COLLEGE OF PHYSICIANS AND

SURGEONS PAKISTAN

IMM AND POST-IMM TRAINING: TOTAL DURATION 5 YEARS

 THIS IS AN EVOLVING DOCUMENT
The College of Physicians and Surgeons Pakistan
would appreciate any criticism, suggestions, advice from the
readers and users of this document. Comments may be sent in
writing or by e-mail to the CPSP at:

DIRECTORATE OF NATIONAL RESIDENCY PROGRAM (DNRP)

College of Physicians and Surgeons Pakistan (CPSP)
7th Central Street, Defence Housing Authority, Karachi-75500.
[email protected]
 CONTENTS

About The College 01

CPSP Competency Model 04
Roles and Responsibilities Supervisor 10
Roles and Responsibilities Resident 12
General Regulations 13
Training Program 18
Intermediate Module (IMM)
General Surgery Training for IMM (First Year) 23
Syllabus 28
Procedural Competencies 31
Neurosurgery Foundation IMM (Second Year) 36
Syllabus 38
Procedural Competencies 40
Assessment 43
Post Intermediate Module (FCPS-II)
Neurosurgery Training (Year 3-5) 52
Syllabus 54
Procedural Competencies 57
Assessment 63
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FELLOWSHIP TRAINING
 ABOUT THE
COLLEGE

The College was established in 1962 through an ordinance

of the Federal Government. The objectives/functions of the
College include promoting specialist practice of Medicine,
Obstetrics & Gynaecology, Surgery and other specialties by
securing improvement of teaching and training, arranging
postgraduate medical, surgical and other specialists training,
providing opportunities for research, holding and conducting
examinations for awarding College diplomas and admission to
the Fellowship of the College.
Since its inception, the College has taken great strides in
improving postgraduate medical and dental education in
Pakistan. Competency- based structured Residency Programs
have now been developed, along with criteria for accreditation
of training institutions, and for the appointment of supervisors
and examiners. The format of examinations has evolved over
the years to achieve greater objectivity and reliability in
methods of assessment. The recognition of the standards
of College qualifications nationally and internationally,
particularly of its Fellowship, has enormously increased the
number of residents and consequently the number of training
institutions and the supervisors. The rapid increase in
knowledge base of medical sciences and consequent
emergence of new subspecialties have gradually increased
the number of CPSP fellowship disciplines to eighty one
including specialties in dentistry.
After completing two years of core training during IMM, the
residents are allowed to proceed to the advance phase of
FCPS training in the specific specialty of choice for 2-3 years.
However, it is mandatory to qualify IMM examination before
taking the FCPS-II exit examination. The work performed by
the resident is to be recorded in the e-Iogbook on daily basis.
The purpose of the e-Iog is to ensure that the entries are
made on a regular basis and to avoid belated and fabricated
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entries. It will hence promote accuracy, authenticity and

vigilance on the part of residents and the supervisors.

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1
 The average number of residents taking CPSP examinations
each year is to a minimum of 32,000. The College conducts
examinations for FCPS-I (11 groups of disciplines), IMM,
FCPS-II (81 disciplines), MCPS (22 disciplines), including MCPS
in Health Professions Education and Health Care System
Management. A large number of Fellows and senior medical
teachers from within the country and overseas are involved at
various levels of examinations of the College.
The College, in its endeavor to decrease inter-rater variability
and increase fairness and transparency, is using TOACS (Task
Oriented Assessment of Clinical Skills) in IMM and FCPS-II
Clinical examinations. Inclusion of foreign examiners adds to
the credibility of its qualifications at an international level.
It is important to note that in the overall scenario of health
delivery over 85% of the total functioning and registered health
care specialists of the country have been provided by the CPSP.
To coordinate training and examination, and provide assistance
to the residents stationed in cities other than Karachi, the
College has established 14 Regional Centers (including five
Provincial Headquarter Centers) in the country.
The five Provincial Headquarter Centers, in addition to
organizing the capacity building workshops/short courses also
have facilities of libraries, I.T, and evaluation of synopsis and
dissertations along with providing guidance to the residents in
conducting their research work.
The training towards fellowship can be undertaken in more than
306 accredited medical institutions throughout the country and
84 accredited institutions abroad. The total number of residents
in these institutions is over 32,659 who are completing
residency programs with around 5,245 supervisors. These
continuous efforts of the College have even more importantly
developed a credible system of postgraduate medical
education for the country. The College strives to make its
courses and training programs ‘evidence’ & ‘needs based’ so
as to meet international standards as well as to cater to the
specialist healthcare needs not only for this country but also for
the entire region.
Prof. Khalid Masood Gondal
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President
College of Physicians and Surgeons Pakistan

2 FELLOWSHIP TRAINING
 FELLOWSHIP DISCIPLINES
The list of fellowship programmes, first & second fellowship,
are given below:
Disciplines for First Fellowship
1. anatomy 24. nuclear medicine
2. anesthesiology 25. obstetrics and gynaecology
3. biochemistry 26. operative dentistry & endodontics
4. cardiac surgery 27. ophthalmology
5. cardiology 28. oral & maxillofacial surgery
6. cardio thoracic anaesthesia 29. orthodontics
7. chemical pathology 30. orthopaedic surgery
8. clinical haematology 31. otorhinolaryngology (ent)
9. community medicine 32. paediatric surgery
10. dermatology 33. paediatrics
11. diagnostic radiology 34. periodontology
12. emergency medicine 35. pharmacology
13. family medicine 36. physical medicine & rehabilitation
14. forensic medicine 37. physiology
15. haematology 38. plastic surgery
16. histopathology 39. prosthodontics
17. immunology 40. psychiatry
18. medicine 41. pulmonology
19. medical oncology 42. radiation oncology
20. microbiology 43. surgery
21. nephrology 44. thoracic surgery
22. neurology 45. urology
23. neurosurgery 46. virology
Disciplines for Second Fellowship
1. breast surgery 20. paediatric endocrinology and
2. child and adolescent psychiatry diabetes
3. clinical cardiac electrophysiology 21. paediatric dermatology
4. community & preventive paediatrics 22. paediatric gastroenterology and
5. colorectal surgery hepatology
6. critical care medicine 23. paediatric haematology oncology
7. developmental and behavioural 24. paediatrics infectious diseases
paediatrics 25. paediatric nephrology
8. endocrinology 26. paediatric neurology
9. gastroenterology 27. paediatric ophthalmology &
10. gynecological oncology strabismus
11. hepato-pancreato-biliary & liver 28. pain medicine
transplant surgery 29. palliative medicine
12. infectious diseases 30. reproductive endocrinology and
13. interventional cardiology infertility
14. interventional radiology 31. rheumatology
15. maternal & fetal medicine (mfm) 32. spine surgery
16. neonatal paediatrics 33. surgical oncology
17. orbit and oculoplastics 34. urogynaecology
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18. paediatric cardiology 35. vitreo retinal ophthalmology

19. paediatric critical care medicine 36. vascular surgery

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 CPSP
COMPETENCY
MODEL
College of Physicians and Surgeons Pakistan has moved to
competency-based medical education and has developed its
own competency model shown below. A generic explanation of
the model is given below and it is expected that all its residency
training programmes follow the components of this model in
accordance to the requirements of each specialty.

Patient or population care occupies the pivotal center. Patient

care includes all clinical skills such as history taking, physical
examination, ordering investigations, making diagnoses and
managing the care. The inner leaves of the model represent
the five major competencies directly related to patient care,
while the three competencies in the outer circle are mega-
competencies related to patient care and also incorporate
education, professionalism, leadership, advocacy and
population health.
By the end of the Residency Programme, residents are expected
to acquire these competencies and their constituent learning
outcomes, and provide promotive, preventive, curative and
rehabilitative patient-centered (or population-centered) care.

Inner Leaves:
1. Knowledge and Critical Thinking
2. Technical Skills
3. Communication Skills
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4. Teamwork
5. Research

4 FELLOWSHIP TRAINING
 Outer Leaves:
6. Professionalism
7. Pedagogy
8. Advocacy

1. Knowledge and Critical Thinking

• Demonstrate application of wide and current readings to
critical thinking and problem solving
• Relate the alteration of body function to the presenting
condition
• Interpret and integrate history and examination findings to
arrive at an appropriate provisional and credible
differential diagnoses
• Sequentially order, justify and interpret appropriate
investigations
• Apply knowledge and reasoning skills to
• Analyze data for problem identification and to rule in
and rule out contending conditions
• Synthesize and evaluate solutions for decision-making
in solving familiar and less familiar problems based on
best current evidence
• Prioritize different problems within a time frame.
• Select, outline and provide, with evidence-based
justifications, appropriate pharmacological and
non-pharmacological management strategies
• Assess new medical knowledge and apply it to resolve
patient problems (Evidence-based practice)
• Apply quality assurance procedures in daily work.
(Professionalism)
• Demonstrate shared-decision-making with the patient
or family
• Provide cost-effective care while ordering investigations
and in management
• Use resources appropriately
• Demonstrate awareness of bio-psycho-social factors in
assessment and management of a patient.
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 2. Technical Skills
• Demonstrate International Patient Safety Goals (IPSG)
• Demonstrate competent performance of all required
technical skills and procedures in the specialty, including:
• Obtaining informed consent
• Preoperative planning
• Pre-interventional care and preparation
• Intervention technique including exposure and closure,
global and task specific items, and
communication and team skills
• Post-interventional care
• Follow-up Care.

