my OSCE exam several times, the preparation for the OSCE changed my approach to my patients tremendously.’

‘Before appearing in this exam I did not ask patients their ideas, concerns, and expectations about their problems.’

‘I never asked about the impact of the patient’s problem on his life (physically and psychologically).’

‘After attempting this exam I feel the positive impact on my life as a physician, because my attitude towards the patients has changed completely.’

The MRCGP[INT] South Asia Board, the examiners, management, and all the individuals involved in this programme have created a sense of community. They are selflessly motivated by a restless desire to see the improvement of family practice in the South Asia region and look forward to continuing this work in the future.