.

Post Graduation & Specialization in Pakistan

Table of Contents After Graduation. The House Job. After House Job. Specializing with CPSP. F.C.P.S Part I Exam. After F.C.P.S Part I. Parts of FCPS Training. Clinical Skills Courses. The Dissertation. F.C.P.S Intermediate Module. F.C.P.S Part II Examination. D.C.P.S Examination. Practical Considerations. Clinical Exposure. Quality of Training. Financial Concerns. Time & Money.

Once you Graduate ! What to do next ?

After graduating from a recognized Pakistani Medical College or University, a doctor is given provisional registration of one year by the Pakistan Medical and Dental Council (PMDC) for house job. Back to Top

House Job
The house job follows soon after the final year results and lasts for minimum of one year. It actually consists of two separate house jobs that last 6 months each. The house jobs are offered in all the major specialties, for example Medicine, Surgery, ENT etc. as well as the subspecialties like Cardiology, Dermatology, etc. Of all the specialties on offer, the Medicine and Surgery ones are the most competitive and allow only the best of each graduating class. Some institutes like PIMS Islamabad offer a mixture of rotations, like in general surgery rotation of 6 months, doctor will go to Orthopedics, Cardiac Surgery, ENT, Eye etc. Similarly in general medicine rotation, doctor will go to rheumatology, endocrinology, pulmonology etc. But this is practiced in very few hospitals. Getting into a house job in the hospital's) associated with your medical college depends on the marks youve obtained in your final year. For example, currently in Jinnah Hospital, Lahore, there are 40 medicine and 40 surgery rotations offered first to the top 80 students of the graduating class. If some of those top 80 decline a medicine and surgery rotation (6 months in medicine and 6 months in surgery), then the students below them in the merit list are accommodated in their place. There are also positions in medicine and surgery in the other teaching hospitals of Lahore, namely Mayo Hospital, Sir Ganga Ram Hospital, Services Hospital, Lahore General Hospital etc. You are also eligible to apply for positions in other hospitals in Pakistan, but it must be kept in mind that hospitals affiliated with medical colleges/universities will prefer their own graduates and give outsiders a place only when the house job positions are not filled by their own graduates or you have to do the job as honorary house officer i.e. with any stipend. The Provisional PMDC Certification is legally must for house job. For those graduates, whom degree is not accepted by PMDC or for foreign graduates, PMDC holds an examination, those who qualify this exam are given temporary registration. When the house job is completed, the provisional registration becomes permanent and the doctor is recognized by the PMDC as a Registered Medical Practitioner (RMP). Back to Top

What Next, You are done with your House Job !

Upon finishing the house job, the doctor becomes eligible to pursue a specialization training program called the FCPS. This stands for Fellow of College of Physicians and Surgeons. The term FCPS is used loosely to refer not only to the system of post-graduate medical training, but the exams needed to complete such training, as well as the qualification itself. In other words after the house job, the doctor will enter the FCPS system of training, will give the FCPS exams in the process, and when successful, will attain the qualification of FCPS. The term FCPS is used to refer to all the specialties. A doctor training and successfully completing the training program in ENT will be called an FCPS just as a doctor completing a training course in Medicine will be called an FCPS. This doesnt mean however that the FCPS training programs for the different specialties are the same - on the contrary, the FCPS exams and training content are different for different specialties. Regardless of the specialty, the FCPS exams consist of two parts: the FCPS-I and the FCPS-II. To enter an FCPS training program, the doctor must pass the FCPS-I exam. After the exam, he will apply for training posts and take interviews to secure those posts. An FCPS trainee is called a Trainee Medical Officer, (TMO) or a Postgraduate (PG). His training will last for either 4 or 5 years, depending on the specialty. When his training period is over, he will be eligible to sit for the FCPS-II exam, and if he passes it, he will be awarded the qualification of FCPS which designates him as a specialist in his field. From 2006, PG's are supposed to take another exam i.e. Intermediate Module once they have completed their basic training in either surgery or medicine, candidates have to pass this exam so that they can appear in FCPS Part II Final Exam at the completion of their training. Back to Top