3. Communication Skills
• Written Communication Skills
• Maintain clear, concise, accurate and updated medical
records
• Write clear, focused, evidence-based and logical
management plans and discharge summaries
• Write respectful, clear and focused letters and referrals
to other colleagues.
• Verbal Communication Skills: Demonstrate
• Effective interpersonal communication skills: clear,
considerate and sensitive towards patients, their
relatives, other health professionals and the public, and
towards students
• Non-verbal communication skills:
• Empathy and respect towards patients and their
relatives
• Effective counseling of the patient and the family with
cultural sensitivity: explain options, educate them and
promote joint decision-making.
• Appropriate verbal and body language on the campus
and all work situations including seminars, bedside
sessions, outpatient sessions and others
• Respect and tolerance for all health care professionals,
including peers, juniors and seniors
• Clear, focused and logical presentation of cases.
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6 FELLOWSHIP TRAINING
 4. Teamwork
• Demonstrate constructive team-communication skills.
• Facilitate collaborative group interaction as a team
member to build strong teams demonstrating respect,
tolerance and interdependence.
• Support other team members to grow
• Demonstrate willingness to assume responsibility and
leadership as needed.

5. Research
• Interpret and use results of various research studies
(critical appraisal)
• Conduct a research study individually or in a group by
using appropriate
• Selection of research question(s) and objectives
• Research design and statistical methods to answer the
research question
• Ethical and R&RC approval of the synopsis
• Demonstrate competence in academic writing by writing
an appropriate dissertation and/or publishing research
article(s) as a step towards resolving issues or concerns in
their specialty
• Guide others in conducting research by advising about
research methodology including study designs and
statistical methods
• Demonstrate clear, focused and logical presentations of
their research.

6. Professionalism
• Demonstrate the highest level of personal integrity:
honesty, punctuality, regularity, timely task completion
• Deal with all patients in a non-discriminatory,
prejudice- free manner, demonstrating the same level of
care for every human being irrespective of gender, age,
ethnic background, culture, socioeconomic status and
religion
• Establish a trusting relationship with patients, their
relatives and care-givers
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• Deal with all patients with honesty, empathy and

compassion, putting patients’ needs first (altruism)

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 • Facilitate transfer of information important for promotion
of health, prevention and management of disease
• Encourage questioning by the patient and be receptive to
feedback
• Pursue self-directed and life-long learning. Keep abreast
of medical literature and assess new knowledge and apply
it to resolve patient problems
• Know one’s limitations and ask for help as needed from
colleagues, consultations or referrals
• Apply quality assurance procedures for improvement in
daily work
• Be a role model for others.

Ethics
• Maintain patient autonomy by demonstrating shared-
decision-making with the patient and/or family
• Obtain informed consent, maintain patient confidentiality
and do no harm
• Provide cost-effective care while ordering investigations
and in management and use resources appropriately.

Leadership
• Demonstrate accountability for their decisions and actions,
and that of their team
• Demonstrate willingness to assume leadership role(s)
when needed in given situations or events (rush call/code).
• Change and bring about change as necessary, as a leader
or supportive leader.

7. Pedagogy
Should be able to demonstrate competence in teaching skills:
• Effective clinical/community-based teaching
• Some evidence of acquisition of theory regarding learning
and education
• Practice some of the best teaching methods.
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8 FELLOWSHIP TRAINING
 8. Advocacy
Advocacy is needed at multiple levels
• Advocacy for the Patient
• Doctors and nurses are the advocates of the patients,
otherwise patients are likely to be lost in the system.
All care should be timely, putting patients first.

• Advocacy for the Practice

• Working in a service or practice, doctors must highlight
limitations and issues
• They must identify solutions for the problems, and
recommend and implement improvements for the
practice(s) and institutional system(s).

• Advocacy for the Health System and Society

• Know one’s role in the Health System(s) and build
strong referral systems
• Keep patient and community interests paramount,
above one’s own personal or professional interest
• Demonstrate advocacy for elimination of the social
determinants of health
• Demonstrate advocacy for prevention of serious
illnesses of their specialty/sub-specialty.

• For the Profession

• Strive for building trust in the public for your profession
• Demonstrate improvement and enhancement of
profession, specialty and sub-specialty
• Be conscientious gate-keepers of their profession,
specialty and subspecialty.
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 ROLES AND
RESPONSIBILITIES
SUPERVISOR
Supervision of a resident is a multifaceted job. Arbitrarily the
task is divided into the following components for the sake of
convenience. This division is by no means exhaustive or rigid. It
is merely meant to give semblance to this abstract and versatile
role.

EXPERT TRAINER
• This is the most fundamental role of a supervisor. S/he has
to not only ensure and monitor adequate training but also
provide continuous helpful feedback (formative) regarding
the progress of the training
• This would entail observing the resident’s performance
and rapport with all the people within his/her work
environment
• S/he should teach the residents and help them overcome
the hurdles during the learning process
• It is the job of the supervisor to make the residents
develop the ability to interpret findings in their patients
and act suitably in response
• The supervisor must be adept at providing guidance in
writing dissertation / research articles (which are essential
components of training)
• Every supervisor is required to participate actively in
Supervisors’ workshops, conducted regularly by CPSP, and
do his/her best to implement the newly acquired
information/skills in the training. It is his/her basic duty
to keep abreast of the innovations in the field of expertise
and ensure that this information percolates to residents of
all years under him/her
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10 FELLOWSHIP TRAINING
 RELIABLE LIAISON
• The supervisor must maintain regular contact with the
College regarding training and the conduct of various
mandatory workshops and courses
• It is expected that the supervisor will establish direct
contact with relevant quarters of CPSP if any problem
arises during the training process, including the suitability
of resident
• S/he must be able to coordinate with the administration of
his/her institution/organization in order to ensure that his/
her residents do not have administrative problems
hampering their training

PROFICIENT ADMINISTRATOR
• The supervisor must ensure that the residents regularly fill
their e-logbook
• S/he must provide quarterly feedback regarding each
resident through e-log system
• S/he might be required to submit confidential reports on
resident’s progress to the College
• The supervisor should notify the College of any change in
the proposed approved training program
• In case the supervisor plans to be away for more than two
months, he/she must arrange satisfactory alternate
supervision during the period
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 ROLES AND
RESPONSIBILITIES
RESIDENT
Given the provision of adequate resources by the institution,
residents should
• accept responsibility for their own learning and ensure
that it is in accord with the requirements of the particular
discipline
• play an informed role in the selection of the supervisor
• seek reasonable infrastructure support from their
institution and supervisor, and use this support effectively
• ensure that all outlined aspects of training are covered
during the defined training period
• work with their supervisors in writing the
synopsis/research proposal and submit the
synopsis/research proposal by the end of first year of their
registration with the R&RC
• accept responsibility for the dissertation and plan to
execute the research within the time limits defined
• be responsible for arranging regular meetings with the
supervisor to discuss and document progress. If the
supervisor is not able/willing to meet with the resident on
a regular basis, he/she must notify the College
• provide the supervisor with word processed updated
synopsis and dissertation drafts (ensure it has been
checked for spelling, grammar and typographical errors,
prior to submission) and provide the raw data to the
supervisor if required
• submit completed dissertation to R&RC or evidence of
publication/acceptance for publication of two research
papers in CPSP approved journal(s) or JCPSP six months
before the completion of (last year of) training. The
resident should be the first or second author of both
papers and the synopsis of both papers must have a prior
approval of R&RC
• follow the College complaint procedure if serious problem
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arises
• complete all requirements for sitting an examination

12 FELLOWSHIP TRAINING
 GENERAL
REGULATIONS

Resident will be admitted to the examination in the name

(surname and other names) as given in the MBBS degree. CPSP
will not entertain any application for change of name on the
basis of marriage/divorce/deed.

ELIGIBILITY REQUIREMENT FOR ENTERING FELLOWSHIP

TRAINING PROGRAM IN NEUROSURGERY
Entry into fellowship programme in Neurosurgery shall begin
with registration for IMM Surgery-Neurosurgery as under:
• Passed FCPS Part-I in Surgery and Allied or allowed
exemption by CPSP or Passed Part-I from Bangladesh
College of Physicians and Surgeons in Surgery & Allied
• Any other qualification as per CPSP Policy

EXEMPTION CERTIFICATE
An application for exemption from FCPS Part-I must be
submitted to the College with all the relevant documents and a
bank draft for the prescribed fee.
After due verification, the College may grant exemption from
FCPS Part-I to the applicants. Those allowed exemption from
training will be issued EXEMPTION CERTIFICATE on payment
of the specified fee. A copy of this certificate will have to be
attached with the application to the Registration & Research
Cell (R&RC) of the CPSP, for registration as FCPS-II resident and
later with the application for appearing in FCPS-II examination.

INDUCTION IN FCPS NEUROSURGERY TRAINING PROGRAM

• With effect from January 2023, candidates desirous of
joining Neurosurgery training will be selected by a
Committee constituted by the Head of the Institution
comprising representatives from both General Surgery &
Neurosurgery Departments as per policy of the organization
• The trainee will be registered with Registration & Research
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Cell (R&RC) as a resident in Surgery-Neurosurgery for

Intermediate Module training, which consists of first year
training dedicated to General Surgery under a General

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 Surgery supervisor and second year reserved for
Neurosurgery training under a Neurosurgery supervisor
Hence, during IMM training each candidate has to register
with RTMC (R&RC) under supervisors of two disciplines.
• Each Teaching Unit in General Surgery & Neurosurgery will
comprise of sanctioned positions of one Professor, one
Associate and one Assistant Professor/Senior Registrar and
will select four candidates in each induction cycle
• In each non-teaching unit two trainees will be inducted per
session per supervisor subject to a maximum of eight
trainees per supervisor at any point in time
• After registration, the residents will spend one year in
General Surgery and other year in Neurosurgery
• At the end of two years, the trainee will be eligible to sit
IMM examination. In case of failure in Intermediate Module
examination, the residents are permitted to continue their
training for the third year in Neurosurgery but must pass
the IMM examination prior to appearing in the final FCPS-II
examination.

