PGIM Disregards Ministry Instructions

by Nirmala Kannangara

• Despite requests to Director PGIM to expedite the training programme for the Diplomates in CCM, the latter has so far failed to abide by the Ministry instructions 
• PGIM under severe criticism for preventing  CCM Diplomates sitting the Medical Degree (MD) to qualify as BCCC Specialists
• According CCM Diploma holders, there are fears amongst Anaesthesiologists that there will be issues as to who is to be appointed in charge of ICUs

Health Ministry letter to the PGIM requesting to expedite the MD CCM programme
The CoA letter opposing the awarding MD in CCM for Diplomates in CCM and The letter sent to PGIM by President CoA informing that they will be withdrawing training the Diploma holders unless the Specialty Board in CCM is formed under the BoA

Despite a request by the Ministry of Health, Nutrition and Indigenous Medicine to the Director Post Graduate Institute of Medicine (PGIM), to expedite the stalled postgraduate training programme for the Diplomates in Critical Care Medicine, the latter has so far failed to abide by the Ministry instructions.

The PGIM has come under severe criticism for preventing Diplomates in Critical Care Medicine (CCM) from sitting for the Medical Degree (MD) to qualify as Board Certified Critical Care Specialists over the past several years. As a result, medical development in many specialties including surgery in the country has been crippled according to Senior Medical Professionals.

In order to give a proper and effective training for the Medical Officers working on roster basis in Intensive Care Units (ICU) to manage the very sick patients in 2007, Prof Chula Goonasekera (Professor in Anesthesiology) and Dr Aruna Munasinghe (Fellow of Critical Care Medicine, USA), after recognizing critical care as a top priority, brought to the notice of the then Director PGIM Prof Rezvi Sheriff the importance of holding exams in Critical Care and Emergency Medicine for the doctors who were working at intensive care units in the country.

After several rounds of discussions with the members of other specialties, Prof Sheriff formulated the Curriculum Development Committee coming under a Multi-disciplinary Study Board (MDSB) to train young doctors working in ICUs in the modern methods of providing intensive care to patients. Prof Chula Goonasekera was then appointed as the chairman, MDSB, while Dr Aruna Munasinghe appointed as the secretary. Both Prof Goonasekera and Dr Munasinghe developed the curriculum – first the Diploma (CCM), then MD (Emergency Medicine) and MD (CCM) curriculum to the Board of Management of PGIM.

Prof Goonasekera meanwhile had brought to the notice of the then Health Minister the importance of conducting the exams for MD (CCM) and MD (Emergency Medicine) to which the minister had responded positively, and thereafter, instructed the Ministry Secretary, Dr Ravindra Ruberu, to recognize the two courses.

Hence, in August 2008, a selection exam to follow the Diploma in Critical Care was conducted where only 20 candidates were selected out of 160 applicants.

However, the then Ministry of Health for an unknown reason did not release these 20 candidates for CCM training, claiming that critical care is not an important aspect of the Ministry. However after a long struggle CCM training for the Diploma took off the ground in June 2009.

It later came to light as to how the Anaesthesiologists who were in charge of certain ICUs harassed the trainees and didn’t give them proper training. “We had to follow a one year full time pre-diploma training period in CCM which involved training in intensive care unit as full time ICU Medical Officers. In most of the ICUs some had to work under Anaesthesiologists while in certain ICUs under Consultant Physicians. Although the Physicians gave effective training, those who worked under Anaesthesiologists were subject to much harassment. They told us that we are not allowed to enter the ICUs for training and there were times when they refused to teach us,” Diploma holders in CCM told The Sunday Leader.

According to Diploma holders in CCM, there are fears amongst Anaesthesiologists that once the Diplomats get the MD (CCM) with board certification, there will be an issue as to who is to be appointed in charge of ICUs – Anaesthesiologists or the MD (CCM) board certified specialists.

“There is no policy but a practice that Anaesthesiologists are in charge of ICUs. Patient care needs more than the input of anaesthesiologists particularly in the non surgical wards,” sources said.

According to the sources, at the end of the one year training programme, the then President of the College of Anaesthesiology Dr A. Warnakulasuriya, by a letter dated September 23, 2009 to Director PGIM, informed that they would withdraw from teaching and training the second CCM batch unless the Board of Study (CCM) is formed under the Board of Study (Anaesthesiology).

