Through the back door: the College and award of Membership without examination

Every year the Royal College of Psychiatrists awards a number of memberships to psychiatrists without examination. This is done under Bye-Law III 2 (ii). The sub-category Bye-Law III 2 (ii) (a) states that the ‘ Membership of the College may be extended to senior psychiatrists who have practised with distinction over many years and are of international repute’. Candidates should be nominated, proposed and seconded by two members or fellows of the College. If the candidate is from outside the UK, one of the sponsors must be from the applicant's home country. Nominations are accepted from all over the world (Royal College of Psychiatrists, 2001).

Although on the face of it, the award of Membership without examination appears well intentioned and above board, there are concerns that in some quarters (particularly in some developing countries) it is being misused as an easy option to gain back door entry to College Membership and the advantages consequent upon it. The case of Pakistan, where a number of such memberships have been awarded in recent years, is taken as an example.

The state of mental health in Pakistan

Pakistan's estimated population of 150 million makes it the sixth most populous country in the world. Community-based prevalence studies estimate that 25-66% of women and 10-40% of men have common mental disorders (Mumford et al, 2000). There are an estimated 3-4 million drug addicts in the country (the majority are young men taking heroin). Suicide rates have increased dramatically in the past few years, from a few hundred annually to more than 3000 every year. Serious mental illnesses such as schizophrenia, bipolar disorder and dementia account for another 1-3% of the population.

Health spending is a pitiable 1% of the annual budget. Mental health does not have a separate budget but is estimated to account for 1% of the annual health budget. Mental health services are almost non-existent and are limited to either psychiatry departments of teaching hospitals or privately run clinics.

There are only 150-200 qualified psychiatrists in the country, giving an alarming ratio of one psychiatrist to one million population. The vast majority of these psychiatrists are located in urban centres, but almost 70% of the population live in rural areas.

Psychiatric training and specialist qualifications in Pakistan

Psychiatric training in Pakistan is overseen by the College of Physicians and Surgeons, Pakistan (CPSP), which also conducts the Fellowship examination (FCPS) in various disciplines, including psychiatry. This is a two-part examination, taken after a candidate has undergone a 4-year training period in an approved training post. Like all higher specialist exams, the FCPS is difficult and requires consistent hard work, application and discipline. Many trainees lacking the penchant for hard work opt for other softer ‘ higher’ qualifications, for example the Membership of College (MCPS; now phased out) and the Diploma in Psychological Medicine (DPM). They have then used these qualifications to obtain an honorary FCPS.

The FCPS is the only accredited higher specialist qualification in psychiatry awarded in Pakistan and is considered equivalent to the MRCPsych or the Board Certification in the USA. Most psychiatrists who are appointed to teaching hospital positions possess one of these three qualifications, although there are many examples of people being appointed with only the MCPS.

MRCPsych and FCPS

Pakistani psychiatrists who have obtained Membership through the longer and more arduous route of General Medical Council (GMC) registration, approved training in the UK and passing the part I and II MRCPsych exams are well aware of the effort, sacrifice and hard work required to obtain the qualification. Many have returned to Pakistan to work in the country's mental healthcare system.

However, at least two of the five psychiatrists of which the author is aware who have been awarded Membership without examination do not even possess the FCPS. One only has the MCPS and the other possesses a minor and largely unknown diploma in psychiatry from Vienna, Austria. Two awardees were granted only honorary FCPS. One of the awardees does not have a single first author publication in a peer-reviewed journal (international, regional or national). How this person qualifies as one ‘of international repute’ is beyond comprehension. Yet the College found it fit to award the Membership to him.

Almost all of the recipients of Membership without examination are heads of psychiatry departments in Pakistan's teaching hospitals.

Cronyism v. merit

Psychiatrists who have obtained Membership through examination feel cheated and betrayed by the College. They feel their efforts and sacrifices have been of little use. Many feel the College has little understanding of the complexities that exist in Pakistan where cronyism, favouritism and rampant corruption are considered normal. It is well known that many of the so-called professors have got where they are, not on merit or their academic achievement, but by how much time they have spent in a given post and who they know in the hierarchy of power. The award of these honorary Memberships is viewed as an extension of the same cronyism that exists in many of the professional medical circles in Pakistan, only in this case the College appears to have become party to it. By awarding the honorary Memberships the College has done a great disservice to those who have obtained MRCPsych via examination, many of whom are shut out from the very institutions the honorary Membership holders inhabit.

In the light of the present controversy surrounding the International Fellowship Scheme in Psychiatry (Khan, 2004), whereby psychiatrists (the majority from the Indian subcontinent) are being offered inducements of GMC registration, Specialist Training Authority approval as well as honorary memberships, the College is being increasingly viewed as having lost all credibility by many psychiatrists in Pakistan.