DURATION OF TRAINING IN NEUROSURGERY

Total duration of the training for fellowship in Neurosurgery is
5 years, divided into two phases:
• Intermediate Module in Surgery and Neurosurgery for the
first two years. After passing IMM Exam residents will
proceed to the next advance phase of Neurosurgery with
the supervisor already registered with.
Further details about the Intermediate Module are given
subsequently in the curriculum.
• Last three years consist of advanced training in
Neurosurgery, known as FCPS-II.

APPROVED TRAINING CENTRES

Training must be undertaken in units/departments/institutions
approved by the College. A current list of approved locations is
available from the College and its regional offices as well as on
the College website: www. cpsp.edu.pk.
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14 FELLOWSHIP TRAINING
 REGISTRATION AND SUPERVISION
All training must be supervised and undertaken on whole time
basis. The residents are required to register with the R&RC
and submit the name of their supervisor. The supervisor will
normally be a Fellow of the College. Only that training will be
accepted which is done under a CPSP approved supervisor.
The residents are not allowed to work simultaneously in any
other department/institutions for financial benefit and/or for
another academic qualification.

RESEARCH (Dissertation/Two Papers)

One of the training requirements is a dissertation or two
research papers on topics related to the field of specialization.
• Synopsis of the dissertation must be submitted to
Registration & Research Cell (R&RC) before the end of
second year of IMM training. The synopsis should be
approved before starting the research work.
• In case the resident opts for research articles, the topic/
title of the papers should be submitted to Registration &
Research Cell (R&RC) before the end of second year of IMM
training.
• The dissertation or evidence of publication /acceptance of
research papers must be submitted six months prior to the
final FCPS-II examination for which the residents intend to
sit in.
MANDATORY WORKSHOPS AND COURSE
It is mandatory for all residents to attend the following CPSP
certified workshops during Intermediate Module (IMM) training.
The supervisor of General Surgery should ensure that the
residents register for the following workshops and both
supervisors: General Surgery & Neurosurgery should facilitate
their participation as and when DME invtes them for the
workshops.
1. Introduction to Computer and Internet
2. Research Methodology Biostatistics and Dissertation
Writing
3. Communication Skills
4. Primary Surgical Skills Workshop
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5. BLS (Basic Life Support) Course

Any other workshop/s as may be introduced by the CPSP.

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15
 E-LOGBOOK
The CPSP council has made e-logbook system mandatory
for all Residency programme residents inducted from July
2011. Upon registration with R&RC each resident is allotted a
registration number and a password to log on and make entries
of all work performed and the academic activities undertaken in
e-logbook on a daily basis. The concerned supervisor is required
to verify the entries made by the resident. This system ensures
timely entries by the resident and prompt verification by the
supervisor. It also helps in monitoring the progress of residents
and the vigilance of the supervisors.

AWARD OF FELLOWSHIP
Fellowship of the College of Physicians and Surgeons Pakistan
is awarded to those applicants who have:
• a recognized medical degree
• completed one year house job in a recognized institution
• passed the relevant FCPS Part-I Examination
• registered with the Registration & Research Cell (R&RC)
• undergone specified years of supervised accredited
training on whole time basis
• passed IMM examination in Surgery-Neurosurgery
• declared successful in final fellowship examinations carried
out by the Examination Department of the CPSP; and
• submitted approval of dissertation / evidence of
acceptance / publication of two research articles (related
to the specialty) in CPSP approved journal(s)
• elected by the College Council
• It is important to note that all applicants must undergo a
formal examination before being offered Fellowship of the
relevant specialty, except in case of fellowship without
examination.

TRAINING ENQUIRES AND REGISTRATION

All residents should notify the College in writing of any change
of address and proposed changes in training (such as change of
Supervisor, change of department, break in training etc.) as soon
as possible.
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16 FELLOWSHIP TRAINING
 TRAINING
PROGRAMME

CURRICULUM: AIM AND OBJECTIVES

Aim
The aim of the Fellowship Program in Neurosurgery is to
produce specialists in the field of Neurosurgery with a strong
base in general surgical principles & skills attained during IMM
training. By the end of the residency program, the resident will
be able to:

Objectives:
• Take appropriate histories
• Demonstrate proficiency in the requisite physical
examinations
• Justify the ordering and interpretation of tests and
investigations
• Appropriately diagnose, and rule in and rule out contending
conditions
• Manage the problem in a cost effective manner
• Apply the requisite knowledge and skills to think critically
and solve problems
• Be an effective team player, leading the team if necessary
• Communicate effectively with, for example
• Patients and their attendants with empathy and
compassion, in interviewing, counseling, breaking bad
news, behavioural modification and shared
decision-making, recognizing the impact of the
condition on the patients and their families
• seniors, peers, juniors, learners and other health
professionals
• Demonstrate risk analysis and emphasis on prevention
• Ensure patient safety
• Manage emergencies related to the specialty
• Present well in the clinics, rounds and conferences
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• Document concise and accurate histories, prescriptions,

progress notes, discharge summaries and referrals

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17
 • Keep up to date and practice evidence based medicine
• Demonstrate putting patients first
• Demonstrate Honesty, integrity and timeliness (punctuality
and task completion)
• Maintain confidentiality, patient autonomy, take
appropriate consent and do no harm
• Consults with colleagues and refers as necessary
• Demonstrates effective teaching and mentoring skills for
juniors and for other members of the health care teams
• Exhibit Advocacy for their patients, practice (service/
department), profession (discipline/specialty) and
population-based problems related to their specialty
• Initiate/participate in/expand clinical governance & clinical
audit
• Recognize and resolve stress in self and others
• Demonstrate a sound research study, and the use of
research in improving clinical practice
• Demonstrate willingness to accept critique constructively
• Demonstrate willingness and the ability to adapt & change
as per changing circumstances & changing technology
• Demonstrate conflict resolution, management skills and
leadership
• Maintain the highest standards of practice
• Apply knowledge and reasoning skulls to
• Analyze data for problem identification
• Synthesize and evaluate solutions
• Decision Making
• Prioritization of different problems
• Evidence based justification
• Demonstrate International Patient Safety Goals (IPSG)
• Demonstrate competent performance in required technical
skills including
• Obtaining informed consent
• Pre-operative assessment and preparation
• Intervention technique including exposure and closure
• Post-Interventional Care
• Follow-up Care
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18 FELLOWSHIP TRAINING
 Communication and Collaboration Skills:
• Establish professional relationships with patients and
families.
• Discuss appropriate information with patients and families
and the health care team.
• Consult effectively with other physicians and health care
professionals.

Teaching and Research Skills:

• Develop, implement and monitor a personal continuing
educational strategy.
• Demonstrate the ability to teach patients, medical students,
interns, other residents and allied health care staff.
• Participate in Grand Rounds.

Professionalism
• Deliver high standard quality care with integrity, honesty
and compassion.
• Exhibit appropriate interpersonal professional behavior.
• Practice medical profession according to established
ethical norms.

Teamwork and Leadership

• Demonstrate constructive team-Communication skills
• Facilitate collaborative group interaction.
• Support other team members
• Demonstrate responsibility and leadership as needed
• Change and bring about change as necessary as a
supportive leader.

Data Entry
• Demonstrate Data entry skills and maintaining of registries,
and use of statistical software and principles.

Procedural Skills

Ethics
• Maintain patient autonomy
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• Maintain Confidentiality
• Obtain Informed consent
• Provide cost-effective care

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 Advocacy
• Advocacy is needed at multiple levels
• Advocacy for patients
• Advocacy for Practice
• Advocacy for Health system and Society
• Advocacy for profession.
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20 FELLOWSHIP TRAINING
 NEUROSURGERY

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21
 NOTE: CLARIFICATION REGARDING ROTATIONS

Year One:
The resident will be at the disposal of the Supervisor of General
Surgery and shall perform all duties assigned by the supervisor.

Year Two:
During second year of IMM the resident will be at the disposal
of the Supervisor of Neurosurgery and shall perform all duties
assigned by the supervisor.

There will be NO mandatory rotation in 1st or 2nd year.

NEUROSURGERY

22 FELLOWSHIP TRAINING
 CURRICULUM: GENERAL SURGERY (YEAR-1)
AIM
Upon completion of training in General Surgery (first year) of
intermediate module in Surgery-Neurosurgery, a resident must
acquire the basic competencies in the principles and practice
of surgery along with outcomes in the domains of knowledge,
skills and attitude in order to:
• Provide appropriate and cost-effective care to patients at
all levels
• Promote health and prevent disease in patients, families
and communities
• Practice continuing professional development.
• For this purpose the resident must acquire:
• Knowledge and expertise in clinical and procedural
management of relevant diseases
• Basic surgical skills
• Effective clinical judgment and decision making in
dealing with surgical problems using evidence based
medicine
• The coverage that each discipline receives below is not
indicative of the relative importance placed on each
discipline in the training program, or in the examination.
These are guidelines and not comprehensive definitive
lists. Only minimum levels of expected competence have
been identified but sufficient scope, volume and variety of
experience are desirable

OBJECTIVES
Upon completion of first year of Intermediate Module in
General Surgery, the resident is able to:
• Plan Preoperative care of surgical patients:
• Evaluate the metabolic response to surgery and
infection
• Assess fitness of patients for Surgery and Anesthesia
• Assess risks involved in surgery
• Test for respiratory, cardiac and renal functions
• Manage patients with associated medical disorders
NEUROSURGERY

FELLOWSHIP TRAINING
23
 •Manage post operative patients:
• Prescribe appropriate analgesics for postoperative
pain control
• Take appropriate measures to prevent postoperative
complications
• Diagnose postoperative complications
• Manage postoperative complications effectively