The letter further said, ‘We wish to state that unless the specialty board in Critical Care is formed under the BoS (Anaesthesiology), we will be reluctantly compelled to withhold training from the next batch until we receive a favourable response. We do not want to create problems to trainees undergoing training at present. It was after much hesitation that we arrived at this decision as we had no other alternatives’.

According to the sources, that was the turning point that prevented them from obtaining the MD (CCM) qualification. It was at this time, the College of Anaesthesiology (CoA) wanted to conduct these courses under their specialty board.

“After this letter, there were several discussions to decide as to whether the BoS (CCM) should be kept under the inspection of the MDSB or under BoS (Anaesthesiology). The CoA got the support of Surgeons and Obstetricians to get BoS (CCM) under their wing to hold the exams for three year. However, even after three year, the powers of conducting the exams were not vested with the MDSB but the BoS (Anaesthesiology) continued to run the ‘show’ according to the dejected Diploma (CCM) holders.

The sources who wished to remain anonymous further said as to how unfair it was for the members of the College of Anaesthesiology (CoA) to agitated against this training from the very inception of the Diploma (CCM) and MD (CCM) programmes.

According to the sources, although the College of Anaesthesiology (CoA) did not support the MD (CCM) programme from the very inception, it was the then Chairperson Board of Study (Anaesthesiology) Dr Neelika Karunaratne that put her fullest effort to implement this programme when her own colleagues were against the decision.

“It was the then President CoA Dr Shirani Hapuarachchi and her stooges that wanted this programme defunct, under a MDSB, but instead to bring it under BoS (Anaesthesiology) to have the full authority in holding the MD examination. Even after Dr Karunaratne stepped downed from the Chairmanship of the Board of Study (Anaesthesiology), she still wanted to see us from becoming Board Certified Critical Care Specialist. Had she still been alive today, she would have been very disappointed as to how the PGIM together with the CoA is preventing us from obtaining the MD (CCM) and only allowing those who have MD (Anaesthesiology) and MD (Medicine) to obtain the MD (CCM),” sources added.

Since the new proposal to allow those who have obtained MD in Anaesthesiology or Medicine could get the board certification in MD (CCM), after several discussions, Prof. Sheriff who did not have any other option due to the exerted pressure decided to hold the exam in two entries- standard and alternative pathways to benefit all groups. Hence those who pass Diploma (CCM) had to sit for the MD (CCM) after following a five year training programme under the standard pathway, and those who have obtained MD in Anaesthesiology or Medicine could get the board certification in MD (CCM) without an exit exam, only after following three years of CCM training under alternate pathway.

“This decision was solely taken with the huge pressure exerted by the Government Medical Officer’s Association as its then Vice President was an Anaesthetic. By 2013, this board had revised the already proposed and approved MD Critical Care program to become a sub-specialty pathway, preventing any of the Diploma holders to proceed with further training in MD Critical Care. Instead, the PGIM introduced a new pathway, allowing for other MD holders of other specialties to obtain board certification in Critical Care Medicine after a short period of training. This also was probably the first time where a board certification was offered to anyone without an exit examination in the specialty itself.  It was almost like a trained and licensed bus driver is allowed to fly an aircraft after one or two flying lessons.  Imagine what consequences this will bring in future,” sources claimed.

The Board of Management at the PGIM and the Senate of the University of Colombo in 2011 after evaluating both pathways gave the approval to commence both pathways simultaneously and instructing clearly to phase off the alternate pathway in five years.

However, everything changed after Dr Nihal Jayathilake was appointed as the Secretary Health Ministry in 2012.

“Dr Shirani Hapuarachchi who was a batch mate of the Health Secretary got him to intervene and took a letter stating that those who have MD in Anaesthesiology or Medicine can enrol to get the Board certification in CCM without an exit exam, annulling the standard pathway preventing Diplomates (CCM) from sitting for the MD (CCM),” sources said.

Sources further stated that the board certification in CCM will be granted for the MD Anaesthesiology and MD Medicine doctors the MD CCM, by BoS (Anaesthesiology) as it will be the body in reality that will both institute the training program and grant the board certification as a specialist. “It is the members of the BoS (Anaesthesiology) that decides the training program, examination performance and offer the certification of fitness to practice as a specialist. This is wrong. The board certification should be given by the Sri Lanka Medical Council (SLMC) but not by the PGIM. The PGIM should conduct necessary training programs but to scrutinize, assess evidence produced by each applicant and board certify them as specialists should be done by the SLMC,” sources said.

