There is a ‘supply’ of hundreds of doctors every year, and there is a need to revisit the whole problem (of pre-reg training) in greater depth and width so as to find a long term solution instead of proceeding piecemeal
The issue of an examination for pre-registration trainee doctors has recently been drawn into the public domain, and mostly people do not have a clear idea of what it is all about. In fact, even in the medical profession there has been confusion about it, for the simple reason that once doctors begin to practise this takes priority and medical education is no longer on their radar.
In fact, medical education is an entirely separate field in itself, requiring different modes of thinking and skills than those needed for medical practice. So anything pertaining to medical education then becomes a matter of state policy, which is articulated through the appropriate institutions geared for the purpose, such as universities, medical colleges, professional bodies or institutes such as the Royal Colleges in the UK, and so on. There is also a national regulatory body (which is usually a medical council) for the specific purpose of the licensing of doctors for practice.
Thus, the examination for pre-registration trainee doctors has been of concern off and on at the Medical Council of Mauritius (MCM) and at the government level. The idea and rationale for the examination has developed in leaps and bounds over the course of several years, and not at all coherently, given that there is no specific body dealing with medical education in the country in all its aspects. There has therefore never been any serious, focused thinking in this regard with participation of all stakeholders.
Nevertheless, given that the issue has gone public, I attempt here to throw some light on it for the benefit of the public at large and those directly concerned as well, since at various stages and levels I have been involved with both medical education and the regulatory and policy aspects too. In so doing, however, I will indicate the sequences and trends in the sector rather than the precise chronology of the changes that have been taking place.
Some history and context
A little bit of history will help to appreciate what has been happening. The Medical Council Bill was presented to the Parliament in August 1967, but was not enacted: this had to await 1989, after several amendments were brought to the original Bill. Until the setting up of the MCM all Mauritian doctors had to register with the Supreme Court after completing their practical training, usually of one year’s duration. This could be undertaken either where they had done their medical studies – which was the case for those coming from the UK and countries following the UK pattern of studies and training (e.g. India and Pakistan) and France; or in Mauritius, which was mainly for those graduating in the Soviet Union and East European countries.
During his year of practical training, the newly-qualified doctor is known by different names in different countries: houseman in the UK, intern in the US and India, pre-registration doctor or simply pre-reg in Mauritius which I will call ‘trainee’ in the rest of the article.
An important point to appreciate is that the MCM is based essentially on the model of the General Medical Council (GMC) of the UK. At the time that the MCM was established, the duration of houseman training there was still one year, which it had more or less been since the inception of the GMC in 1858. The idea of such training was to prepare the doctor for independent practice as a ‘general practitioner’, serving patients in a community setting. However, this training was mandatory even for those who went on to specialize.
The houseman was to undergo his practical training in two major specialties, namely general medicine and either general surgery or gynaecology/obstetrics. With the advent of the National Health Service after the Second World War and the increasing complexity of medicine along with its expansion into specialties, the houseman had to undergo further ‘vocational training’ totalling four years (including the one-year housemanship) and then sit for an examination held by the Royal College of General Practitioners.
If he was successful, he then became a Member of the College (MRCGP), following which he was registered to practise as a general practitioner, also known in some countries as ‘family doctor’ or ‘primary care physician’. The sanctioning by an examination and obtaining a qualification raised general practice medicine to the status of specialty. For the record, it may be noted that only one Mauritian doctor ever obtained the MRCGP, but he was not given specialist status in Mauritius.
For some time now the UK has replaced the houseman year by two foundation years, FY1 and FY2, after which the doctor is registered to practise, and has also to undergo the further training and sit for the MRCGP.
A very important point to note is that the houseman or intern training is done in a teaching hospital, where there is rigorous supervision by the seniors, and participation in a night duty roster. Further, there are regular daily teaching rounds by the Registrar who is training to become a specialist, in addition to twice-weekly (at a minimum) teaching ‘grand rounds’ by the Consultant. At the end of the year, there is no examination, but the houseman is given a ‘certificate of completion’ by the teaching hospital which is to be submitted to the medical council for the purpose of registration.
The situation elsewhere, including Mauritius
Countries which followed the UK model, such as India and Pakistan, have continued with the one-year ‘rotatory internship’ i.e. the intern rotating or changing over to different specialties. In India, it is three months each of general medicine, general surgery, gynae/obs., one month of Public Health or Community Medicine, two weeks each in Ophthalmology, ENT, Radiology and some other ‘minor’ specialty e.g. skin.
Locally, we have followed the Indian model, but some time after the setting up of MCM this became two years, the rotation then covering more specialties, and more recently the two years were reduced to 18 months.