• Understand and demonstrate basic principles of surgical

craft and theatre technology:
• Understand the principles of antisepsis, sterilization
and concept of aseptic surgery
• Demonstrate correct methods of scrubbing, gowning
and gloving
• Demonstrate use of common surgical instruments and
appliances (suction, diathermy, retractors, general
instruments)
• Identify appropriate uses of suture and ligature
materials
• Understand basic principles of anastomosis
• Demonstrate various techniques of biopsies: needle
aspiration, trucut, open
• Discuss the uses of tourniquet and precautions
regarding its application
• Discuss the principles involved in various types of
anesthesia: Local, Regional and General Anesthesia
• Monitor patient during anesthesia
• Distinguish between analgesia and sedation

• Understand the impact of infection in surgery:

• Describe surgically important micro-organisms
• Identify sources of surgical infections and take
effective measures for their prevention and control
(asepsis and antibiotic usage)
• Discuss body’s response to infection
• Use appropriate methods for carrying out surgery in
hepatitis and HIV carriers
NEUROSURGERY

24 FELLOWSHIP TRAINING
 • Demonstrate appropriate wound management:
• Classify surgical wounds
• Describe pathophysiology and principles of wound
healing
• Describe principles and methods of wound
debridement and closure
• Describe mechanisms of scar and contracture
formation
• Manage the surgical wounds appropriately

• Resolve nutritional problems in surgical patients:

• Assess nutritional status of patients
• Prescribe nutritional values and components of
different enteral and parenteral food preparations
• Select different routes of nutrition administration
based on indication/limitations

• Correct fluid, acid base and electrolyte imbalances:

• Describe physiological processes contributing to fluid,
acid base and electrolyte balance
• Describe principles of fluid and electrolyte
replacement
• Discuss etiology and mechanism of shock
• Assess and manage various types of hemorrhage
• Manage shock
• Describe indications and hazards of blood transfusion
• Prescribe blood products and their substitutes

• Manage critically ill patients:

• Diagnose and manage an unconscious patient
• Operate monitoring devices and interpret their
findings
• Describe etiological factors for cardiac arrest
• Resuscitate patients with cardiac arrest
• Discuss various ionotropic agents
• Identify features of brain death
NEUROSURGERY

FELLOWSHIP TRAINING
25
 • Manage individual and mass Trauma by attaining
following competencies:
• Understand Epidemiology of trauma
• Understand and demonstrate initial assessment and
resuscitation of a traumatised patient including:
• Primary and secondary survey
• Airway clearance and ventilation of patient
requiring assisted respiration
• Management of hemorrhage and shock
• Application of Principles of triage
• Management of:
• Thoracic trauma
• Abdominal and pelvic trauma
• Head and spine trauma
• Manage limb trauma including fractures,
tendon and nerve injuries
• Factors, etiology and principles of healing of soft
tissues, tendon and bone
• Immobilization and fixation
• Fracture and its complications
• Compartment syndrome, crush syndromes, fat
embolism, fasciotomy
• Neurological and vascular injuries in limb trauma

• Assess and manage head injuries

• Order and prepare for appropriate imaging according to

their indications and limitations
• Plain and contrast X-rays, Ultrasound examination,
CT Scan etc.

• Communicate and collaborate effectively:

• Establish professional relationships with patients and
families.
• Discuss/counsel appropriate information with patients
and families, and the health care team.
• Consult effectively with other physicians and health
care professionals.
NEUROSURGERY

• Demonstrates appropriate respect for health care team

• Demonstrates appropriate respect for seniors, juniors

26 FELLOWSHIP TRAINING
 • Practice Teaching
• Demonstrate the ability to teach medical
students, interns, other residents and allied health
care staff.

• Practice Professionalism:
• Deliver high standard quality care with integrity,
honesty and compassion.
• Exhibit appropriate interpersonal professional
behavior.
• Practice of medical profession according to
established ethical norms.
• Ethics EBM upto date

NEUROSURGERY

FELLOWSHIP TRAINING
27
 SYLLABUS
PRINCIPLES & PRACTICE OF SURGERY
• Surgical infections
• Principles of wound healing
• Hemorrhage & control / resuscitation
• Sterilization and disinfection
• Fluid & electrolytes
• Perioperative care (Pre-op, Post-op) Cirrhosis, DM, HTN,
• IHD, Renal failure, Jaundice)
• Blood & products & shock
• Antibiotics/Antiseptic/resistance
• Clinical features & investigations of vascular disorders
• Clinical features & investigations of lymphatic disorders
• Nutrition/TPN/Enteral
• Specific infections: tetanus, gas gangrene, TB, typhoid,
Hepatitis B, C, AIDS, synergistic gangrene.
• Tissue diagnosis/ Biopsy techniques
• Diagnostic imaging principles/ USG, CT, MRI
• Principles of anastomosis & basic surgical skills
• Principles of Gastrointestinal endoscopy
• Principles of MIS/ Robotic surgery/ AI
• Usage of energy devices
• Principles of pain management
• Principles of L/A, regional, G/A
• Metabolic response to trauma
• Palliative care - Principles
• Principles of surgical oncology (Lumps of skins and
subcutaneous tissue) principles of chemotherapy
• Principles of burn management
• Principles of surgery in extremes of ages (Pediatric &
Geriatric)
• Cardiothoracic trauma – initial management
• Indications, management & complications of tube
thoracotomy, pneumothorax, chest pain)
• Chest physiotherapy rehabilitation
• Principles of urologic surgery
• Indications and principles of HDU & intensive care (CCRT)
NEUROSURGERY

• Principles of management of diabetic foot

• Hand infection

28 FELLOWSHIP TRAINING
 • Ethics
• Research
• Professionalism
• Principles of managing mass/multiple casualties including
disaster & triage
• Postop complications

CRITICAL CARE
• Respiratory failure
• Principles of assisted ventilation
• Principles of invasive monitoring (CVP + Arterial)
• Inotropic support
• ARDS
• Principles of acute renal shutdown
• Sepsis
• DIC
• Brain death & end of life decision
• Acid base balance
• ABG analysis
• Nutrition in ICU (critically ill)
• Monitoring of critically ill patient in ICU
• Abdominal compartment
• MODS / MOSF
• Cardiac arrest

TRAUMA (INITIAL ASSESSMENT AND RESUSCITATION ON ATLS

PRINCIPLES) COMMON TO ALL
Neuro-Trauma:
• Head injuries
• Spinal shock
• Neurogenic shock
• Diagnostic imaging
• Skill: Spinal immobilization
• Cervical spine immobilization

Urogenital Trauma:
• Urethral injury
• Urinary catheterization
NEUROSURGERY

• Suprapubic cystostomy

FELLOWSHIP TRAINING
29
 Vascular Trauma:
• Peripheral vascular injuries (investigations & management)
Examination of peripheral vascular system (Arteries+ veins)

Pediatric Trauma:
• Principles of management of pediatric trauma including
anatomical considerations regarding
• Airway, thoracic, l/V fluid, resuscitation and routes
• Intraosseous needle

Thoracic Trauma:
• Tension pneumothorax
• Needle decompression
• Chest tube insertion
• Occlusive dressing

Abdominal Trauma:
• Penetrating injury
• Blunt injury
• Diagnosis - DPL/CT/FAST/eFAST
• Principles of damage control, resuscitation and surgery
NEUROSURGERY

30 FELLOWSHIP TRAINING
 CLINICAL AND PROCEDURAL COMPETENCIES
The clinical skills, which a surgeon must have are, varied and
complex. A complete list of the same necessary for residents
and trainers is given below. Some examples, which are a sub
sample of the whole, follow. These are to be taken as guidelines
rather than definitive requirements. Key for assessing
competencies:
1. Observer Status
2. Assistant Status
3. Performed Under Supervision
4. Performed Independently

NEUROSURGERY

FELLOWSHIP TRAINING
31
 NEUROSURGERY

32
first year (surgery) total #
03 months 06 months 09 months 12 months of cases

clinical competencies
• elicit a pertinent history 4 50 4 50 4 50 4 50 200
• communicate effectively with patients,
families and the health team (observed)
• perform a physical examination
• order appropriate investigation
• interpret the results of investigations assess
fitness to undergo surgery
• decide and implement appropriate treatment
• postoperative management and monitoring
• maintain accurate and appropriate records

FELLOWSHIP TRAINING
 first year (surgery) total #
03 months 06 months 09 months 12 months of cases

pre-operative preparation for various surgical procedures

use of aseptic techniques (e.g draping) 2 5 2 5 4 8 4 8 26
positioning of patient for diagnostics and 2 5 2 5 3 3 3 3 16

FELLOWSHIP TRAINING
operative procedures (variety)
identification and appropriate use of common 2 8 3 8 3 3 3 3 22
surgical instruments, suture materials and
appliances
controlling hemorrhage 2 3 2 3 3 3 4 3 12
debridement, wound excision, closure/suture 2 3 2 3 3 1 3 1 8
of wound (excluding repair of special tissues
like nerves and tendons)
uretheral catheterization 2 3 3 3 3 1 3 1 8
suprapubic puncture 2 1 2 1 3 2 3 2 6
circumcision 2 2 2 2 3 3 3 3 10
nasogastric intubation 3 4 3 4 3 3 3 3 14
venesection 2 2 2 2 3 1 3 1 6
tube thoracostomy 2 3 2 3 3 2 3 4 12
biopsy of lymph nodes 2 2 2 2 - - - - 4
biopsy of skin lesions, subcutaneous lumps or 2 2 2 2 3 2 3 2 8
swellings
excision of soft tissue benign tumors and cysts 2 2 2 2 2 1 3 1 6
(surface surgery)
opening and closing of abdomen 1 1 1 1 3 3 3 3 8
proctoscopy and interpretation of findings 2 3 2 3 3 1 3 1 8