Since the Diploma holders in CCM were prevented from sitting for the MD (CCM) examination, filed a case in the Appeal Court (CA 672/ 2011) to get an order for them to sit for the MD (CCM) examination.

“By this time the MD (CCM) prospectus has been handed over to the BoM and not to the University Council or to the Senate to get the UGC approval. As a result the Court of Appeal gave an order stating that ‘in the event of awarding an MD (CCM), diploma holders in CCM should be considered’. Knowing that we will get the opportunity to sit for the exam, Director PGIM, President GMOA and its Vice President went to the Attorney General and got the name changed of the degree,” they said.

According to the sources, when this injustice was brought to the notice of the Higher Education Minister Lakshman Kiriella and Health Minister Dr. Rajitha Senaratne, both Ministers had given strict instructions to their respective officers – the Higher Education Ministry Secretary D.C. Dissanayake and Dr Lakshmee Somathunge of the Health Ministry to instruct the PGIM to allow the Diplomates (CCM) to follow the five year course and sit for the MD (CCM) to prevent brain drain.

“Both Ministers listened to us very carefully and instructed the relevant officials to instruct the PGIM to allow us to sit for the MD examination,” sources claimed.

However, when contacted Secretary Higher Education Ministry D.C. Dissanayake, said that Minister Kiriella’s request had been forwarded to the PGIM. “ Since these are academic matters we cannot interfere. It is the PGIM that has to consider,” Dissanayake said.

Meanwhile when contacted Dr Lakshmee Somathunge said that she was busy and to call her later. All attempts taken thereafter to find out whether she informed the Health Minister’s request to the PGIM failed as she did not answer the calls.

BOM has not turned a blind eye – Director PGIM, Prof. Janaka de Silva

Director PGIM, Prof. Janaka de Silva, when asked as to why the PGIM has put a blind eye to the Health Ministry request, said that the current BOM has not turned a blind eye on this issue.

“On the contrary, it has taken a pro-active stance and has officially requested the Specialty Board in Critical Care and the BOS in Anesthesiology to develop a standalone MD and Board Certification Programme in Critical Care Medicine. The BOS and Sp. Board have agreed with this request and are currently developing such a programme. In the meantime, Critical Care Diplomates can now enter the MD Anaesthesiology programme with exemption from the MD Anesthesiology Part 1A examination, complete that MD and opt for post-MD training in Critical Care Medicine,” the PGIM Director said.

When asked why he took more than three years to implement the standard pathway, Prof. De Silva said that the PGIM has to follow due process when implementing new programmes, taking into consideration the views of all stakeholders, not just proponents of a programme; there have also been strong arguments against starting a standalone programme.

The PGIM Director when questioned why the Anaesthetists could not abide by the 2011 senate decision to commence both standard and alternate pathways simultaneously, said that it is the BoS in Anesthesiology that could give the best answer.

When questioned whether he is misleading both Health and Higher Education Ministers by hiding the truth to the delay in implementing the standard pathway because of his close association with Anaesthetists, Prof. De Silva said that all decisions of the Board of Management have been made in the most transparent manner, and both Ministers have been briefed on the processes being undertaken with regard to the standalone programme for MD in Critical Care Medicine.

He also said that he does not want to stop the alternate pathway until the standalone programme is implemented and produces its first board certified specialists.

When asked why there are no Cardiologist, Nephrologist, Neurologist or Pediatric Intensivist in the current board, the PGIM Director said that the critical care specialty board has been appointed in accordance with representation from the relevant major specialties, with three anaesthetists, three physicians, two surgeons, an obstetrician and gynaecologist and a microbiologist and added that Paediatric critical care is a different programme under the BOS in Paediatrics.

When told that if the PGIM could start so many programs for the first time without existing specialists in the said specialty Ex: Transfusion Medicine, Emergency Medicine and Clinical Nutrition, why cannot the Critical Care programme too be started without existing specialists, Prof. De. Silva said it was because of the difficulties in obtaining sufficient numbers of training centres and lack of consensus among stakeholders.

When told that there is an allegation that he is playing a survival game to please Anesthetists by not reverting the current inefficient board to a multidisciplinary board of study in critical care medicine, he refuted the allegation and added that the functioning of the current board and the current training programme have been found to be satisfactory.