The effect on the standard of teaching and training

It is inevitable that when poorly trained and under-qualified people hold positions of power and authority the whole system suffers. Having got where they are through means other than merit, these people are more concerned with securing their positions than in encouraging progress and advancement. Competition is stifled and progress and promotion of juniors is according to their whim and fancy. These poorly trained and under-qualified people have had a devastating effect on the standard of mental health training, teaching and postgraduate examinations in Pakistan. For example, many psychiatrists in the UK and USA are reluctant to return home because these very individuals will not allow better qualified and better trained people to enter their institutions. Other bright young psychiatrists have left the country rather than waste their time and energy battling these individuals.

What should be done

It is important that the College recognises the problems it has created in awarding the Membership without examination. The College has not only acted irresponsibly, but inadvertently has validated the dubious credentials of many psychiatrists, bringing them on a par with their more qualified and better trained colleagues. This needs to be redressed immediately. Below are some suggestions the College should consider to improve the present flawed system. These are written from the point of view of Pakistan but may also apply to other developing countries.

The mandatory requirement of FCPS

The FCPS (through examination only) must be the minimum prerequisite for all candidates who are being sponsored for Membership without examination. Any candidate from Pakistan who does not possess FCPS by examination should be automatically ineligible for Membership.

The credibility of the sponsors

The credibility of the local sponsoring member/fellow must be beyond reproach. In the context of Pakistan, this point cannot be overemphasised. Many psychiatrists are shocked that the College is not aware of the lack of credibility of these local sponsors. This has given the whole process an extremely bad name and has further eroded the credibility of the College in the eyes of many Pakistani psychiatrists.

An objective and critical appraisal of the application

The application process itself is limited and cannot objectively assess the candidate's true worth (or lack of it). The process should be such that it allows not only an objective but a critical appraisal of the candidate's achievements and accomplishments. This should include the quality of the candidate's training, his/her qualifications (through examination or honorary), original research and publications (first author, peer-reviewed, indexed journals) and contribution to psychiatry in the country of origin. Although some of these variables can be measured objectively, others rely purely on the letters of support from the sponsors. This is the crucial link in the process and one which can make a critical difference in how the candidate's record is viewed.

The writing of ‘honorary’after MRCPsych

Members who have been awarded Membership without examination should be required to write ‘honorary’ after MRCPsych. This will, at the very least, serve to distinguish those who have been awarded the qualification without examination from those who have earned it through examination. This is done by many other Colleges and awarding bodies and may go some way to assuage the growing discontent among qualified psychiatrists in Pakistan.

The role of the College

The College must set and practise the highest standards of integrity and objectivity in all its dealings. This is particularly important when the College interacts with professionals from developing countries. A patronising attitude and different set of standards for judging people from developing countries does irredeemable harm. The College must realise that the award of Membership without examination has an entirely different effect in countries such as Pakistan, where it is invariably used as validation of poor qualifications and position and to further careers, than in a developed Western country, where it will be of more academic value.

Above all the College must listen and act when concerns are raised about issues and not turn a blind eye, hoping the problem will go away. Concerns about the award of Membership without examination to a Pakistani psychiatrist with dubious qualifications were raised by the author in 2001 in a letter to the then President of the College. Apart from receiving a standard letter of acknowledgement and a promise that this would be brought to the notice of the Court of Electors nothing more was heard (copy of letter and President's reply available from the author). The subsequent award of honorary memberships to a number of other poorly qualified Pakistani psychiatrists is evidence that no action was taken and no lessons have been learnt.

The College's credibility

Psychiatrists in developing countries look to the College to set standards and provide leadership based on principles of integrity, ethics and fairness. They do so because the leadership and professional bodies in their own countries have not yet evolved or matured to a level to take over the role. Many of these bodies lack the rigorous approach needed to set and maintain high standards. When the very institution we look up to becomes a party to the practices one is trying to break, where does one turn to?

If the leadership of the College wants to take the issue of awarding Membership without examination seriously, it must take notice of the growing discomfort of many genuine Pakistani members who feel betrayed and disillusioned. Not doing so will further erode its credibility, causing irreparable damage to its reputation.

Declaration of interest

The author passed the Professional and Linguistic Assessment Board (PLAB) test in 1981, obtained Membership of the College through examination in 1986, has full registration with the GMC and dual certification (general adult and old age psychiatry) with the Specialist Training Authority. He was turned down for Fellowship of the College in 1997. The author is seriously interested in maintaining the highest standards of ethics for the College and its members.