33
NEUROSURGERY
 NEUROSURGERY

34
first year (surgery) total #
03 months 06 months 09 months 12 months of cases

general surgery procedures

Proctosigmoidoscopy 2 1 2 1 3 1 3 1 4
fine needle aspiration (FNAC) 2 1 2 1 3 2 3 2 6
removal of skin stitches/staplers 2 2 3 2 3 3 3 3 10
removal of drains/NG tube/Foley`s 2 3 3 3 3 1 3 1 8
trucut biopsy for body surface lesions 1 1 2 1 2 1 2 2 5
inguinal hernia repair 1 1 2 1 2 1 2 1 4
suprapubic cystostomy 1 1 2 2 2 1 3 1 5
hemorrhoids, fissures, fistulae in ano 1 1 2 2 2 1 2 1 5
exploratory laparotomy 1 1 2 1 2 3 3 3 8
appendicectomy 1 1 2 2 2 1 2 1 5
cholecystectomy 1 1 2 1 2 1 2 1 4
laparoscopic/endoscopic surgery (principles 1 1 2 1 - - - - 2
and instrument handling)
breast operations and benign lesions 1 1 2 1 2 1 3 1 4
use of ventilators 1 1 1 1 2 1 2 1 4

FELLOWSHIP TRAINING
 first year (surgery) total #
03 months 06 months 09 months 12 months of cases

FELLOWSHIP TRAINING
peri-operative care
wound healing and peri-operative complication 1 2 2 2 3 2 3 2 8
cpr 1 1 2 1 2 2 3 2 6
cvp lines 1 1 1 1 2 1 2 1 4
fluid and electrolyte balance 2 2 3 2 4 3 4 3 10
monitoring devices 1 2 2 2 2 3 2 3 10
inotropic agents 1 2 2 2 2 3 2 3 10
care of unconscious patient 1 1 2 1 2 1 3 1 4
replacement of nutrition 2 1 3 1 3 1 4 1 4
airway maintenance & passing of endotracheal 1 1 2 1 2 1 3 2 5
tube
ippr and other methods of ventilation 1 1 2 1 2 1 3 1 4
local anesthesia 1 1 2 1 2 1 3 2 5
regional anesthesia 1 1 1 1 1 1 2 1 4
lumber puncture and spinal anesthesia 1 1 1 1 1 1 2 1 4
principles of general anesthesia 1 1 1 1 2 1 3 1 4

35
NEUROSURGERY
 NEUROSURGERY FOUNDATION (YEAR-2)
Upon completion of Neurosurgical Training for the intermediate
module in Neurosurgery, the trainee should be able to:

LEARNING OBJECTIVES
Principles of Neurosurgery:
• Understand the anatomy of skull, spine, brain & spinal cord.
• Understand basic neurophysiology including cerebral
blood flow, intracranial pressure and its regulation, and
management of raised intracranial pressure, cerebral
metabolism, blood-brain barrier and different types of
edema, cerebral nutrition.
• Comprehend anatomy and physiology of spinal cord
including tracts and various spinal syndromes

Neuro-Trauma:
• Recognize different types of head injuries and their overall
management.
• Understand the principles & management of spinal injury.
• Undertake common trauma procedures such as craniotomy
for extradural subdural depress fractures and
(intra-cerebral hematomas) in modern era prognosis has
improved and should be done by a senior.
• Differentiate acute from chronic subdural hematomas and
other types of hematomas.
• Comprehend basics about different types of trauma
craniotomies.
• Manage individual and mass trauma by attaining following
competencies (as per ATLS):
• Understand the epidemiology of trauma.
• Understand and demonstrate initial assessment and
resuscitation of traumatized patients,including:
• Perform Primary and secondary survey.
• Perform Airway clearance and ventilation of patients
requiring assisted respiration.
• Intubate the patient.
• Manage hemorrhage and shock.
NEUROSURGERY

• Apply principles of triage.

36 FELLOWSHIP TRAINING
 • Perform triage and initial management:
• Thoracic trauma.
• Abdominal and pelvic trauma.
• Head and spine trauma.
• Manage limb trauma, including fractures, tendon and nerve
injuries:
• Factors, etiology and principles of healing of soft
tissues, tendon and bone.
• Immobilization and fixation.
• Fracture and its complications.
• Compartment syndrome, crush syndromes and fat
embolism, fasciotomy.
• Neurological and vascular injuries in limb trauma.
• Understand, assess and manage head injuries.
• Communicate and counsel patients effectively.

NEUROSURGERY

FELLOWSHIP TRAINING
37
 SYLLABUS
Principles of Neurosurgery
Anatomy
Understand cortical anatomy, sulcus on axial scans, surface
anatomy of brain, surface landmarks of spine, cranial foramina
and their contents, Internal capsule, CP angle anatomy,
Occipitoatlantoaxial complex anatomy and Spinal cord
anatomy with special reference to:
• Skull
• Spinal Cord
• Brain
• Vertebral Column
• Brain vasculature (Arteries and Veins)
• Spine vasculature
• Cerebral vascular territories, Cerebral arterial terriotories
and spinal cord vasculature,

Physiology and Homeostasis

• Increased intracranial pressure,
• Nutrition and parenteral therapy.

Diagnostic Procedures
Routine radiology of skull and spine, Basics of
electro-encephalography and ventriculography, Radio nuclear
imaging studies, computerized tomography, magnetic
radiation imaging, lumbar puncture, CSF studies, myelography,
ultra-sonography, Doppler studies, cerebral angiography,
CT Angiography of Brain and Carotid Arteries in the neck.

Anesthesia and Operative Techniques

Preoperative preparation including management of high-risk
patients. Basics of neuro-anaesthesia, Asepsis and sterilization
techniques, Positioning of the patient for surgery General and
micro-operative techniques and Postoperative care.
NEUROSURGERY

38 FELLOWSHIP TRAINING
 Head Injury
Patient with multiple trauma, Scalp and facial injuries,
Mechanism of cerebral trauma, Pathophysiology of head
injuries, Care of minor head trauma, Non-operative
management of closed head injury including elective
ventilation, Hematomas, Cerebral contusions and their
management, Fractures of the skull, Trauma to carotid arteries

Spine Trauma
• Spinal injuries, Whiplash injuries, Sports injuries to spine
and spine neurological assessment.
• Spine injury trauma management, including management
in hospital and at scene.
• Traction and reduction of Cervical spine injuries and timing
of injuries.
• Occipitoatlantial axial injuries including, occiput, C1 and
C2 fractures.
• Sub axial cervical spine mechanism of injuries and types of
fractures and classifications.
• Thoracic and lumbar spine fractures.
• Penetrating injuries to spine and long-term outcomes.

NEUROSURGERY

FELLOWSHIP TRAINING
39
 CLINICAL AND PROCEDURAL COMPETENCIES

The clinical skills, which a Neurosurgeon must have are, varied

and complex. A complete list of the same necessary for
residents and trainers is given below. Some examples, which
are a sub sample of the whole, follow. These are to be taken as
guidelines rather than definitive requirements.
1. Observer Status
2. Assistant Status
3. Performed Under Supervision
4. Performed Independently
NEUROSURGERY

40 FELLOWSHIP TRAINING
 competencies year-2
level cases
clinical competencies
history, examination and investigation 3 10
interpretation of results, decision making 3 20

FELLOWSHIP TRAINING
counselling patient 3 20
procedural competencies
scrubbing and gowning 3 30
microscope handling 2 10
suturing and knots 3 40
lp, evd, fontanel tap and lumbar drain 3 10
apply cervical collar and traction 3 20
management of er patient 3 15
management of ward and icu patient 3 15
management of trauma patient 3 20
management of fits. 3 10
management of post op patients 3 20
positioning in or 3 20
application of mayfield clamp 2 10
setting up navigation/ neuro-monitoring 2 5
handling of drills, perforators, cutter and endoscope 1 10
skin incision. 3 15
scalp flap 3 5
burr hole , craniotomy, craniectomy 3 5
post fossa craniotomy 1 3
durotomy+ dural hitches, trauma flap 2 10
duroplasty 2 5

41
NEUROSURGERY
 NEUROSURGERY

42
competencies year-2
level cases
dural grafts 2 2
exposure for spine surgeries 1 10
laminectomy approach 2 20
nerve root retraction 2 20
basics of spinal fixation 1 10
introduction to fixation/ fusion instruments 1 10
anterior spinal approach 1 10
basics of cages and grafts 1 10
chronic sdh drainage 3 10
decompressive surgery 3 10
surgery for edh and sdh 3 20
frontal and temporal lobectomy 3 10
csf diversion procedures 3 10
vp shunt 2 10
va shunt 1 5
programmable shunt 1 5
peritoneal end placement by open and close method 2 10
etv 1 5

FELLOWSHIP TRAINING
 ASSESSMENT
FORMATIVE ASSESSMENT
College of Physicians and Surgeons Pakistan, in order to
implement competency based education in letter and spirit, is
introducing Work Placed Based Assessment (WPBA) in addition
to institutional/ departmental assessments. To begin with
college is introducing Mini-CEX and DOPS to ensure that the
graduates are fully equipped with the clinical competencies.
• WPBA tools are entirely formative tools of assessment and
are to be accompanied with constructive feedback.
• Each Mini-CEX / DOPS encounter extends for about 20
minutes with 05 minutes for feedback & further action
plan.
• In case of unsatisfactory performance of the resident, a
remedial has to be completed within stipulated time frame.
• Topics given below are to be covered accordingly, focusing
each time on a different area/procedure/topic.
• The resident has the onus to report to the supervisor when
he/she is prepared to appear for either Mini-CEX or DOPS.
• The supervisor will arrange for the session of WPBA and
after completing the session will retrieve online prescribed
assessment form (sample given below), fill it and make
entries online (e-portal).
• Non-compliance by the resident has to be reported in
quarterly feedback.

