Rashid Jooma  ( Aga Khan University Hospital, Member, CPD Committee, PM&DC, Islamabad. )

Despite the efforts over a decade by various national institutions and funding from the WHO,¹ little progress has been made in design or implementation of a national scheme for Continuing Professional Development (CPD) in Pakistan. The imperatives of such a scheme have been well perceived in the profession\\\'s circles and the Pakistan Medical and Dental Council (PM&DC) which, like other medical regulatory authorities round the world, consider that it is the physicians\\\' professional responsibility to maintain and improve the quality of their practice. It is desired that all physicians regularly engage in educational activities with documented demonstration that they are fulfilling this professional obligation and it is foreseen that in the future this will be a pre-requisite for re-registration. However, it must be appreciated that strict regulatory measures are not likely to be effective in assuring quality practice but rather that the motivating factor for continuous learning should be a sense of pride in his/her performance as a physician.²
Recently, the PM&DC has notified a Committee for CPD and the observations arising from consideration of ways and means of the Committee\\\'s subject are the basis of this submission.
CPD vs. CME:
As opposed to continuing medical education which is usually in the nature of a teacher- based didactic clinical update, it is desired to stress more physician-centered continuing professional development which focuses on not just medical but also social, communication, personnel and management skills.³
The Difficulties Ahead:
Establishing a widely accepted scheme of CPD that is sustainable and of the desirable quality is fraught with difficulty. This is owing to the poorly inculcated habit of self-directed learning amongst our physicians, a poorly developed infrastructure of educational opportunities for practitioners and poorly practiced documentation of professional activity.⁴ Thus, if the PM&DC were to pursue its objectives relating to CPD by edict, setting out its expectations in this regard and then hoping that these are embraced by the physicians as well as the individuals and organizations that would provide the programmes, the outcome is likely to defeat the stated objectives. The Council would require playing a proactive role in all the various steps and aspects of CPD in order to achieve the desired results.
Practitioners:
There are some 145,000 medical and dental practitioners registered with the PM&DC of whom 60% have current registration and probably a similar proportion is professionally active in the country. These are the practitioners whom the Council would wish to accrue to its schemes of CPD. As this would be on a voluntary basis, the motivation should be engendered by the quality and relevance of the programmes. The subdivision of medical and dental practitioners into those with basic and those with specialist qualification lends itself to the two tracks along which the CPD schemes would be organized i.e. One for the General Physician and Second for the Specialist.
Providers:
The critical links in the CPD chain are the individuals, the organizations and the institutions which would function as the providers of programmes and courses. The most comprehensive resource of providers are the medical professional organizations (MPOs) which are well established in the country particularly for the specialists, with virtually all medical specialties covered. The general practitioners are represented by the College of Family Medicine, the Forum of General Practitioners and the Pakistan Medical Association. These organizations all have considerable experience of offering continuing medical education activity to their members and would be the naturally facile partners of the PM&DC in a coalition to offer national CPD programmes. Recently, the CPD Committee convened a meeting of the MPOs and they have been tasked with the provision of specialty-specific educational activity, accreditation of courses and quality assurance by feedback besides a verifiable certification of the extent of a physician\\\'s CPD activity for eventual submission to the PM&DC.
There are now in excess of 100 universities and colleges imparting medical and dental undergraduate teaching in the country and these could be engaged to participate in the CPD scheme by involvement of their faculty in educational meetings in their geographical areas and other outreach events, besides offering refresher teaching modules in their institutions. The ability of the medical colleges to contribute to CPD as an outreach activity would be enhanced by encouraging the establishment of Departments of Family Medicine.
Venues and Facilitation:
Clearly, the acceptability is greatest when the physician can participate with least disruption of routine and minimum traveling. It is anticipated that the District Headquarter Hospitals (DHQs) are eminently suited to serve as the focal point of CPD activity for the general practitioners supported by the regional medical schools. The Executive District Officers for Health (EDOs), the Town Health Officers (THOs) and the respective Medical Superintendents (MS)would be engaged, through the good offices of the Provincial Health Departments, to serve as the interface between the providers and the programme sites. They would be assisted in undertaking situational analyses to determine from their local practitioners, the clinical problems for discussion and learning. They would facilitate the hosting of events for the practitioners of their catchment areas and contribute to documentation of activities. They would work with PM&DC and all others concerned to upgrade the educational infrastructure in the DHQ Hospital with the provision of appropriate spaces, audio- visual aids and teaching aids etc.