Specialization Options with CPSP

There are many specialties that the FCPS is offered in, although it must be kept in mind when choosing to pursue a certain specialty that the number of training posts for that particular specialty may be limited. The major specialties are: Medicine and Allied. Surgery and Allied. Anesthesia. Diagnostic Radiology. Dentistry. Gynecology and Obstetrics. Ophthalmology. ENT. Pathology. Psychiatry. Basic Medical Sciences. The Allied specialties for Medicine are: Cardiology. Clinical Hematology. Dermatology. Gastroenterology. Neurology. Pulmonology. Physical Medicine & Rehabilitation. Clinical/Chemical Pathology. Community Medicine. Family Medicine. Nephrology. Nuclear Medicine. Pediatrics. If you wish to go into one of the specialties allied with medicine, you can do your house job in medicine and be eligible to enter the training

program of a specialty that is allied with medicine. For example, doing a house job in medicine (6 months) and then surgery (6 months) will allow you to be eligible to pursue a Pediatric FCPS program. However, when applying for such specialties (as a TMO/PG), you must keep in mind the number of available TMO/PG positions available in that specialty and the location of such positions. Information regarding the competitiveness of a specialty can best be obtained by asking those senior to you in the hospital you wish to apply to. If for example, there are only 5 TMO/PG positions available in Clinical / Chemical Pathology (for the whole province), you should investigate the locations and availability of these positions and keep this information in mind when planning your FCPS training. It is quite possible, for example that a certain specialty is not available in your province. The same principles apply to the specialties allied to Surgery:

Cardiac Surgery. Orthopedic Surgery. Plastic Surgery. Urology. Neurosurgery. Pediatric Surgery. Thoracic Surgery.

The period of training for Medicine, Surgery and Allied is 4 years. For the minors like ENT and Eye, its 5 years while Gynecology/Obstetrics is 4 years. Every specialty has a detailed prospectus with information regarding the FCPS exams for that specialty, training requirements, dissertations, etc. Anyone interested in pursuing an FCPS training program should obtain the prospectus from regional CPSP offices or from the central CPSP headquarters in Karachi, or you can visit their website at http://www.cpsp.edu.pk. Back to Top

F.C.P.S Part I Exam

The FCPS-I exam, in all the specialties tests knowledge in the basic sciences. It consists of 2 papers, each of 3 hrs. duration which take place same day simultaneously. The exam focuses on those sections of basic sciences that are relevant to its specialty. For example the FCPS-I exam for Gynecology and Obstetrics will focus more on the Pelvis and Perineum in its questions of gross anatomy while the FCPS-I exam for ENT will focus on Head and Neck in its anatomy questions. Similarly, the FCPS-I contains questions from the other basic sciences (besides anatomy) that are relevant to its own field besides containing general questions relevant to all specialties. There is no negative marking in this exam of 100 questions - however the pass rate is low, ranging from 8-30%. This is because the passing margin is set quite high at approximately 80%, which means a candidate cannot afford to get more than 15-20 questions wrong. The subjects tested in the FCPS-I exam are:

Anatomy (Gross, Histology, Embryology, Neuro-anatomy). Physiology. Pharmacology. General and Special Pathology (Part of special pathology). Microbiology. Community Medicine (not a major subject, unless the specialty itself is Community Medicine).

Specialty Related subject: Although clinical sciences are not included in the FCPS-I exam, reading a specialty related book would help integrate the relevant basic sciences information. For example, reading an ENT book for FCPS-I ENT exam would most definitely be of some benefit. The FCPS-I exam is held 3 times a year. The dates for the exams are not the same every year, but approximately in the time-periods mentioned below.

February/March. June/July. October/November.

