Farhan Raza Khan BDS, MS, MCPS, FCPS
There are two known pathways of becoming an accredited dental specialist in Pakistan.
1. Residency training under supervision of clinical faculty (FCPS)
2. University based post-graduation (MDS)
FCPS training is based on an apprentice model in which a master trainer mentors the apprentice and inculcates his/ her skills into the junior doctor with an objective to transform the apprentice into a skilled craftsman.
Strength of this model is that it’s a time-tested way by which a senior passes down his/ her clinical skills to the young generation of clinicians. The leading surgical/dental institutions of the world such as Royal Surgical Colleges in England, Scotland, Ireland, Canada and Australia have been offering clinical training under their aegis adhering to this model. The College of Physicians and Surgeons of Pakistan too follows the footstep of the aforementioned prestigious institutions. The CPSP offers residency fellowship to the aspiring young dentists in five specialties of dentistry.1 The trainee has the privilege to receive a stipend for rendering his/ her services to the work institution as an employee. Another noteworthy strength of FCPS pathway of specialization is the impartial and neutral system comprising of series of assessments offered by the CPSP. There is a pool of examiners in each discipline who assess the basic competency of the trainees at entrance, intermediate and exit level examinations, thus eliminating any bias in favor or against the candidate. Lastly, the supervisor: trainee ratio is fixed by the regulating body (CPSP) at 1:8, thus an adequate supervision and training standards are ensured.2
Weakness of the FCPS model is that a substantial amount of trainees’ time is spent on provision of the clinical services than on academic scholarship. Less emphasis is paid on classroom teaching and limited focus is towards research. There is no spoon-feeding of knowledge. The FCPS residents follow the adult pedagogy of self- directed learning where the trainer merely acts as a facilitator rather than a teacher.
On the other hand, MDS training is based on class room teaching. Thus, it’s a taught program in which an MDS student pays a fee to the university for his/ her tuition. Strength of this variety of advanced training is that the tutor is bound to give lectures and training to the students. More time is given to writing mini-essays, term papers and research projects.
Weakness of MDS system is lack of uniform stringent criteria regarding induction of students in the training. Some institutions take admission test, some arrange interviews too and only a few have both but the majority of the institutions do not follow an impartial, needs blind system of admission into MDS. Thus, a meager student can easily make his/ her way into MDS and later makes life of supervising tutor difficult. Moreover, there are no third party assessments at the entrance and intermediate level examinations and a weak final assessment resulting in a high success rate at the exit examination. Thus, after graduation, an MDS (average duration 4-5 years) is fortunate to apply and compete for faculty positions and jobs, well ahead of their FCPS counterparts cohort (which on average takes 6-7 years to graduate), making MDS pathway quick and attractive for the students.
There may be more or less differences in the MDS and FCPS programs depending upon the training institution and the local needs. However, the two broad classes of specialization remain the same.
Why choosing between MDS and FCPS is a dilemma for dental graduates aspiring to become specialists? The reasons are following:
1. The pass rate in FCPS-II examination is low, resulting in frustration among candidates. This affects fresh graduates seeking easier way of becoming specialists.
2. The number of supervisor actually imparting FCPS training in dental specialties is strikingly low, resulting in an ever increasing list of trainees waiting for suitable match for training slot.
3. A number of dental colleges/ universities perceive that FCPS system is based on CPSP’s monopoly, so they want to nullify CPSPs influence by creating a parallel system of producing subject specialists.
4. Various dental colleges are run by businessmen rather than academics and for reasons of cost-effectiveness; they don’t want to pay any stipend to the FCPS trainees. On the other hand MDS students pay a tuition fee thus, having an MDS program is a win-win situation for the dental college business owners.
5. PMDC gives equal weightage to both the programs. Then what’s the point in joining the longer and difficult pathway (i.e. FCPS)?
At present, there is unrest among dental graduates as the number of MDS slots are gradually increasing and FCPS slots are decreasing (mainly because of point #4 and 5, mentioned above). Moreover, due to an acute dearth of paid FCPS training positions in dentistry, a big proportion of dental graduates who have passed their FCPS-I are left with no choice other than to join an MDS program.
The question is what would be the standing of the two programs in future? And can there be a middle ground to bring harmony, reciprocity or equivalency in the two systems of advanced education and training [especially in the clinical subjects]. The answer is not difficult. The royal surgical colleges in UK and Ireland have solved this equation several years ago. The Royal College of Surgeons (RCS) allows the two categories of dentists i.e. with higher clinical training (similar to our FCPS residency) and with University MClin Dent (similar to our MDS training) to sit in the exit level examination at single level playing field. Thus, whether trained at a hospital residency slot or via university post-graduation, a dentist will only be admitted into the specialist register of the UK-General Dental Council if he/she is successful at the membership examination of the RCS.3 With the same token, all Pakistani MDS students should mandatorily be asked to sit in the FCPS-II examination of CPSP at the end of their respective training so that all future specialists are subjected to same assessment criteria before being labeled as a specialist at national level.
To uplift the bar even higher, only those students should be allowed to write the MDS admission test, who have already passed their FCPS-I exam. This would not only limit the unnecessary sub-standard influx into the MDS training but would also ensure that such positions are offered to the brightest candidates only. With an entrance and exit level examination of FCPS system, the MDS students will get dual qualifications with their names i.e. MDS-FCPS within their four year training compared to just one diploma conferred to their counterpart trained in FCPS residency slots alone. This proposal may appear difficult at the outset as it hits the vested interests of dental college business owners but if given a thoughtful chance, may turn out to be a workable solution for the larger interest of dental community in Pakistan.
Lastly, without being biased, let’s ask ourselves a simple question. A 3- year old child is scheduled for a complex surgery operation under general anesthesia and the parents are indecisive in choosing a surgeon to operate upon their child. Doctor A has a master’s degree in Surgery from a University, has successfully defended a Master’s thesis and serves as teacher to undergraduate students as well. Whereas, surgeon B possesses a mere clinical diploma (FCPS in this case) acquired after residency training in a busy hospital but has no class room teaching experience. Both doctors have equal years of experience after post-graduation. For a well-informed family, the choice in this scenario should not be too difficult; they are likely to go with the surgeon who has managed more pathology and have spent more hours in clinics, wards and operation room rather than in laboratory or class room.
To summarize, it’s apparent that for clinical specialties (Operative Dentistry, Orthodontics, Oral Surgery, Periodontics and Prosthodontics), the FCPS system has an edge whereas for basic dentistry subjects (such as Oral Biology, Oral Pathology, Dental Public Health, Dental Materials and Oral Anatomy), MDS is the recommended training pathway.
The author is an accredited FCPS supervisor of Operative Dentistry which may influence his point of view regarding the subject matter. The opinion stated above is solely of the author for which no institution or other individual is responsible.?
Consultant & Head of Dentistry Aga Khan University, Karachi, Pakistan
1. Khan FR, Mahmud S, Rahman M. The need of paediatric dentistry specialists in Pakistan. J Coll Physicians Surg Pak 2013; 23 (4): 305-7.