Only recently, our honourable Health Minister Mohammad Nasim declared a radical change in the system of training doctors in Bangladesh. Instead of one year, doctors after MBBS, will have to go through two years of internship training program.
This decision must be applauded, and credit should go both to the prime minister, who dreams of an exemplary health care for her population, and the health minister himself who executes the plans to carry out that dream.
Some have raised concern, my belief is, due to the gap in communication in understanding the enormous benefits imparted by changing to two years of internship on the quality of doctors, provided that the further comprehensive way to train doctors in the developed world is followed now without further delay.
Getting a medical degree (MBBS) in the developed economies is just the beginning of medical education. Training continues, taking at least five years to become a general practitioner and 8-10 years to become a hospital consultant.
Bangladesh’s health care sector has arrived at a crossroads. The phenomenal success in primary health care, the “Bangladesh Miracle,” has resulted in the demographic transition that requires our doctors to be trained in the way of the developed countries’ training methods.
There is no scope of the argument that Bangladesh is still a developing country and therefore needs short-cuts in producing doctors. Because our success in reducing infant mortality, combating communicable diseases (such as polio, diphtheria, diarrhoeal diseases), and the astonishingly successful improvement in other health indicators, mean we are now threatened by the same diseases like those in the West: Cancer, injury, complications of pregnancy, heart disease, diabetes, and so on.
A comprehensive, structured training process must be in place to ensure that sufficient number of doctors are available in Bangladesh, who are capable of combating these new health threats for our survival.
The system of training doctors in Bangladesh is mainly an individual effort of the doctor — ambiguous, erratic, baffling, vague, and most importantly unstructured, lacking in direction and vision. This is the reality, despite the determination and efforts of the government for the last few years, to provide the best health care to its population for the 21st century.
Any doctor wishing to practice as an independent practitioner in Bangladesh, be it as a general practitioner in the villages or as a specialist in major hospitals in rural and urban settings, without exception will have to undertake further training.
Today, I shall try to throw some light on the training system of doctors in the UK to either become general practitioners in the community, that falls under primary health care or to be specialists in hospital practice under secondary and tertiary health care systems.
First, let’s see what the doctors’ regulatory body in the UK requires as pre-requisite for the doctors to possess, before they are allowed to take care of their patient independently and without direct senior professional supervision:
The General Medical Council of Great Britain comprehensively defines a doctor as someone who makes the care of her/his patients the first priority.
Someone who is competent, armed with the required knowledge, skills, and attributes, capable to establish and maintain good relationships with patients and colleagues, honest and trustworthy, and acts with integrity and within the law.
A good doctor must be competent in all aspects of his/her work, including management, research, and teaching — taking every step to monitor and improve the quality of work in order to provide a good standard of practice and care, adequately assessing the patient’s conditions, taking account of his/her history (including the symptoms and psychological, spiritual, social, and cultural factors).
Their views and values must have the consent or other valid authority to perform, when necessary, examination of the patient, investigations, or treatment that serves the patient’s best interest.
In providing clinical care, a good doctor must prescribe drugs or treatment only when he/she has adequate knowledge of the patient’s health and is satisfied that the drugs or treatment serve the patient’s needs based on the best available evidence.
After MBBS, each doctor has to complete a two year generic Foundation Training Program that forms the bridge between medical school and specialist/general practice training — similar in principle what Mr Nasim is proposing regarding the internship program years. The F1 and F2 provide trainees with opportunity to gain experience in a variety of specialties and health care settings.
What the honourable health minister does not propose, but is essential that he does, is the subsequent training program for doctors in Bangladesh to prepare them for the responsibility of providing appropriate care for the deadly diseases of today.
After successful completion of the Foundation Training Program, doctors are awarded the Foundation Achievement of Competence Document (FACD). They are then able to go on to training in a chosen specialty, or general practice (GP) training.
Training program differ in length and structure according to specialty: General practice lasts three years and other specialties can last five to eight years.
Length of training can also depend on the rate of achievement of competencies.
In order to enter into specialist training in Medicine (ST3 level) a doctor passes the MRCP Examination and to enter into specialist training in Surgery (ST3 level) a doctor passes the MRCS Examination. MRCS/MRCP are essential post-graduate qualifications required before entering the UK specialist training program.
MRCS and MRCP both are examinations — a doctor in the UK will have to pass before entering Specialist Training Program in surgery (MRCS) or in medicine (MRCP). Then doctors in both medicine and surgery are assessed by Annual Review of Competence Progression (ARCP).
When the Joint Royal Colleges of Physicians Training Board (JRCPTB) in case of medicine and the Joint Committee on Surgical Training (JCST) is satisfied that a doctor has achieved sufficient competencies in medicine/surgery to practice as an independent consultant that may take six additional years of training (ST3 to ST8), after MRCS/MRCP examination and entering the Specialist Training Program by competition, the JCST/JRCPTB recommends for award of CCT (Certificate for Completion of Training) to the General Medical Council.
The CCT confirms that a doctor has completed an approved training program in the UK and is eligible for entry into the Specialist Register of the GMC and it is a legal requirement that a doctor practicing as a substantive or honorary consultant in NHS UK holds specialist registration.
It is time that we wake up to the reality of the consequence of our successes in primary health care so far, and plan to invest in proper health care and human resource development — if we wish to prevent death, disability, and further economic loss.