Whereas in the beginning one could count the number of trainees in one regional hospital on the fingers of one hand, what has happened down the years is that their numbers have swelled so that there can be up to ten trainees in one department. Further, they have graduated from over 30 different countries, and in many of them done their studies in the local language.
Our regional hospitals were not prepared for this surge both as regards infrastructure (especially accommodation during night-duties) nor in terms of teaching as our public health system is essentially a service-provider and not a teaching structure – which refers not only to physical infrastructure but to the pedagogical component too, that is, specialists interested in or trained to teach, which also meant having the time to do so what with outpatient consultations running into the hundreds and wards overflowing with patients. Plus, of course, the other aspects such as incentives and the technical support structures for such teaching and training.
The trainees were pretty much left to themselves, and had to assume a degree of self-responsibility for their training – by being diligent, punctual, seeking out the specialists interested in teaching them, following up patients and being inquisitive and focused, and revisiting their textbooks as well as reading new material and journals.
In due course, the MCM required that they fill up a log book after their passage in each specialty. The consultant of the respective specialty would then clear the trainee by assigning a qualitative grade, satisfactory, good, etc., after an oral evaluation of the trainee in the same hospital where he worked by the consultant he had ‘trained’ under.
There was criticism of this system by a number of trainees, who felt that there was unfairness and bias. Repeated allegations led to the institution of an alternative method of assessing them: conducting the oral evaluation in only five major specialties, namely general medicine, general surgery, orthopaedics, paediatrics and gynae/obs. Since there were five regional hospitals, each hospital would be ‘responsible’ for one of the specialties, and the evaluation would be held twice a year at about 6-months interval. The evaluating panel would consist of five consultants, one from each regional hospital, and this would thus tackle the issue of bias. Further, the trainee could take the evaluation in more than one specialty if he had completed the postings in those specialties before the due date for evaluation. That would allow him to concentrate on the remaining ones, and thus give him a greater chance to succeed.
Those who did not make it would be asked to repeat the posting, without stipend, for a period to be determined by the panel.
The idea of doing the evaluation after the training was that those who had not studied in English would then have had time to catch up by using the well-known English texts available. They would get familiar with the names of medications prescribed locally and familiarize themselves with the local medical and health procedures and the working environment.
Shortly, though, there were rumbles about this mode of evaluation too, which had by then shifted out of the regional hospitals to the Mauritius Institute of Health at Pamplemousses (which was used merely as a convenient venue), both on the part of trainees and the consultants doing the evaluation.
After discussions between the two major stakeholders, the Medical Council and the Ministry of Health, it was decided that an exit exam would be a better alternative for the same reason as above, that is, being fair to those who had not studied in English, etc. Additionally, they faced a major constraint (lack of coaching facilities) compared to countries which did a screening at entry, that is before undergoing pre-reg training, and that was only for their citizens who had graduated outside their country. Thus, in the case of India, such graduates attend coaching classes which are well organized, and are taught by academicians over a period of several weeks before they sit for the exam, an MCQ (multiple-choice questions) paper. Such coaching is inexistent locally. Following a technical recommendation, a decision was taken to conduct the local examination using MCQs as well.
Unfortunately, the setting of the paper and the organization of the examination was entrusted to a foreign (Indian) entity instead of to the MIH as also recommended, as the latter institution has been involved in organizing and conducting examinations in the medical, paramedical and allied medical fields at certificate, diploma and post-graduate levels for nearly three decades. The problem with foreigners setting the paper is that they do not know the local context, and many of the MCQs reflect the problems of their country e.g. leprosy, which have hardly any relevance for Mauritius.
In our context therefore, to be fair to the trainees, it would be better to hold an exit exam, that is, at the end of their training of 18 months, using MCQs, and organized and conducted by the MIH with help from the MES if needed. It is not rocket science to have a bank of MCQs prepared with local expertise by people who would factor in the local specificities in terms of epidemiology, pathologies and management of medical problems.
Moreover, the whole structure of pre-reg training has to be looked into, as without this the trainees will continue to be adrift. For parents who would have begged and borrowed to give an opportunity to their children, this will indeed be a tragedy. There is a serious challenge to be met here, and the country must be well prepared to face it if we don’t want to add further to the already long list of social problems that we have.
This is a simplified overview of the important issue of pre-reg training which, however, underlines the major dimensions of the problem. There is a ‘supply’ of hundreds of doctors every year, and there is a need to revisit the whole problem (of pre-reg training) in greater depth and width so as to find a long term solution instead of proceeding piecemeal as we have been doing so far.