If you are a medical student in the country right now, especially a recent graduate, you would know what NLE is: the newly introduced licensing exam which has led to mass protest among doctors and medical professional communities in the country. In fact, the test, which was scheduled on this Friday, has now been postponed to Sunday due to protests outside the venue - Sapphire Hall, in Garden Town, Lahore - where peacefully protesting students were met with a baton charge, shelling and violence by the police.
Here is a deeper look into why students are opposed to the exam and want the PMC Act to be reversed.
The PMC Act
The national licensing exam is a part of the new rules and regulations under the PMC Act 2020. The background of this goes back to October 2019, when the Pakistan Medical and Dental Council (PMDC) was dissolved and replaced by the Pakistan Medical Commission (PMC) following President Arif Alvi’s signing of the Pakistan Medical Commission Ordinance 2019. The move was done in order to improve and standardize medical education, training and recognition of qualifications in medicine.
According to the PMC Act and under section 21 of the PMC Ordinance 2019, the NLE will be conducted twice a year as per the schedule approved by the Council. Passing the NLE shall be mandatory for obtaining a full licence – for both students holding an undergraduate medical/dental qualification from the country or any foreign institution duly recognized by the Council. However any student holding a foreign undergraduate degree and a postgraduate qualification from Pakistan will be exempted from NLE.
An ex post facto law Although the primary reason for the introduction of NLE is the standardization of medical education in Pakistan, it has received a lot of objections from the medical community. The first one is the fact that the exam is being introduced from March 2020. Thus it cannot be held legally, as pointed out by a number of people, because the PMC Act is an ex post facto law – which simply means that it cannot apply to batches of students admitted to medical colleges before the PMC Act itself was introduced! At the very least, students till the batch of 2024 should be exempted from the exam.
Perhaps the most important questions being raised by students are about the centralization and standardization of the exam. Pakistan has been unable to successfully hold even the National Medical and Dental College Admission Test (NMDCAT), which was also a part of the PMC Act
As such, the introduction of medical assessments is not a new thing. It is the mechanism followed which matters, so as to prevent applying ex post facto legislation.
In fact, an excellent example of this is the United Kingdom Medical Licensing Assessment (UKMLA), a two-step licensing exam which is going to be applicable on all international medical graduates and UK graduates (who were previously exempted from the Professional and Linguistic Assessments Board test or PLAB) from early 2024. In this case, the first suggestion for the exam was made in 2005 and the official announcement was made by the General Medical Council in 2017 – almost 6 years before the actual exam is going to be conducted. Meanwhile, here in Pakistan, the PMC is holding the exam within less than one year of the introduction of the PMC Act.
NLE versus its British and US equivalents
The Special Assistant to the Prime Minister on National Health Services (NHS) Dr. Zafar Mirza has called the NLE the best filter to ensure that only competent doctors are allowed to practice in the country. He made a point that such exams are taking place in other countries, like the United States Medical Licensing Examination (USMLE) in the United States and the aforementioned Professional and Linguistic Assessments Board (PLAB) in the United Kingdom.
Students respond to Dr. Zafar Mirza by arguing that there is no reason to hold a national exam when all medical students appear in standardized annual professional exams every year (5 in total). This is in addition to other professional qualifications including IMM, FCPS- M-S/MD parts 1 and 2, etc – hence there is no need to burden the students any further. In contrast with medical education in Pakistan, we find that in the United States, there are no annual professional exams. According to the examination’s official website, “the USMLE is not administered immediately after graduation but students actually take the USMLE Step I when they are halfway through medical school, then the Step II closer to the end of medical school and Step III before the end of their internship [house job] year.”
Another worrying aspect is that through the introduction of the new ordinance and assessment exam, influential private college owners are under no obligation to keep a minimum mandatory strength of qualified faculty – as most of the burden for regulation and quality of education would now fall on the Medical Commission
Similarly, it is also worth mentioning that similar to the USMLE, the UK’s licensing examination - discussed earlier in this article - will be introduced and undertaken as part of the medical school degree programme. It will not be an isolated examination with an unknown format and undeclared outcomes, imposed suddenly after graduation - which is what the NLE is!
Hence, one must disagree with Dr. Zafar Mirza, for there remains no real reason for comparing this NLE with licensing examinations in the US or UK.
Lack of standardization
Perhaps the most important questions being raised by students are about the centralization and standardization of the exam. Pakistan has been unable to successfully hold even the National Medical and Dental College Admission Test (NMDCAT), which was also a part of the PMC Act. This single uniform test for all public and private colleges became notorious last year because of a number of ambiguities, including difference of syllabus among provinces, problems with multiple-choice questions (MCQs) as well as the pandemic situation resulting in court cases – some of which are still going on.
(Image Credits - AP Photo/Fareed Khan)
If we cannot hold a single entrance test, how would we ensure a competitive and credible test for young medical professionals?
Leeway for the private sector
Many senior doctors and faculty members have labelled the NLE as an eyewash by the PMC, since it is unable to hold up standards in medical colleges. Our medical professionals argue that the PMC's mismanagement has already resulted in many shady and substandard medical colleges operating in the country.
Another worrying aspect is that through the introduction of the new ordinance and assessment exam, influential private college owners are under no obligation to keep a minimum mandatory strength of qualified faculty – as most of the burden for regulation and quality of education would now fall on the Medical Commission. And the latter body will inevitably fail, because the NLE has been imposed abruptly and without any visible professional preparation; with unknown outcomes, format and mechanisms of examination.
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The many objections raised by students, which we have examined above, all point towards the fact that the NLE is going to be a problem - not merely for students, but an even bigger one for the regulatory body itself, because Pakistan like all other countries is required to keep up with the standards of international bodies like the World Health Organisation (WHO). If the country fails to do so, then it faces the threat of having its name removed from the World Directory of Medical Schools by the year 2023, and, as a consequence, all of Pakistan’s medical graduates will have no recognition of their degrees in the rest of the world. That would be an alarming situation.
Before we conclude, it bears mentioning that it is highly discouraging for both doctors and medical students to be treated so unprofessionally. They are not only some of the country's most hard-working students and professionals, but are also fighting Covid on the front lines.
For them to not be heard and simply forced to abide useless and poorly conceived laws is quite unacceptable.
