FOUNDATIONAL PROGRAM AND SPEX EXAMINATION
The Bahamas Medical Council (BMC) has been fielding many questions related to the Foundational Program (FP), the Special Purpose Examination (SPEX) and the Council’s licencing process. Change brings much uncertainty and we are aware that there is much angst among the physician community due to misinformation, poor communication and a general misunderstanding of the actions being taken by both the Ministry of Health/ Public Hospitals Authority and the BMC.
Passage of the Medical Act 2014 has resulted in certain changes in the requirements for Independent licensure (what was previously known as a “Section 9” licence). The three major changes compared to the previous Act are:
1. Creation of a Specialist Register and Licensure (those licences are pre-fixed with a “S” preceding the licencee’s licence number).
2. A requirement that candidates applying for the General Medical Licence have, after an approved Internship, complete “two years of a supervised rotational medical practice…” (Section 16 b ii). This would be accomplished by the two year Foundational Program.
3. The requirement of “twenty Continuing Medical Education (CME) Credits” for annual licence renewal. This was passed as an addendum to the Medical Act in 2015.
The BMC registers physicians upon receipt of an application and confirmation of legitimate medical education credentials. The registered physician is given a registration number which they will keep for their professional lifetime. In fact the BMC does not reuse registration numbers. The category of registration may change with a change (advancement) of the physician’s credentials and so may the category of their licensure. For example, one may be initially registered as an intern, but later acquire the credentials for the General Medical Licence or the Specialist Licence. In that instance they will be re-registered (and licenced) under the new section of the Act, even though they would keep their licence number. See the major categories of Registration and Licences, with the relevant Medical Act (2014) Sections cited, below:
Registered under Section 26(4)
Licenced under Section 29 (1)(a)
2. General Medical Practitioner:
Registered under Section 15
Licenced under Section 29(1)(a)
3. Public Hospitals Authority Physicians:
Registered under Section 22(3)(d)
Licenced under Section 29(1)(b)
4. Public Health Physicians:
Registered under Section 22(3)(c)
Licenced under Section 29(1)(b)
Registered under Section 22(2)
Licenced under Section 29(5)
In the main there are only two types of registrations posted and licences issued by the BMC:
1. Independent licences (specialty and general), which permit a physician to practice independently and unsupervised. (“1.” and “2.” above).
2. Non-independent licences, which are Provisional (these are not meant to be permanent). These licences are given to PHA and Public Health physicians only. The licences have always been meant to be time-limited in order to facilitate medical training, mentorship and clinical experience, as well as to facilitate employment of qualified physicians within the public healthcare services. It is imperative to emphasize that these licencees MUST BE SUPERVISED. They are not meant to practice independently and their practice is tied to an independently licenced physician/ physician practice (within the public system).
There has been a major escalation in the number of Bahamian physicians presenting themselves for licensure. These are mostly in the category of Interns and Senior House Officers (SHO’s).
We have been informed that the University of the West Indies (UWI) alone has some fifty Bahamian medical students in each year of their five year program. Many Bahamians who are studying in Cuba, China and other “Offshore” medical schools regularly apply to the BMC and the Ministry of Health for licensure and medical postings respectively. The PHA now hosts some forty-five Interns per year in their Internship Program. The PHA/ Ministry of Health has some three hundred SHO’s within their employ. The vast majority of these physicians are provisionally registered and licenced. And while many of these SHO’s have been employed for more than ten years most have not previously sought to acquire independent licences.
The requirements of the Medical Act 2014 has forced several responses from both the Ministry of Health and the BMC. Namely the institution of a formal two year, post internship supervised medical rotation program, the Foundational Program, and the SPEX examination.
The addition of this two year medical rotation was recommended by physicians in the Bahamian community and was never altered over the five or so years that the proposed changes to the Medical Act was circulated amongst them. The Foundational Program is the response by the Ministry of Health to provide the opportunity for physicians to meet these new criteria. As the largest employer of physicians, and because of their huge investment in medical education, the executives at Ministry of Health and PHA have graciously agreed to fund this Program in the hopes that it will improve the standards of practice, and facilitate the dispersement of trained public and private physicians throughout the archipelago.
Since the MOH/PHA annual salaries for SHO’s exceeds $16.9 million it was thought that this would allow the training of these young physicians and that many, on completion of their training, will opt to join Public Health to practice in our poorly served Family Islands, pursue specialty training or exit the public service into private practice. This would free up training spots for subsequent interns and medical students already in the pipeline.
It is worth remembering that All employees joining PHA at the dawn of the twenty-first century (PHA was incorporated in 1997)are contracted employees, with none exceeding three years per contract. Most SHO’s are hired under this regime and are regarded as “temporarily” employed, unlike their predecessors who are “Permanent & Pensionable”.
Not all physicians will need to participate in the Foundational Program. The Council has determined that those physicians (including SHO’s) who graduated from medical school in 2013, and earlier, would be “grand-parented in”. The rationale for choosing this particular year was because these physicians would have been eligible for their licences if they had applied prior to introduction of the new Medical Act. Additionally, it was felt that during those five years they would likely have had “supervised rotational medical practice”, whether during their day-to-day work, or moonlighting within the public clinics or PHA. As such they should have had reasonable exposure to most aspects of a general practice. These applicants may elect to rotate through the Foundational Program, in whole or in part, and may seek advice of the Council in making this decision. In order to determine their theoretical clinical knowledge, these candidates are still required to sit the SPEX.
Those applicants who have completed the UWI Family Medicine Diploma will be given credit for that experience and will not need to participate in the Foundational Program. These applicants will also have to take the SPEX exam.
Regarding the Family Medicine Program, we understand it to be a specialty program in which candidates hope to obtain the Doctor of Medicine Degree (DM). Upon completion of the DM, these physicians are awarded a specialty medical licence by the BMC. Neither the Ministry of Health nor the BMC have been approached by the UWI Family Medicine to administer the Foundational Program. It was suggested to the Ministry and the BMC that this would have overwhelmed their current program if the initial one hundred and fifty candidates (and possibly fifty participants per year subsequently) were to materialize. Also many rotations of our proposed Foundational Program include aspects of public health and community medicine not included in the first two years of the Family Medicine residency. As such it is proposed that the Foundational Program be a separate entity to the Family Medicine residency, even though their consultants have been invited as Preceptors. Interestingly, Great Britain has recently introduced a Foundational Program, that our locally proposed program mirrors, for the training of their general practice doctors prior to licensure.
Lastly, the Council’s SPEX exam was developed for the BMC by the Federation of State Medical Boards in the US. It is comprehensive, verifiable and objective. It is similar to the USMLE 3. An internet search will reveal that the SPEX is now also offered to candidates in other countries to fulfill multiple requirements. Previously the Council attempted to get the Caribbean Association of Medical Councils (CAMC) to create a second tier exam to fulfill these requirements, as the CAMC 1 exam now helps us assess non-UWI graduates for Internship positions. However CAMC has yet to develop such an exam. The SPEX will not be part of the Foundational Program. They each fulfill different requirements, the Foundational Program is a clinical/ practical course and the SPEX, like the USMLE 3, evaluates theoretical clinical knowledge. Candidates will have to prepare separately for this exam as they do for any other exams like the SAT, MCAT, British GMC’s PLAB and so forth.
We are hopeful that our physician colleagues will acknowledge the need to maintain high standards, seek the best possible outcome for the health of citizens in our nation and encourage mentorship and teaching within the profession.
Mark Weech, M.B.,B.S.