In order to take the FCPS exam, the application form must reach CPSP two months before the exam date itself. So if a candidate wants to

give the exam in February/March, the exam application must be in the CPSP offices in November / December. With the application form candidate must submit his House Job Experience Certificate and PMDC full registration. Those who have not finished theirs house job and do not have elevated their provisional registration to a full registration are not eligible to sit in the examination, so you may lose a chance to avail FCPS Part I attempt, if your house job session is delayed. This means that the candidate cannot appear in the February/March FCPS-I exam and he has to wait for 5 months till the June/July attempt. CPSP has made another provision that if you have passed your FCPS in later time and you were working in a teaching hospital in a capacity of a PG student, that training will be counted towards your FCPS requirement up to maximum of one year, provided you are working under Registered CPSP Supervisor. It is suggested that to save time, candidates must plan their FCPS part I according to their house job completion & eligibility to appear in the exam, and they must apply for some PG / MO post under CPSP supervisor, so that the time before the examination is utilized in the best possible way. Back to Top

Once You Pass Your F.C.P.S Part I Exam

After passing, you will apply for a Post Graduate Trainee post in CPSP recognized hospital. It must be mentioned here that not all PGs are awarded the post. Every province in Pakistan has a fixed number of PG posts which it can give and if the number of applicants exceeds the number of PG positions available then some will be left out. Such applicants thereafter can either join the PG training as Honorary (i.e. without pay) or can apply for non-training jobs in private or government hospitals as Medical Officers. The pay, in private hospitals may be marginally higher for non-training posts (although this is not always the case), but the downside of it is that the experience will not be counted towards an FCPS degree. Due to a limited number of PG seats available in teaching hospitals, number of doctors are doing their PG training as Honorary. Pay for PG Trainee is Rs. 10,000 per month in Punjab. Before joining any hospital, one must confirm the following

The consultant under whom supervision you will be working is a registered CPSP supervisor for that specialty. You can check this from the list of registered supervisors available on CPSP website. The department / unit / ward is recognized for PG training by CPSP. It can also be checked from CPSP website. Back to Top

Components of FCPS Training

After you have secured an FCPS training post, you will begin your duties. It is generally acknowledged that the workload for PGs is very demanding, more so perhaps than for junior doctors in the US and UK. In many hospitals, PGs are given a lot responsibility for patient care and management with these responsibilities increasing as the PG moves forward in his training. During the course of training, the medical PGs must take 3 mandatory workshops while the surgical ones must take 4. These workshops have to be taken within the first 18 months of PG-ship:

Computer and Internet Skills. Lasts for 5 days and imparts basic knowledge of how to use computers and the internet. For those who feel they already have such skills, there is an equivalence test one can pass to attain a certificate attesting to the fact. Research Methodology, Biostatistics, Dissertation Writing. Lasts for 5 days and gives an intensive course on how to conduct research, how to interpret the data from such research and how to incorporate these skills in a Dissertation (see below). Communication Skills. A 3 day course on effective communication techniques in presentations, workshops and seminars.

These three workshops are mandatory for all PGs regardless of their specialty and must be taken within the first 18 months of training. For the PGs in surgery, an additional 3 day workshop on Basic Surgical Skills is also mandatory also to be taken within the first 18 months of PG-ship.

These workshops cost Rs. 8,500 each except for the Computer and Internet Skills workshop which costs Rs. 7,500. They are held several times a year. (The workshops can be taken by any doctor, not just a PG. This fact was mentioned in the UK section of this manual to point out that such workshops strengthen an individuals CV as they are officially organized by the CPSP and therefore recognized abroad.) Back to Top

Clinical Skills Courses

These are non-mandatory courses lasting 5-7 days in which a group of senior doctors volunteer to conduct a thorough revision of clinical examination procedures to candidates who will soon be appearing for the FCPS-II exam (which contains a clinical examination component). The course cost around Rs. 500-2000 and are usually held some time before the FCPS-II exam dates. For those non-FCPS-II candidates who wish to add to their CV, it should be noted that these courses are not formally organized by the CPSP, and as such will have limited value to a doctor who is not an FCPS-II candidate. In other words, attending such a course will not add appreciably to your CV in the way the CPSP-organized workshops will. Back to Top

The Dissertation
To quote the FCPS Dissertation Instruction Manual, issued by the CPSP. Submission of Synopsis/Protocol on a chosen topic, its approval from Research and Training Monitoring Cell (RTMC), CPSP, and preparing a dissertation, acceptable to the College, is mandatory for all candidates aspiring to appear in the FCPS II theory, clinical and oral examinations. In doing so, the CPSP aims at:

Cultivating

an

inquiring

mind

in

its

potential

specialists.