PM&DC:
The PM&DC would have to commit to funding the gestational stages of the scheme. This would involve the creation of a CPD Cell within its secretariat which would prepare the ground work for implementation of nation-wide CPD including a situational analysis of the educational needs of the medical practitioners to guide programme development. The CPD Cell would work with the health officers of local government to bridge the disparity between the possibilities and the realties of education within the DHQs. It would seek a budget line from the Government through Public Sector Development funds or international funding of an "Establishment of CPD for Medical Practitioners" project.
The CPD cell would aim to develop an electronic database capability to log the CPD activities across the country in an interactive process of data collection and guidance to support the CPD programmes of the providers. In addition the PM&DC could work towards and in-house capacity of CPD programmes to supplement the resources of the providers.
Ministry of Health:
The education section of the Federal Ministry of Health could make an important contribution to the implementation and success of the national CPD scheme by assisting in securing material resources and facilitating the involvement of the health officials across the country. The effective functional incorporation of the health officers in the scheme will require political will on the part of the Provisional and the District Governments. In particular, commitment of the EDO Health to the CPD scheme would require to be embedded into his/her job description.
Programme Content:
The programme content of CPD activities credentialed by the PM&DC, particularly for the community physicians would have to be innovative and broad-based to appeal to the Pakistani medical practitioner and encourage maximum participation. A considerable degree of creative work would be required to be done in this regard, utilizing input from medical educationists, family medicine specialists and representatives of the practitioners themselves. Prior experience affirms that learning is most effective when linked to clinical practice and this rather that the traditional didactic model would be pursued.
Accreditation of CPD Programmes:
The crucial role of the PM&DC in the national scheme of CPD would be the process and procedures for accreditation of programmes and sites. This would be best achieved in conjunction with the MPOs and EDOs as an ongoing process designed to also serve as a robust mechanism for quality review and updating and improving activities. At its best, this is a function of trained and full-time auditors who review documentation from the providers including feedback from the physicians and site visits to allow recognition and accreditation of the provider\\\'s programmes and venues.
The activities granted accreditation may be divided into three categories: (a) "live" or external activities (courses, seminars, meetings, conferences, audio and video presentations and visits or brief attachments to teaching institutions), (b) internal activities (practice based activities, case conferences, grand rounds, journal clubs, teaching, consultation with colleagues), and (c) "enduring" materials (books, journals and other printed matter).
Documentation of Credits:
It is recommended that the Council adopt an hours related credit system in vogue internationally. In this one hour of educational activity equates to one credit. Practitioners with a basic qualification may be expected to initially devote a minimum of 2 hours per month for professional development. If a three-year cycle is introduced initially, then 75 points would be required to be accumulated. Specialists have more mature systems of continuing educational activities and should be expected to demonstrate 5 hours per month of CPD which would equate to 200 hours in a three-year cycle. At a later stage weightings or categories could be accorded to various activities to reflect their educational merit. The educational activities should receive documentation from the providers and the practitioner would be expected to compile a folio of CPD to submit to the Council in a three-year cycle of verification and certification.⁵
Funding and Budgets:
It is suggested that in the initial stages of the CPD scheme, the providers should receive material support from the PM&DC to allow low cost programmes. Once established, the providers should be encouraged to follow the principle of no profit, no loss in the pricing of their courses and programmes. Unabashed commercialism can make a mockery of education and for CPD to achieve its altruistic motives of enhancing physician performance with a view to improving patient care outcomes, the profit motive, which may attract the unscrupulous providers, must be kept out of the equation.
Rewards and Motivation for the National CPD Scheme:
While the rewards of CPD, undertaken sincerely and diligently, should be intrinsic and self-evident, the Council should recognize compliance by physicians of the set out requirements by special certification and posting of their names on its web-site as Proficient Practitioners. The Council should work with its partners in its CPD scheme to encourage employment and promotions of only those doctors with the requisite credits.
It is the intent of the PM&DC to progress to re-certification contingent on CPD achievements but it is crucial that all involved in the development and implementation of the national CPD scheme be clear that the motivation that drives the efforts towards the National CPC scheme is to improve the health of the population by improving the effectiveness of physicians through positive changes in professional knowledge, skills and consequently, health care outcomes.⁶

1.Samad S. Continuing Medical Education: National Policy and Strategic Guidelines for Pakistan (Consensus document). Karachi: CPSP, 2005; pp 62.
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