Topic List for Mini-CEX

1st Year:
General Surgery (Minimum 3 Mini-CEX encounters, focusing
each time on a different area/topic):
• Breast
• Thyroid
• Abdominal Masses
• External Hernias
• Neck Masses
NEUROSURGERY

FELLOWSHIP TRAINING
43
 2nd Year:
Neurosurgery Foundation year (Minimum One Mini-CEX
encounter per quarter focusing each time on a different area/
topic)
• Back pain
• Neck pain
• Headache
• Fits
• Facial pain
• Increased head size
• Swelling at back
• Peripheral nerves involvement
NEUROSURGERY

44 FELLOWSHIP TRAINING
 P L E A S E C O M P L E T E T H E Q U E S T I O N N A I R E BY F I L L I N G /C H E C K I N G A P P R O P R I AT E B O X E S

please grade the following areas on below expectations satisfactory above expectation excellent
not observed /
the given scale: applicable
1 2 3 4 5
informed consent of patient
interviewing / communication skills
systematic progression
presentation of positive & significant
negative findings
motor and sensory exam
special test
justification of actions
grade the disease
• severity
• mobility status
• effects on daily routine
• red flags in past
diagnostic skills
management and follow up planning
professionalism
organization/efficiency/time management
any further exam recommended
overall clinical competence

Strengths Suggestions for Improvement

NEUROSURGERY

FELLOWSHIP TRAINING
45
 Topic List for DOPS
1st Year:
General Surgery (Minimum 2 DOPS encounters focusing each
time on a different procedure/topic)
• Suturing
• Core/True Cut Biopsy
• Endotracheal Intubation
• Basic Laparoscopic Skills e.g. Port Insertion

2nd Year:
Neurosurgery Foundation year (Minimum One DOPS encounter
per quarter focusing each time on a different procedure/topic)
• Scrubbing and gowning
• Microscope handling
• Suturing and knots
• LP, EVD, Fontanel tap and lumbar drain
• Apply cervical collar and tractioin
• Application of Mayfield clamp
• Setting up navigation/ Neuro-monitoring
• VP shunt
• Scalp flap
• Burr hole , craniotomy, craniectomy
• Nerve root retraction
• Handling of brain retractors
• Methods for hemostasis including:
• Chemical method for e.g use of surgicell, fibrillar and
adhesive glue
• Thermal method for e.g use of bipolar cautery and
monopolar
• Physical method for e.g use of ligature, clip,
spongostan and clamps
• Placement of bone flap in abdomen
NEUROSURGERY

46 FELLOWSHIP TRAINING
 P L E A S E C O M P L E T E T H E Q U E S T I O N N A I R E BY F I L L I N G /C H E C K I N G A P P R O P R I AT E B O X E S

please grade the following areas on below expectations satisfactory above expectation excellent
not observed /
the given scale: applicable
1 2 3 4 5
indications, anatomy & steps of procedure
informed consent, with explanation of
procedure and complications
preparation for procedure
marking of incision and positioning
use of anesthesia, analgesia or sedation
observance of asepsis
safe use of instruments
detailed knowledge of all instruments
use of accepted techniques
adequate control of haemostasis
management of unexpected event (or
seeks help)
post-procedure instructions to patient
and staff
professionalism/consideration of patient
communications skills
completed required documentation
overall ability to perform whole
procedure

Strengths Suggestions for Improvement

NEUROSURGERY

FELLOWSHIP TRAINING
47
 SUMMATIVE ASSESSMET
Eligibility requirements for appearing in Intermediate Module
(IMM) examination.
• Passed FCPS Part-I in Surgery and Allied or allowed
exemption by CPSP
• Completion certificate of two years of R&RC registered
training including one year in General Surgery under a
General Surgery approved supervisor and One Year in
Neurosurgery under an Neurosurgery approved supervisor
Training has to be undertaken in an institution recognized
by the CPSP
• Complete entries in e-logbook duly verified by respective
supervisors
• Completed CPSP mandated Mini-CEX & DOPS in e-logbook
• Submitted certificates of attendance of mandatory
workshops
• Submitted synopsis of dissertation or topics of research
articles

EXAMINATION SCHEDULE
• The Intermediate Module theory examination will be held
twice a year
• Theory examinations are held in various cities of the
country usually at Abbottabad, Bahwalpur, Fasisalabad,
Hyderabad, Islamabad, Rawalpindi, Karachi, Nawabshah,
Larkana, Lahore, Multan, Peshawar and Quetta centres. The
College shall decide where to hold TOACS examinations
depending on the number of candidates in a city and shall
inform the candidates accordingly.
• English shall be the medium of all examinations for theory
and TOACS.
• The College will notify of any change in the centres, the
dates and format of the examination.
• A competent authority appointed by the College has the
power to debar any candidate from any examination if it is
satisfied that the candidate has indulged in unfair practices
in College examination, misconduct or because of any other
disciplinary reason.
NEUROSURGERY

48 FELLOWSHIP TRAINING
 EXAMINATION FEES
• Fees deposited for a particular examination shall not be
carried over to the next examination in case of withdrawal/
absence/exclusion.
• Applications along with the prescribed examination fees
and required documents must be submitted by the last
date notified for this purpose before each examination.
• The details of examination fee and fees for change of
centre, subject, etc. shall be notified before each
examination.

REFUND OF FEES
If after submitting an application for examination, a resident
decides not to appear, a written request for a refund must be
submitted before the last date for withdrawal with the receipt
of applications. In such cases a refund is admissible to the
extent of 75% of fees only. No request for refund will be
accepted after the closing date for receipt of applications.
If an application is rejected by the CPSP, 75% of the
examination fee will be refunded, the remaining 25% being
retained as a processing charge. No refund will be made for fees
paid for any other reason, e.g. late fee, change of centre/subject
fee, etc.

FORMAT OF EXAMINATIONS
Intermediate Module examination consists of the following
two components:

Theory Examination:
Paper-I (General Surgery): 100 MCQs Single Best Type
Paper-II (Neurosurgery): 100 MCQs Single Best Type
Only those candidates who pass through the written
examination will be allowed to appear in clinical examination.

Clinical Examination:
To test clinical competence, the examination shall consist of:
TOACS (Task Oriented Assessment of Clinical Skills)
Only those candidates who qualify in the theory will be eligible
NEUROSURGERY

to take the TOACS examination which will be held at the nearest

regional centers depending upon the number of candidates.

FELLOWSHIP TRAINING
49
 TOACS
TOACS will comprise of 12 to 20 stations with a minimum
duration of 6 minutes and change over time of one minute
for the candidate to move from one station to the other. 50%
TOACS stations will be from General Surgery & 50% from
Neurosurgery. Each candidate has to pass separately in TOACS
examination dedicated for General Surgery and Neurosurgery.
It will also include one station on research synopsis and one
on e-log. All stations will be interactive where candidate will
demonstrate a competency and shall answer the questions of
the examiner related to the task (for example, taking history,
performing a clinical examination, counseling).
NEUROSURGERY

50 FELLOWSHIP TRAINING
 NEUROSURGERY

FELLOWSHIP TRAINING
51
 NEUROSURGERY TRAINING (YEAR 3-5)

OBJECTIVES
Neurosurgery:
• Select the patient for the surgery.
• Perform preoperative evaluation of basic surgical
procedures.
• Position, mark & start the basic surgeries specially trauma
surgeries.
• Manage post-operative patients.
• Understand different imaging studies.
• Evaluate patients thoroughly & make differential diagnosis
and order investigations accordingly in clinics.
• Postulate a plan for patient’s treatment.
• Manage spine trauma. Apply traction and should have a
sound knowledge for it.
• Demonstrate an in-depth knowledge of the assessment
and investigation of patients with head and spine trauma.
• Manage intracranial pressure & neurorehabilitation.
• Submit topics to R&RC for research articles.
• Publish two articles by the end of final year.
• Perform short cases and detailed physical examination.

Neuro Oncology:
• Critically interpret and apply the evidence base in the
assessment and management of patients with central
nervous systems tumors.
• Demonstrate skills to appraise & reflect upon the differing
needs of patients with central nervous system tumors.
• Critically apply combined professional knowledge of
neuro-oncology to improve delivery in complex situations.
• Demonstrate an in-depth understanding of the evidence
relating to the diagnosis, investigation and management of
patients presenting with neuro-oncological disorders.
• Demonstrate leadership skills in coordinating academic
activities, engaging and responding to colleagues’
academic interrogation.
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52 FELLOWSHIP TRAINING
 Neurovascular Disorders:
• Critically interpret and apply the evidence base in the
assessment and management of vascular disorders of the
central nervous system.
• Critically appraise, reflect upon, and adapt treatment
depending on the evidence-base for vascular pathology of
the central nervous system.
• Apply combined professional knowledge of neuro-vascular
disorders to improve delivery in complex situations.
• Demonstrate an in-depth understanding of the evidence
base relating to the diagnosis, investigation & management
of neuro-vascular disorders.
• Manage common aneurysms, AVMs and IC bleeds.

Spine and Spinal Cord:

• Critically appraise common spinal conditions including
appropriate examination, assessment and management.
• Evaluate and apply evidence based practice to the delivery
of spinal services and outcome assessment.
• Demonstrate an in-depth understanding of spinal anatomy
and its relation to pathology.
• Critically appraise & evaluate the evidence relating to the
diagnosis, investigation & management of spinal disorders.
• Evaluate, investigate and make treatment plan of common
degenerative diseases of spine and brain.
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53
 SYLLABUS
The residents will be required to have knowledge and its
application in following areas:

Diagnostic Procedures
Routine radiology of skull and spine, Basics of electro-
encephalography and ventriculography, Radio nuclear imaging
studies, computerized tomography, magnetic radiation
imaging, lumbar puncture, CSF studies, myelography,
ultrasonography, Doppler studies, cerebral angiography,
CT Angiography of Brain and Carotid Arteries in the neck
Electromyography, evoked potentials and nerve conduction
studies. Neuro-ophthalmological and otological evaluation of
patients.