Encouraging in-depth studies related to common health problems afflicting our people. Generating scientific data in various medical and allied fields.

Basically, the dissertation is an original work of research that is carefully preparing over the course of FCPS training and must be submitted at least 9 months before the date the trainee wishes to appear in the FCPS-II exam. Before writing dissertation, candidate apply to the CPSP for formal approval of topic of his / her dissertation, this application with details that how that dissertation work will be carried out is called as synopsis. So approval of synopsis is first step towards dissertation writing. Back to Top

F.C.P.S Intermediate Module

Recently, CPSP has decided that all candidates (fresh and repeaters) must have passed the Intermediate Module examination as one of the mandatory eligibility requirements for appearing in FCPS-II examination in September 2007 and onwards in the subjects listed below
SUBJECT OF FCPS-II Anaesthesiology Diagnostic Radiology Obstetrics & Gynaecology Ophthalmology Paediatrics Psychiatry Internal Medicine General Surgery SUBJECT OF INTERMEIATE MODULE EXAMINATION Anaesthesiology Diagnostic Radiology Obstetrics & Gynaecology Ophthalmology Paediatrics Psychiatry Medicine Surgery

The condition of passing the Intermediate Module examination one year before appearing in FCPS-II examination has been withdrawn. Thus, if all other requirements have been completed, candidates can appear in FCPS-II examination any time after passing the Intermediate Module examination. The Intermediate Module Examinations in Medicine & Surgery are already being held and they will continue. For all other subjects listed above, the first Intermediated Module Examination will be held in March 2006. Those FCPS II candidates who have passed MCPS examination in the relevant subject earlier, will be exempted from Intermediate Module Examination. The candidates who pass this examination will be issued a certificate of passing Intermediate Module examination. Such candidates will also be issued MCPS Diploma after they have completed all requirements for appearing in final FCPS-II examination and have appeared in this examination once. Back to Top

F.C.P.S Part II Examination

This exam has two components, a paper exam and a clinical/oral exam. The FCPS-II paper exam consists of 100 MCQ questions while the clinical/oral exam is held with the cooperation of real patients. When presented with a patient, the candidate will have to take history, conduct the clinical examination, and propose a management plan. In the oral component of this part of the exam, the candidate will be thoroughly tested for in-depth knowledge of his specialty. The oral exam is divided into 2 parts, the Long Case and the TOACS (Task Oriented Assessment of Clinical Skills). Candidates must pass TOACS so that they can move to long case portion. The FCPS-II is not considered to be an easy exam. The pass rate is low and it is not uncommon for doctors to take it more than once before they pass. After passing however, the FCPS period of training is officially over and the doctor is awarded the highly regarded FCPS degree, and qualified as a specialist in that field. Back to Top

D.C.P.S Examination
DCPS stands for Diploma of the College of Physicians and Surgeons. The DCPS is a two year training program structured just like the FCPS program. The minimum criteria for eligibility is full registration with the PMDC (i.e., the candidate must have finished his house jobs). The DCPS program was introduced in 2004 and the first batch of doctors are currently (in 2005) in their first year. There is no entrance exam into the DCPS program (as FCPS-I is for the FCPS program). However, there is an exit exam which will be conducted in 2006 for the first batch of DCPS doctors - the precise structure and content of which is still being formulated at the present time. The DCPS was introduced to correct the deficiency of doctors at the junior PG level. A DCPS doctor will be a junior level doctor and will progress only by the strength of his seniority and experience. His promotion and progress therefore will only come about as the years pass by or if he enters and completes an FCPS program. Currently, it is proposed that a DCPS doctor who wishes later on to pursue FCPS training will have one year of his DCPS training counted towards an FCPS. That is to say, a DCPS doctor in medicine who enters an FCPS program in medicine will only have to train for three years as a PG and not the usual four. The specialties and sub-specialties in which the DCPS program is offered are listed below. The range of specialties offered reflects the current shortage of junior doctors in these fields:

