A Questionnaire-Based Survey of Physical Medicine and Rehabilitation Residency Training in Pakistan

Pakistan is one of the three countries in South East Asia that has an active postgraduate physical medicine and rehabilitation (PM&R) training program. College of Physicians and Surgeons Pakistan (CPSP) offers a four-year structured training program in PM&R. It consists of clinical teaching, lectures, rotations in other specialties, and writing a research dissertation. The aim of this survey was to provide an objective analysis of the current PM&R training program, including the facilities available for training, the participation of residents in academic activities, and their participation in different PM&R procedures. Hospital ethics committee approval was obtained. The questionnaire had sections on informed consent; basic demographics; the different components of residency training; and self-assessement of competence in different procedural skills. It was approved by the dean of PM&R at CPSP. There are six accredited training centers in Pakistan. Twelve residents are undergoing residency training at four different centers (Dec 2015). Key persons were nominated at each center to facilitate data collection. All residents (100% response rate) completed the survey. Almost all had read the CPSP training manual. Most had submitted the research dissertation. Training facilities varied across different centers, with the military center being the best equipped. The self-assessed competence of residents in different PM&R procedures varied among different centers, but overall it conformed to the competency levels specified in the training manual. Overall PM&R residency training in Pakistan is satisfactory, but there is a need to strengthen the weak areas and standardize the training across all centers in the country.


Introduction
Pakistan is one of the three countries in South East Asia that has an active postgraduate physical medicine and rehabilitation (PM&R) training program (the others being India and Bangladesh). College of Physicians and Surgeons Pakistan (CPSP) offers the only postgraduate 1 2 3 4 Measuring the quality of residency training programs is imperative to produce competent doctors and ensure patient safety [4]. Critical analyses and evaluations of residency training programs in different specialties have been published globally [5][6][7][8]. They help identify weaknesses, highlight strengths, and recommend future directions for their programs.
We were unable to locate any published analysis of any residency program in Pakistan. The aim of this study is to provide an overview from the residents' perspective of the current PM&R residency program in Pakistan, including the facilities available for training, the participation of residents in academic activities, and their participation in different PM&R procedures.

Questionnaire development
The authors designed a self-administered questionnaire after mutual consultations and discussion. The authors are attending physicians in PM&R with professional experience ranging from 6-15 years. They are registered as faculty members in PM&R with the Pakistan Medical and Dental Council (PM&DC). Two of the authors (AWB and NS) were among the pioneer batches of residents who qualified FCPS-II in PM&R more than a decade ago. AWB, NS, and NA are current faculty members at CPSP and have been examiners and supervisors in PM&R for more than five years. NA is the only physiatrist in Pakistan with a degree in medical education. The lead author (FR) did clinical observerships in PM&R at leading institutes in the US, where he had a chance to closely observe the PM&R residency training program there and interact with the residents and faculty members. The questionnaire was sent for review and comments to the dean of the PM&R department at CPSP, who approved the content and format. The ethics review committee of the Armed Forces Institute of Rehabilitation Medicine (AFIRM), Rawalpindi, approved the research.
The questionnaire had four parts. The first part was informed consent, which explained the title and rationale of the study. It also assured the respondents of their anonymity, and that it would have no impact on their residency training in future or on their evaluations. The second part consisted of demographic data. It had questions about respondents' age, gender, institute, and year of residency training. The third part consisted of 21 questions. The respondents had to answer "Yes" or "No". The questions inquired if the resident had studied the PM&R training manual published by the CPSP; whether inpatient setup for training was available; whether regular clinical teaching rounds were carried out; and if training in electrodiagnostics was available in their department. It also asked about the residents' participation in national and international PM&R conferences, and if they had made posters or oral presentations. Residents were asked about their primary textbook for PM&R and their library or personal subscriptions to PM&R journals. In the end, residents were asked about their plans to go abroad for further training after completing the residency program. The fourth part assessed the self-reported training level of residents in 11 different PM&R procedures. These included procedures required as core competencies in the training manual and some additional procedures. Residents had to mark themselves at one of the four levels: performed independently; performed under supervision; have only observed the procedure; and have not observed or performed the procedure. These are the levels of competency specified in the CPSP training manual.
At the end, space was provided for additional comments. Residents were thanked for their time and were again assured that responses will remain confidential and will not have any effect on their training and assessment.

