Registration and Ranking of Medical Graduates

Medical Education is a continuous stepwise process including selection, undergraduate medical education, internship, full registration and continuous Professional Development. It is important to getting each of these steps right, since the quality of medical doctors is one of the most important determinants of quality of health system of the country. It is a right of the patient to obtain treatment from qualified medical staff. Thus, safeguarding quality of medical education has a direct impact on the rights of the patients.

Registration to Practice

Medical doctors must register with the Sri Lanka Medical Council (SLMC) in order to practice Medicine in Sri Lanka. The doctors registered with SLMC can either be graduates from Sri Lankan state medical schools or overseas medical schools. Registration to practice has two steps, provisional registration and full registration.

Overseas medical graduates must pass a licensing examination (Examination for Registration to Practice Medicine (ERPM/ Act 16 exam), conducted by SLMC. The candidates should possess a MBBS or equivalent degree from a medical school recognized by the SLMC, to be eligible to sit this examination. Passing this examination enables them to apply for Provisional Registration for internship appointment or full registration with the SLMC.

Upon obtaining provisional registration, medical graduates are required to complete one year of internship. Successful completion of internship is a mandatory requirement for SLMC full registration.

Prerequisites for full Registration at SLMC are;

·      Common Exit Examination for graduates of state Faculties of Medicine

·      Licensing examination for overseas medical graduates

·      Successful completion of internship

There are over 26000 doctors registered with SLMC. These Medical graduates may work primarily in one of five different employment sectors i.e. (1) Ministry of Health, (2) university sector (3) private sector, (4) defense services (5) overseas. It is estimated that 70 % of active registrants are employed in the Health Ministry, 3% in the universities, about 12% in the private sector, and the remaining 15% are overseas.

Examination for Registration to Practice Medicine (ERPM)

The objective of this Licensing Examination is to determine whether the graduate is fit to do internship and fit to practice medicine in Sri Lanka. This is due to the fact that clinical teaching and the relative emphasis on various aspects of training differ from country to country due to variations in the pattern of disease prevalence, the facilities and resources available for the provision of health services. This is a part of a system is in place to absorb overseas qualified doctors into the country's medical cadre after an examination which evaluates their factual knowledge, skills and their suitability to practice medicine in Sri Lanka as the training they receive in overseas medical schools is not uniform and lacks exposure to Sri Lankan context.

In order to be eligible to sit for ERPM;

·      Should be a citizen of Sri Lanka

·      Should possess a MBBS degree or equivalent qualification obtained abroad, from a medical school recognized by the SLMC

 SLMC has taken measures to streamline the process of recognizing medical schools

When the SLMC gives "recognition" to certain medical schools overseas, it means that Sri Lankan students, who obtain medical degrees from these medical schools, will be eligible to sit for the ERPM.

The ERPM is designed to ascertain whether medical graduates qualified at medical schools overseas possess appropriate knowledge, skills and attitudes for clinical training and patient care as an intern medical officer under local conditions.

In 2005 the Education Committee of SLMC carried out a major review of the ERPM. Recommendations were made to have a new format for the examination so that it would serve to test the following competencies:

·      Core knowledge of common communicable and non-communicable diseases and their prevention.

·      Ability to make a provisional diagnosis and plan initial management.

·      Ability to adapt to the facilities and resources available in the hospital.

·      Basic knowledge of the healthcare structure and the medico-legal system in Sri Lanka and the responsibilities of medical practitioners.

The new format ERPM that was implemented in 2014 has four parts.

Part A - The written component (MCQ) in the medical and surgical tracks

Part B - A clinical assessment in medical and surgical tracks

Part C - An oral examination on Emergency Medicine

Part D - The written component in Community Medicine and Forensic Medicine

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One frequent criticism against ERPM is that the pass rates are very low.

An analysis conducted by SLMC in 2010 puts this misconception on low pass rates into perspective.

In June/July 2008, 34% of those who sat completed the ERPM; in Nov/Dec 2008, 46.5% and in May 2009, it was 42%. The examination was conducted by SLMC. From September 2009, as per a Supreme Court order, the University Grant Commission (UGC) was asked to conduct the ERPM. Overseas medical graduates had to then sit the common MCQ papers that students from state medical schools sit. The pass rate in the written papers, which was previously about 30%, plummeted to 6.1%. In December 2009, 10.3% passed the common MCQ papers, and in April 2010, 9.3%. Thereafter, overseas medical graduates requested that the responsibility of conducting ERPM to be handed over back to SLMC.

It is relevant to point out that licensing examinations in the overall world are not easy to pass. E.g. In the UK, about 15% pass the licensing examination called the PLAB (Professional and Linguistic Assessments Board) test; about 50% them pass the Part I and only about 7.5% pass the PLAB Part 2 of those who sit.

Some of the overseas medical graduates may not sit for ERPM. Since 1999, 2264 have obtained approval of their degrees to sit the ERPM. Of those registered to sit the ERPM between 1999 and 2005, about 234 have not sat the ERPM. Of those registered between 2005 and 2009, 219 have not sat the ERPM.

In the past, there was no restriction on the number of attempts that a candidate can sit for the examination. In comparison, the students who enter state medical schools in Sri Lanka have to leave if the medical course has not been completed in 10 years after commencement.

The number of candidates who sit for the ERPM has increased during recent years. In the past it ranged from 300 to 400. However, over 750 candidates sat for the last ERPM. The pass rates too have increased with over 50% passing the theory component. This may be due to multiple reasons;

1.     Implementation of higher entry criteria that was implemented by SLMC since 2010

2.     Streamlined application of Minimum standards of medical education in recognizing medical schools by SLMC

3.     Extensive tutoring and coaching now available for ERMP applicants.  

4.     The new format of ERPM, which is more candidate-friendly than the previous version.

However, the pass rates in the clinical component still remain low (approximately 30%). This, coupled with the extensive coaching most of the candidates require to pass the ERPM points out towards the possible deficiencies in the training they receive and those medical schools. This calls for strict application of Minimum standards in medical education across the board, i.e. for state as well as overseas medical schools.

Ranking for Internship

Allocation of places for internship is extremely competitive. Currently this is done by ranking all medical graduates who are eligible for internship into a common merit list. This common merit list is also considered in deciding on subsequent appointments in the Ministry of Health. Graduates who top the list can opt for an internship in a hospital of their choice before those placed below them.

All state medical graduates qualifying are ranked in a single list, based on a common multiple choice (MCQ) and a clinical examination. Students from a single intake sit for two different common MCQ examinations, which were held 6 months apart, in two different calendar years. Students sitting in both exams are pooled into a single common merit list assuming uniform standards.

Fifty percent of the marks, which goes into formulation of the common merit list is from the common MCQ examination and the remaining fifty percent is from the standardized marks obtained in the clinical components of the final MBBS examinations of respective universities. Participation of external examiners from other universities is to maintain uniform standards across universities.

Overseas medical graduates are included in the formulation of common merit ranking order based on their ERPM performance.

In conclusion, Sri Lanka has systems in place for selection, licensing and ranking of medical doctors. However, each of these steps has some loopholes that can be manipulated by those with vested interests. Proper implementation of minimum standards in medical education is an essential condition to prevent these manipulations.

The next article will further discuss these issues as well as the need for continuous professional development (CPD). CPD is a phase in medical education that needs more a