Examination Background

Historical perspective of South Asia

South Asia hosts one quarter of the global population. Yet about half the population lives below the poverty line and has limited access to health care. South Asian countries are faced with a triple burden of diseases: They are faced not only with communicable diseases, such as respiratory infections, malaria, dengue, typhoid fever and tuberculosis but also non- communicable diseases, that include diabetes mellitus and hypertension. This is coupled with increasing incidence of mental health problems.

In the year 2000, 44% of the disease burden in this region was attributed to non-communicable diseases. Also in 2000, more than half of the 16.7 million world deaths from cardiovascular diseases were in developing countries, many of these in South Asia.

The General Practitioners (Family Physicians) of South Asia are the front line of coping with the care of this triple burden of disease in the community. The countries in the region have very few well-established postgraduate qualifications in general practice/family medicine, leading on from a period of vocational training – Nepal has the MD (GP) qualification; Pakistan the FCPS(FM) qualification; and Sri Lanka the MCGP qualification – but the annual numbers of candidates graduating in each country are very small. For the other general practitioners in most countries there is no opportunity to gain any higher qualification in their chosen specialty of family medicine/general practice. As a result, many general practitioners go directly into practice after completion of their undergraduate training without any further education, resulting in substandard health care in the community for the population at large. As yet, there is no government ruling for reaccreditation of doctors or mandatory continuing medical education in most of the countries of the region. The great majority of general practitioners are untrained, but a significant number are interested in improving their knowledge and skills.

Leading Family Medicine representatives from five South Asian countries - Bangladesh, India, Pakistan, Nepal and Sri Lanka - met to discuss the feasibility of establishing a common post-graduate exam, which could be accredited by the Royal College of General Practitioners (RCGP), UK, to drive learning in Family Medicine, supported by a shared syllabus and curriculum in 2003.

Many of the countries in South Asia were enthusiastic about the development of this exam, but no single country had the expertise or the numbers to consider an individual development and submission. However the leading family physicians of the countries recognized that whilst no one country in South Asia could develop MRCGP [INT.] exam (approved by the RCGP) by itself, nevertheless by working together and combining expertise and knowledge, the region could potentially establish an MRCGP [INT.] examination relevant to the context of practice in South Asia.

The group was attracted by the opportunities offered by The Royal College of General Practitioners (RCGP), UK, which has had the vision of developing international exams for general practitioners contextual to the countries in which they are held, while having the same rigorous standards as the MRCGP UK exams. A number of International MRCGP assessments were being developed and implemented in other individual countries like Brunei, Oman, Dubai, Kuwait, but none on the scale envisaged by this project, which would embrace five countries serving one quarter of the world’s population

A Board with a secretariat in Dhaka, Bangladesh was established to take the project forward. It was agreed that the Board would have two representatives from each of the main participating countries( Bangladesh, India, Nepal, Pakistan and Sri Lanka), with one observer each from other interested countries (Afghanistan, Bhutan and Maldives), along with two representatives from the RCGP. The RCGP offered the initial financial support for the development of the MRCGP [INT] South Asia Exam. Prof. Valerie Wass (VW) was appointed by the RCGP as the first International Development Advisor along- with the supporting role of Dr. Garth Manning, the RCGP’s previous Medical Director, to take the project forward. The department of Family Medicine at the Aga Khan University, Karachi also played a significant academic role in the development process of the exam. Purpose of the Exam: The purpose of the examination is to provide MRCGP International Assessment, which is relevant to the care being given by the doctors working in the South Asia region. The main justification for having MRCGP International examination on regional basis instead of at country level is the belief that the collaborative use of the available resources and expertise in the region would more likely produce a higher quality, rigorous sustainable examination as compared to the attempt by the individual countries to establish and host separate examinations. The MRCGP [INT.] South Asia Examination aims to confer only the MRCGP International qualification to successful candidates. This examination differs from some other MRCGP International sites examinations where it is an accreditation of a distinct locally based examination. The MRCGP [INT.] qualification from all the sites DOES NOT provide a license or right to practice in the UK or confer the right to practice in any other country. However, institutions in some countries(e.g. Australia, Canada) give extra credit to the candidates holding the MRCGP [INT.] qualification The Need:

The MRCGP [INT.] South Asia Board had the vision and encouraged the development of this exam in the light of the following conditions in General Practice, prevailing in the countries of the region at the time:

There were very few vocational training programs in Family Medicine in the region
Low status of General Practice and General Practitioners
No governmental attempt at reaccreditation or mandatory CME programmes
No post- graduate training or qualification requirement to practice as a GP
great majority of GPs lacked confidence and expertise in dealing with complex physical, psychological and social problems, as first contact physicians
For most of the GPs of South Asia, there were no opportunities to improve their knowledge, skills and attitudes through a reputable assessment process, prior to the development of MRCGP[INT.] South Asia
No single country of the region had the required expertise, or the numbers and the finance to consider individual development and submission to the MRCGP [INT] Board.

Objectives:

To drive learning through assessment and accredited qualification.
To establish a shared Family Medicine clinical exam relevant to family physicians working in South Asia.
To have common accreditation across the region through the establishment of a shared Family Medicine clinical examination relevant to family physicians working in South Asia
To promote recognition of Family Medicine as a specialty in the region

Impact of the Exam:

Personal Impact:

A series of focus groups with successful and unsuccessful candidates were conducted in Pakistan (Karachi and Lahore) and Sri Lanka. The focus group looked at the impact of this intervention on the practice of the candidates.

Comments of some of the participants are:

“The course really helped us in improving our practice, even if we do not give the exam it does not matter as our approach towards our patients care has improved a lot”
“I would have never learned the GP consultation models if I had not attend the course”
“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 had led to a financial gain for me”
“Previously I used to tell patients what to do. Now I share information”

National Impact (Pakistani Perspective):

The MRCGP [INT.] examination has made a noticeable impact in Pakistan. It has created awareness among the people and the government regarding the importance of this specialty. Some of the examples are given below:

The development of CME/CPD programs for GPs
Positive effect on practice
Improved job opportunities

Academic contributions from the Aga Khan University (AKU) specialist colleagues in GPs CME programs has enhanced the quality of care and mutual understanding
Many GPs attend with the sole purpose of refurbishing their knowledge and skills
Distance learning initiated in Lahore. A learning resource center has been set up at College of Family Medicine, Karachi.
All the major Family Medicine organizations in the country have played a major part in the dissemination of knowledge and skills among fellow Family Physicians, by organizing preparation courses for this exam. The respect of the organizations among the medical profession at large has also increased.

National Impact (Sri Lankan perspective):

The MRCGP [INT.] exam has been accepted as an international examination in family medicine of a high standard. It has had a significant impact on some areas of family medicine in the country, in particular e.g.

Improved awareness of the practice of evidence based medicine and appropriate use of guidelines

Has become a driving force in continuous professional development activities

Has increased the interest in research in family practice

Has translated into higher quality service for patients

Has become a high level of achievement in postgraduate family medicine to aspire to

Become a catalyst for change in teaching in family medicine in the country

Has been recognized as an extra qualification in Family Medicine by the local Council

National Impact (Indian Perspective):

This exam has increased the awareness regarding the importance of Family Medicine in the medical profession and the public. Representatives of two major Indian Family Medicine Organizations in the Board report similar benefits for patients and Family Physicians as reported by their Pakistani and Sri Lankan counterparts

International Impact

The member countries of the region are helping each other to strengthen local and regional linkages to improve the quality and standards of General Practice/ Family Practice.

Aspects of this partnership include:

Bringing various Family Medicine organizations under one roof
Learning from each other
Common research agendas
Envisioning a common South Asian journal
Strong ties of friendship & collegiality
International recognition (presentations/publications)

Basis of the Content of the Examination The academic model and framework for the examination have been developed by identifying those aspects of good primary medical care that are truly international, as well as the significant differences between countries in the region in terms of culture, epidemiology, health systems and provision, history and geography.

The content of the exam reflects contextual aspects, the principles whereby they can be assessed to modern international standards and the criteria and the template against which assessment procedures from different health care systems might be developed, evaluated, endorsed, accredited and quality assured and validated.