Physiology and Homeostasis

Increased intracranial pressure,Nutrition & parenteral therapy.

Anaesthesia and Operative Techniques

Preoperative preparation including management of high risk
patients. Basics of neuroanaesthesia, Asepsis and sterilization
techniques, Positioning of the patient for surgery General and
microoperative techniques Postoperative care.

General Care and Rehabilitation

Urological problems associated with central nervous system
disease, their evaluation, complications and management,
rehabilitation following brain and spinal cord lesions.

Developmental and Acquired Anomalies

Hydrocephalus, Midline fusion defects, Defects of formation
of neural tube, Craniosynostosis, Anomalies of craniovertebral
junctions, Leptomeningeal cyst.

Cerebrospinal Fluid Diversion Procedure

External ventricular drainage, Ventriculo-peritoneal shunts,
Ventriculo-atrial shunts, Lumbo-peritoneal shunts. Endoscopic
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Third Ventriculostomy.

54 FELLOWSHIP TRAINING
 Vascular Diseases
Cerebral blood flow, Cerebrovascular accidents, Aneurysms
of intracranial circulation Carotico-cavernous fistula,
Arteriovenous malformations of the brain and spinal cord
Carotid artery stenosis and Carotid endarterectomy

Trauma
Patient with multiple trauma, Scalp & facial injuries, Mechanism
of cerebral trauma, Pathophysiology of head injuries, Care of
minor head trauma,Nonoperative management of closed head
injury including elective ventilation, Hematomas, Cerebral
contusions and their management,Fractures of the skull,Trauma
to carotid arteries.
Management of Traumatic CSF fistulae, Cranial defects and their
repair, Post-traumatic leptomeningeal cysts, post-traumatic
syndromes, post-traumatic epilepsy, Cranial nerve injuries,
Spinal injuries, Peripheral nerve Injury

Spinal Cord Compression

Extradural, intradural, extramedullary & intramedullary lesions
and their management.
Anterior, anterolateral and posterior approaches to the spine.

Degenerative Diseases of the Spine

Prolapsed intervertebral disc disease, Spondylosis,
Spondylolisthesis, Rheumatoid arthritis.

Infections of the Spine and Spinal Cord Including Tuberculosis

Discitis, Osteitis, Tuberculosis, Parasitic infestations, Epidural
abscess.

Spinal stabilization
Principles of spinal stability, stabilization procedures & spinal
instrumentation.
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55
 Neoplasia
Tumours of the skull and orbit, Classification and biology of
brain tumours, Intrinsic tumours of cerebral hemispheres.
Haemartoma Hemangiopericytoma, Hemangioblastoma,
Dermoids, Epidermoids, Lipomas Teratomas, Optic gliomas,
Metastaticlesions, Tumours of the posterior fossa,
Chemotherapy of brain tumours Neurofibromas.
Tumours of peripheral and sympathetic nerves and their
management, Pathophysiology and management of sellar,
parasellar and suprasellar tumours, Surgical approaches for
pituitary tumours, craniopharyngiomas, colloid cysts, pineal
and skull base tumours.

Cranial infections
Cranial and extra cranial infections, Meningitis, Epidural
and subdural empyema,Ventriculitis & brain abscess,
Viralencephalitis and fungal infections, Parasitic infestations of
the paranasal sinuses.

Pain
Anatomy and physiology of pain, Psychiatric consideration of
pain Cephalic pain, Trigeminal, glossopharyngeal and other
neuralgias, Atypical facial pain, Entrapment neuropathies,
Management of hemifacial spasm.
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56 FELLOWSHIP TRAINING
 CLINICAL AND PROCEDURAL COMPETENCIES

The skills, which a Neurosurgeon must have are, varied and

complex. A complete list of the same necessary for residents
and trainers is given below. Some examples, which are a sub
sample of the whole, follow. These are to be taken as guidelines
rather than definitive requirements.
1. Observer Status
2. Assistant Status
3. Performed Under Supervision
4. Performed Independently

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57
 NEUROSURGERY

58
R-3 R-4 R-5

clinical competencies
history, examination and investigation 4 10 4 10 4 10
interpretation of results, decision making 3 30 4 40 4 40
counseling patient 4 30 4 40 4 40
procedural competencies
scrubbing and gowning 4 40 4 40 4 40
microscope handling 3 20 4 30 4 30
suturing and knots 4 50 4 50 4 50
lp, evd, fontanel tap and lumbar drain 4 20 4 30 4 30
apply cervical collar and traction 4 30 4 40 4 40
management of er patient 4 30 4 40 4 40
management of ward and icu patient 3 20 4 25 4 30
management of trauma patient 3 30 4 40 4 40
management of fits. 3 20 4 25 4 30
management of post op patients 3 30 4 35 4 40
positioning in or 3 25 4 30 4 35
application of mayfield clamp 3 15 4 20 4 25
setting up navigation/ neuro-monitoring 3 10 4 15 4 20
handling of drills, perforators, cutter and endoscope 3 20 4 30 4 35
skin incision 3 20 4 30 4 35
scalp flap 3 10 4 15 4 20
burr hole , craniotomy, craniectomy 3 10 4 15 4 20

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 R-3 R-4 R-5

FELLOWSHIP TRAINING
post fossa craniotomy 3 6 4 10 4 15
durotomy+ dural hitches, trauma flap 3 15 4 20 4 30
duroplasty 3 10 4 20 4 30
dural grafts 3 4 4 10 4 10
opening of redocraniotomy 3 3 4 3 4 5
approach to endoscopic and trans-nasal surgeries 2 5 2 10 3 10
exposure for spine surgeries 3 10 3 20 4 20
laminectomy approach 3 5 3 10 4 15
nerve root retraction 3 10 3 15 4 20
basics of spinal fixation 2 5 2 10 3 10
introduction to fixation/ fusion instruments 2 5 3 10 14 10
anterior spinal approach 3 1 3 1 4 2
basics of cages and grafts 3 5 3 10 4 10
chronic sdh drainage 3 8 4 10 4 10
decompressive surgery 3 8 4 10 4 10
surgery for edh and sdh 3 8 4 10 4 10
frontal and temporal lobectomy 3 5 4 10 4 10
csf diversion procedures 3 8 4 10 4 12
vp shunt 3 10 4 15 4 15
va shunt 1 1 2 1 3 1

59
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 NEUROSURGERY

60
R-3 R-4 R-5

programmable shunt 3 2 3 2 4 2
peritoneal end placement by open and close method 3 5 4 10 4 10
etv 2 2 3 2 4 3
posterior cervical laminectomy 2 3 3 5 4 8
approaches to brain tumors 2 5 3 5 4 10
craniotomy for brain tumors 2 5 3 5 4 10
burr hole biopsy 3 5 3 5 4 5
open biopsy 2 5 3 5 4 5
debulking of tumors 2 5 3 5 4 10
approach to ventricular pathology 2 5 3 5 4 5
approach to post fossa tumors 2 5 3 5 4 5
post fossa craniotomy for tumors 2 5 2 5 3 5
approach and principles of extradural spinal tumors 2 5 3 5 4 5
approach and principles of intradural spinal tumors 2 5 3 5 4 5
pediatric spinal pathologies (mmc, encepheloceleetc) 2 5 3 5 4 5
approach to cv junction pathology 1 2 2 5 3 5
foramen magnum decompression 1 2 3 5 4 5
craniotomy for lesions adjacent to venous sinuses 1 2 2 5 3 5
corpectomy 1 2 2 5 3 5
tlif 1 2 2 5 3 5

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 R-3 R-4 R-5

FELLOWSHIP TRAINING
posterior cervical fusion and instrumentation 1 2 2 5 3 5
occipito-cervical fixation 1 2 2 5 3 5
c1- c2 fixation 1 2 2 5 3 5
approach to spinal fixation 1 5 2 10 3 10
thoracic psf 1 5 2 10 3 10
lumber psf 1 5 2 5 3 5
thoracic discectomy 2 10 2 15 3 15
lumbar discectomy 1 5 2 5 3 5
endocscopic approach to 3rd ventricle tumors 1 5 2 5 3 5
endoscopic approach to pituitary tumors 1 5 2 5 3 5
approach and debulking of skull base tumors 2 2 2 5 3 5
approach to cp angle tumor 2 2 2 5 3 5
craniotomy for cp angle tumors 1 2 2 5 3 5
debulking of cp angle tumor 1 2 2 5 3 5
approach to foramen magnum tumors 1 2 2 5 3 5
debulking of foramen magnum tumors 1 2 2 5 3 5
approach to pineal region tumors 1 2 2 5 3 5
colloid cyst 1 5 2 5 3 5
aneurysm surgery. (approach) 1 2 2 3 3 3
sub arachnoid dissection 1 1 2 1 3 2

61
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 NEUROSURGERY

62
R-3 R-4 R-5

sylvial fissure dissection 1 5 2 10 3 10

interpretation of angiogram 1 1 2 1 3 1
temporary and permanent clipping 1 5 2 5 3 5
approach and craniotomy for avm 1 5 2 5 3 5
dissection of avm 1 5 2 10 3 10
ic bleed management 1 5 2 7 3 7
endoscopic clot evacuation 1 1 2 2 3 2
microvascular decompression 1 1 2 1 3 1
translabrynthine approach 1 1 2 2 3 2
approach and dissection of orbital tumors 1 2 2 5 3 5
craniosynostosis 1 1 2 2 3 5
dissection of redo surgeries 1 1 2 2 3 2
epilepsy surgery 1 1 2 1 3 1
rhizotomy 1 5 2 5 3 7
management of high grade tumors 1 1 2 1 3 1
gamma knife principle 1 1 2 1 3 1
cyber knife principle 1 1 2 1 3 1
dbs 1 1 2 1 3 1
radiotherapy and chemotherapy 1 1 2 2 3 2
awake surgeries 1 3 2 5 3 5
facial nerve monitoring 1 1 2 1 3 1
spinal pumps 1 1 2 1 3 2