Data collection procedure
Data collection was done in Nov-Dec 2015. There are four centers with an active PM&R residency training program in Pakistan, with 12 residents undergoing training. The four residents enrolled in the FCPS training program at the Department of Physical Medicine and Rehabilitation, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia, were excluded from this survey. A supervisor or a key resource person at the institute was approached for the data collection. Each was briefed in advance and was provided written guidelines to facilitate the data collection (see Appendix). All residents gave consent to participate in the survey. The residents at each center were provided a blank copy of the questionnaire in an unmarked envelope. The questionnaire response time was estimated to be approximately 10 minutes. Therefore, respondents were requested to fill in the questionnaires on the spot. The email address and phone number of the corresponding author was provided for questions and clarifications. The residents completed the questionnaire, placed it in the unmarked envelopes, sealed it, and handed it over to the key resource person. Response rate was 100%. No financial or other compensation was offered for completing the survey.

Data analysis
Data were analyzed using Statistical Package for the Social Sciences (SPSS) V 20 (IBM, New York). Descriptive statistics were used to compute the frequencies of basic demographics (age, location of institute) and different responses while mean and standard deviation (SD) was calculated for age.

Results
There were 12 residents from four centers, totalling 100% of the resident population (   Residents' self-assessed competence in different PM&R procedures varied between different centers, but overall it conformed to the competence levels specified in the training manual. Most of the residents had independently passed an indwelling catheter (n=10), done manual muscle testing (n=10), had managed autonomic dysreflexia (n=7), and had performed an intraarticular injection of the knee or shoulder for pain management (n=7). Three residents had observed the procedure of urodynamics and the rest (n=9) had not. Only one fourth year resident had done independent electrodiagnostic studies while three had done so under supervision. (All of them were from a single center: AFIRM) ( Table 3).

Discussion
This is the first survey from Pakistan that analyzes PM&R training programs. It included all residents currently enrolled in the FCPS residency training program in Pakistan. Although the number of residents enrolled in the various CPSP fellowship programs (Nov 2015) is more than 21,276 [9], only 12 of these are from PM&R. In addition, two training centers are dormant. This should be a matter of concern, and steps should be implemented to increase the number of PM&R residents in future in order to combat the rising burden of disability in Pakistan. One of the reasons for this low number of PM&R residents might be lack of exposure regarding PM&R among medical students [2].
The survey revealed wide variations in the residency programs at different centers. Some centers are well-equipped and have all the elements of residency training (including lectures, teaching rounds, adequate infrastructure, and regular assessment), while other centers lack these facilities. Although most of the residents had read the CPSP training manual for PM&R, the manual itself was written in 2002. It was recently revised in 2016, by incorporating the recent advances in PM&R. Now there is a need to implement all the elements of training mentioned in the manual in the residency training programs across the country.
Inpatient rehabilitation is an essential element of training for residents. This facility is available only at two military centers (AFIRM, Rawalpindi, and CMH, Peshawar). Training based only on outpatient consultations and attending calls from other specialties lacks critical components in teaching the essential principles of PM&R. This needs to be addressed in order to improve the training.
Electrodiagnostic training facilities are available only at the military training centers, and the residents from the other two centers visit these military centers for training in electrodiagnostics. A system of periodic assessment by monthly or quarterly exams can assess if the residents are learning the required skills and advancing their knowledge. Assessments in the form of written exams, viva voice, and task-oriented assessments of clinical skills are regularly done at three centers.
Journal club meetings form an important component of residency training in any specialty. They encourage regular consultation of the literature and can result in enhanced medical knowledge, improved patient care, better understanding of biostatistics and research competency, and better critical literature appraisal skills [10][11][12]. This activity is regularly conducted at most PM&R training centers, although the format and content varies among centers. Mostly, it is limited to selecting and presenting a recent review article on a topic and then discussing its relevance and application to local circumstances. There is a need to revise the current format to include original research articles and incorporate the principles outlined by Deenadayalan, et al. [13].
The residents do not have institutional access to PM&R journals. This problem is not specific to PM&R, but probably reflects the lack of well-established medical library services in the majority of institutes and hospitals in Pakistan.
Medical research and writing is rapidly progressing in Pakistan [14]. There has been a paradigm shift in the research output of Pakistani physiatrists in the last decade, and residents and young fellows are spearheading much of this change. This is also evident from this survey. Most of the residents had received training in medical research and writing, mostly in the form of lectures and workshops on research writing. This training was in addition to the mandatory workshops by CPSP on communication skills, research writing, biostatistics, and internet skills [15]. This was not the case a decade ago. Many current residents have had their mandatory dissertation synopsis approved, and some have already completed their dissertation writing. Residents' involvement in research and writing from the start equips them with the essential skills that will help them survive in a competitive academic environment marked by the pressure to publish or perish. PM&R residents have already been making their mark: the residents from AFIRM have been participating in the annual Research Neurology Day at Shifa College of Medicine, Islamabad, since 2007; they have won many grants and other prizes for best posters and oral presentations.
Due to the large volume of patients they see, the residents are exposed to a diverse range of patients with different diseases. This is a strength of the current training system, and it allows residents to examine a large number of patients and see nearly all the diseases mentioned in textbooks. FR noticed during his stay in the US that the annual average number of patients with stroke, spinal cord injury (SCI), pediatric disabilities (particularly cerebral palsy and myopathies), and rheumatologic disabilities seen by a Pakistani PM&R resident was much higher than the number of patients seen by a resident working in the US. This might be a reason why almost all the residents surveyed appeared to have achieved the procedural competencies outlined in the training manual.
Many physiatrists who have qualified from the current PM&R residency program in Pakistan have travelled abroad for clinical observerships and fellowships. Some of them are working as attending physicians in the Middle East. This is a testimonial to the rigorous quality of the current residency program in Pakistan.
Some major revisions are underway to improve the current PM&R residency training program in Pakistan. These include revision of the training manual, recruitment of new faculty members, faculty development workshops, improving the examination structure, and introducing an intermediate module at two years of training. It is hoped that these changes will lead to a better and stronger PM&R residency training program that will be able to produce physiatrists better equipped to face the growing burden of disability in Pakistan.