Anesthesia. Clinical Pathology. Diagnostic Radiology. Family Medicine. Obstetrics (without Gynecology). Ophthalmology. ENT. Pediatrics.

Dermatology. Psychiatry. Community Medicine. Pulmonology.

The DCPS program has replaced the MCPS (Member of College of Physicians and Surgeons) program. The MCPS was also a training program designed to produce junior doctors, and was restructured, renamed, and redesigned into DCPS. This change was effected in order to bring the program on par with similar programs in developed countries a move that will lead to its acceptance in developed countries. Back to Top

Practical Considerations about F.C.P.S

Unlike the process of entering UK and US system of post-graduate medical education, in the Pakistani system there are no visa problems to address, no prolonged, expensive registration requirements and little (if any) traveling to far off places. Besides these factors are other practical considerations a doctors must bear in mind when deciding to pursue the FCPS option. Back to Top

Clinical Exposure
There is little doubt that a PG working in practically any teaching hospital in Pakistan would see more patients, and a greater variety of pathologies than doctors training for a similar period in the US or UK. This is a consequence of the underdeveloped health-care system in Pakistan (in which the doctor - patient ratio is very low), but it ultimately works to the advantage of the trainee. In the 4-5 years of his PGship, the trainee would get much more practical experience and exposure than his counterparts in developed countries. If the PG is very hard working and actively incorporates his clinical exposure with formal in-depth study, he will evolve into a highly competent and experienced doctor. In surgery for instance, junior PGs and even house officers quickly learn to perform common major surgeries, an experience which greatly contributes to their confidence and expertise in a relatively short time. Back to Top

Quality of Training
In the US all residency programs must adhere to a minimum standard of training, work hours and patient load. To ensure that these minimum standards are met, these programs are kept under tight check by a National Residency Control Commission (RCC). Vigilant supervision of training programs by the RCC ensures that all teaching hospitals in the US provide - at the very least an acceptable standard of active training to its residents. In Pakistan, while certain minimum standards are in place (which are mostly concerned with accrediting hospitals as being fit to offer training) a proactive supervised evaluation of training standards (similar to that in the US) is not in effect in Pakistan. With a lack of such standardization arises the inevitable difference in the proficiency and excellence of the training programs in different hospitals throughout Pakistan. As a result, the quality of training imparted to FCPS trainees varies greatly from one hospital to the next. For the most part, the quality of training in any hospital is largely in the hands of its senior doctors. In some training hospitals, where the senior doctors have the time and inclination, the PGs will be regularly monitored and assessed with an active interest taken in their professional development to ensure their evolvement into competent doctors. Such environments makes it easier for FCPS trainees to make the most of their training and evolve into highly competent doctors. On the other side of the spectrum are training hospitals where the senior doctors are overworked and simply dont have the time (or inclination) to focus their energies on their PGs. In such places the PGs suffer the inevitable consequences that come with such an environment. This is not to say, however, that it will be become impossible for PGs in such settings to acquire a high degree of competence in their specialty rather, they will have to work harder themselves in order to overcome the short-comings of a training environment that offers them little instructional support. Keeping this in mind, choosing a teaching hospital in which to pursue FCPS training should become an important aspect of planning the FCPS option. Currently, most doctors choose to pursue FCPS training in the hospitals affiliated with the medical college they graduated from - with little or no consideration given to the quality of training these hospitals can offer them. Such an approach is probably strongly influenced by the fact that the doctor feels comfortable in familiar territory, surrounded by old friends and family and would continue to work in the environment / city he lived in during his days as a medical student.

However, with numerous teaching hospitals available throughout Pakistan, a more calculated approach should be taken when pursuing an FCPS training program. If you feel youll receive a good training experience in a hospital located in a city other than the one youre currently living in, then that option should be seriously considered and you should investigate the procedure and requirements needed to get into such a hospital as an FCPS trainee. Such research is best conducted by talking directly to PGs working in that hospital as they would be able to give you the most accurate picture of the quality of training. Back to Top

F.C.P.S Financial Concerns

By far, entering the FCPS program is the most cost-effective of all the options mentioned in this manual. The major costs involved are: FCPS-I Exam Fee Registration Fee as a FCPS Trainee Workshops Dissertation FCPS-II Exam Fee Rs. Rs. Rs. Rs. Rs. 9,000 6,500 25,000 - 35000 1,000 - 1500* 9,000

*The dissertation costs range from 1,000 to 15,000 depending mostly on whether or not you employ the services of a computer professional who will type and arrange the format of your document. If you are skilled at using a word processor and can prepare the document yourself, the cost of preparing the dissertation will be correspondingly lower. Assuming that the exams are passed in the first attempt (which is not the case for the majority of candidates), the costs range from Rs. 49,500 to Rs. 72,000. This is hardly 10% of the costs entailed in the entire USMLE and UK pathways. It is cheaper to enter the FCPS pathway, but this fact needs to be considered in conjunction with the Time and Money factors described below. Back to Top

Time & Money

These two factors are intertwined. Recall that the FCPS program lasts for 4-5 years (depending on the specialty). Also remember that in our institute, Allama Iqbal Medical College, the final year class has been, in recent years, graduating in April - with the house job starting in May. After the house job, there is a six months - one-year delay before the FCPS training begins (provided you pass the FCPS-I exam in the first attempt). After the 4-5 FCPS years are over, most candidates study for 4-5 months before attempting the FCPS-II exam. If they pass in the first attempt, they will have successfully completed the pathway. Adding up the years from graduation, the time taken to complete the FCPS program is approximately 6 years (for medicine and surgery) and 7 years for other specialties like ENT and Ophthalmology. If you graduate at the age of 24, then youll be 30-32 years old by the time you finish the FCPS. The long amount of time spent training and studying for the FCPS degree is not a problem in itself. However, the situation does become problematic when the time taken to complete the FCPS pathway is considered in conjunction with the money factor. A PG is currently paid Rs. 10,000 a month. He will continue to get this stipend for the duration of his training. It is generally agreed upon that this amount is hardly adequate to support oneself, let alone ones parents or family (i.e., wife and children). Resultantly, the FCPS trainee is often in a financially difficult position a situation that often leads to the great frustration and anxiety that comes from financial dependence on others. This is a particularly pressing problem in our poor society where a man in his late 20s or early 30s is usually expected to be financially independent and be able to contribute to, rather than drain from, the economic position of his family. The financial problem is further compounded by secondary financial demands: The mandatory workshops cost Rs. 24,500 (for the medical specialties) and Rs. 33,000 (for the surgical specialties). This is how much money a PG makes in 4-5 months. Besides the costs of books, are the costs of preparing the dissertation, which ranges from Rs. 1,000-15,000. From examination of post-graduate medical training systems in the UK and US, it is apparent that the primary motive most people have for seeking further education abroad is the time-money factor. Many doctors in our poor society have financial obligations to their families they would be unable to discharge with a stipend of Rs. 10,000 a month. They feel that the relative lack of a rigorously monitored, qualitycontrolled FCPS training program, when combined its associated financial drawbacks, add up to make the FCPS option an unattractive one. This conclusion is manifested by the fact that despite the exhausting period of study and uncertain visa situation in the US option; and the dire job situation in the UK option - many doctors still prefer to invest their time and money for a chance to go abroad for further training .