Strengths and limitations
This is the first survey to present an objective analysis of the PM&R residency training program in Pakistan. We successfully gathered data from all residents based in Pakistan. The survey has comprehensively addressed the different aspects of the residency training program being carried out by CPSP.
The survey did not include the opinions and feedback of the course directors and supervisors. We did not formally assess residents' competency level in procedural skills or knowledge domains. In addition, comparisons with similar residency programs in other subjects or with PM&R residency programs in other countries was not made.

Recommendations for the future
The PM&R residency program in Pakistan is structured, competitive, and offers many opportunities to the willing resident to learn. However, there is a need to standardize the training across the country. Moreover, there is a need to develop subspecialty programs in PM&R, including spinal cord injury medicine, pediatric rehabilitation, neurorehabilitation, cancer rehabilitation, cardiac rehabilitation, etc.
Plans are already underway to conduct a similar and more comprehensive survey in Bangladesh and India to assess and compare PM&R residency programs across countries in the same region. In addition, a SWOT analysis of the current PM&R training program will be conducted by getting structured feedback from all stakeholders (residents, supervisors, examiners, and faculty members). PM&R training varies across different countries, with each system having its unique strengths and peculiar weaknesses. Therefore, there is a need for closer collaboration and coordination between different national examining and accreditation bodies, the International Society of Physical and Rehabilitation Medicine (ISPRM), different regional societies (e.g., European Society of Physical and Rehabilitation Medicine (ESPRM), Asia-Oceania Society of Physical and Rehabilitation Medicine (AOSPRM)), and subspecialty societies so that a curriculum and minimal competency levels of training can be defined for PM&R training across the globe.

Conclusions
The residency training program in PM&R in Pakistan is relatively young but has substantially improved in the last decade. This model can be successfully implemented in similar low resource areas to facilitate the development of academic PM&R. There is a need for continuing improvement and the implementation of the current curriculum uniformly across all training centers in order to produce better-qualified physiatrists.
The developed regions should facilitate the transfer of PM&R knowledge to low resource countries and promote residents and faculty exchange programs in order to develop PM&R in the developing world.