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 ASSESSMENT
FORMATIVE ASSESSMENT
College of Physicians and Surgeons Pakistan, in order to
implement competency based education in letter and spirit, is
introducing Work Placed Based Assessment (WPBA) in addition
to institutional/ departmental assessments. To begin with
college is introducing Mini-CEX and DOPS to ensure that the
graduates are fully equipped with the clinical competencies.
• WPBA tools are entirely formative tools of assessment and
are to be accompanied with constructive feedback.
• Each Mini-CEX / DOPS encounter extends for about 20
minutes with 05 minutes for feedback & further action plan.
• In case of unsatisfactory performance of the resident, a
remedial has to be completed within stipulated time frame.
• Topics given below are to be covered accordingly, focusing
each time on a different area/procedure/topic (Minimum
One Mini-CEX and One DOPS per quarter are to be
carried out).
• The resident has the onus to report to the supervisor when
he/she is prepared to appear for either Mini-CEX or DOPS.
• The supervisor will arrange for the session of WPBA and
after completing the session will retrieve online prescribed
assessment form (sample given below), fill it and make
entries online (e-portal).
• Non-compliance by the resident has to be reported in
quarterly feedback.

List of Topics for Mini-CEX

3rd Year:
• Proptosis
• Diplopia
• Vision loss/ blurring
• Hearing loss
• Trauma
• Anosmia
• Paraparesis
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63
 4th Year:
• Monoplegia
• Paraplegia
• Quadriplegia
• Foot drop
• Sphincter disturbance
• CSF leak
• Pulsatile Headache
• Endocrine symptoms

5th Year:
• Loss of consciousness
• Walking difficulty
• Blackouts
• Tremors
• Syncope
• Spasm
• Vertigo
• Dementia
• Rotatory Paralysis
• Pulsatile Headache
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64 FELLOWSHIP TRAINING
 P L E A S E C O M P L E T E T H E Q U E S T I O N N A I R E BY F I L L I N G /C H E C K I N G A P P R O P R I AT E B O X E S

please grade the following areas on below expectations satisfactory above expectation excellent
not observed /
the given scale: applicable
1 2 3 4 5
informed consent of patient
interviewing / communication skills
systematic progression
presentation of positive & significant
negative findings
motor and sensory exam
special test
justification of actions
grade the disease
• severity
• mobility status
• effects on daily routine
• red flags in past
diagnostic skills
management and follow up planning
professionalism
organization/efficiency/time management
any further exam recommended
overall clinical competence

Strengths Suggestions for Improvement

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65
 List of Topics for DOPS
3rd Year:
• Exposure for laminectomy/ discetomy
• Chronic sub dural hematoma drainage
• Decompressive Craniectomy / trauma flap
• Programmable shunt
• Posterior fossa craniotomy
• Durotomy+ dural hitches
• Duroplasty
• Dural grafts
• Cranioplasty
• Meningiocele repair

4th Year:
• Approach to spinal tumors
• Debulking of tumors
• Spinal fixation
• Screw placement/ graft placement
• Spinal decompressions/ laminectomy
• ACDF approach
• Posterior cervical laminectomy
• Approach to endoscopic surgeries
• Surgical approach to Brain tumors
• Debulking of gliomas
• Approach to posterior fossa tumors
• Meningomyelocele repair including identification of
placode and neural structures. Separation of dura and
closure in multiple layers
• Encephalocele repair including identification of
placode and neural structures. Separation of dura and
closure in multiple layers
• Removal of extradural spinal tumors
• Lumbar discectomy
• Approach to CP angle pathology
• Endoscopic intracerebral clot evacuation
• Frontal and temporal lobectomy
• Burrhole biopsy
• Open biopsy
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• Facial nerve monitoring

66 FELLOWSHIP TRAINING
 5th Year:
• Approach to endoscopic and trans-nasal surgeries
• Posterior fossa tumor excision
• Approach to fourth ventricle pathology
• Approach to intradural spinal tumors
• Approach to CV junction pathology
• Foramen magnum decompression
• Craniotomy for lesions adjacent to venous sinuses
• Corpectomy
• Posterior cervical fusion and instrumentation
• Occipito-cervical fixation
• C1- C2 fixation
• Endoscopic approach to 3rd ventricle tumors
• Endoscopic approach to pituitary tumors
• Approach and debulking of skull base tumors
• Debulking of CP angle tumor
• Aneurysm surgery (approach)
• Sub arachnoid dissection
• Sylvial fissure dissection
• Approach and craniotomy for AVM
• Microvascular decompression
• Approach and dissection of orbital tumors
• Craniosynostosis ( including strip craniectomy,
suturectomy and fronto-orbital advancement)
• Dissection of redo surgeries
• Epilepsy surgery
• Awake surgeries
• Facial nerve monitoring
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 P L E A S E C O M P L E T E T H E Q U E S T I O N N A I R E BY F I L L I N G /C H E C K I N G A P P R O P R I AT E B O X E S

please grade the following areas on below expectations satisfactory above expectation excellent
not observed /
the given scale: applicable
1 2 3 4 5
indications, anatomy & steps of procedure
informed consent, with explanation of
procedure and complications
preparation for procedure
marking of incision and positioning
use of anesthesia, analgesia or sedation
observance of asepsis
safe use of instruments
detailed knowledge of all instruments
use of accepted techniques
adequate control of haemostasis
management of unexpected event (or
seeks help)
post-procedure instructions to patient
and staff
professionalism/consideration of patient
communications skills
completed required documentation
overall ability to perform whole
procedure

Strengths Suggestions for Improvement

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68 FELLOWSHIP TRAINING
 SUMMATIVE ASSESSMENT
Eligibility requirements for residents appearing in FCPS-II are:
• To have passed FCPS Part-I in Surgery and Allied, or been
granted exemption
• To have undertaken two years training in Neuro specific
Intermediate Module
• To have undertaken two years of specified training in
Neurosurgery
• To provide certificate of having passed Neuro specific
Intermediate Module
• Completion of requisite entries in e-logbook along with
validation by the respective supervisors
• Completed CPSP mandated Mini-CEX & DOPS in e-logbook
• To provide a certificate of approval of dissertation or
acceptance of two research papers which must accompany
the application form
• To provide a certificate of attendance of mandatory
workshops
EXAMINATION SCHEDULE
• CPSP theory examinations may be held once or twice a
year depending upon the number of candidates
• Theory examinations are held in various cities of the
country usually at Abbottabad, Bahawalpur, Faisalabad,
Hyderabad, Islamabad, Karachi, Lahore, Larkana, Multan,
Peshawar, Quetta and Rawalpindi, centres. The College
shall decide where to hold oral/practical examination
depending on the number of residents in a city and shall
inform the residents accordingly
• English shall be the medium of examination for the theory/
practical/ clinical and viva examinations
• The College will notify of any change in the centres, the
dates and format of the examination
• A competent authority appointed by the College has the
power to debar any resident from any examination if it is
satisfied that such a resident is not a fit person to take the
College examination because of using unfair means in the
examination, misconduct or other disciplinary reasons
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69
 • Each successful resident in the Fellowship examination
shall be entitled to the award of a College Diploma after
being elected by the College Council and payment of
registration fees and other dues.

EXAMINATION FEES
• Fees deposited for a particular examination shall not be
carried over to the next examination in case of withdrawal/
absence/exclusion
• Applications along with the prescribed examination fees
and required documents must be submitted by the last
date notified for this purpose before each examination
• The details of examination fee and fees for change
of centre, subject, etc. shall be notified before each
examination.

REFUND OF FEES
If after submitting an application for examination, a resident
decides not to appear, a written request for a refund must be
submitted before the last date for withdrawal with the receipt
of applications. In such cases a refund is admissible to the
extent of 75% of fees only. No request for refund will be
accepted after the closing date for receipt of applications.
If an application is rejected by the CPSP, 75% of the
examination fee will be refunded, the remaining 25% being
retained as a processing charge. No refund will be made for fees
paid for any other reason, e.g. late fee, change of centre/subject
fee, etc.

FORMAT OF EXAMINATIONS
Every resident applying for the Fellowship of the College of
Physicians and Surgeons Pakistan must pass both parts of the
Fellowship examination unless exemption is approved. Since
the College is continually seeking to improve its examinations,
changes are likely from time to time and residents will be
notified in advance of such change.
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70 FELLOWSHIP TRAINING
 PART-I: THEORY EXAMINATION
The written examination consisting of two papers:
• Paper I: 100 Single Best Type MCQs
• Paper II: 100 Single Best Type MCQs
Only those candidates who pass through the written
examination will be allowed to appear in clinical
examination.

PART-II: CLINICAL EXAMINATION

The Clinical section comprises of two components:
• First Component:
• TOACS
• Second Component:
• One Long Case
• Four Short Cases
Only those candidates who pass through TOACS
examination will be allowed to appear in the remaining
components of clinical examination.

TOACS
Task Oriented Assessment of Clinical Skills (TOACS) has been
introduced since November, 2001 in FCPS examinations.
The minimum number of TOACS stations is 10. However, the
number can be increased if deemed necessary. All stations are
required to be “Interactive”. At these stations, the residents
will be required to perform a task, for example, taking history,
performing clinical examination, counseling, assembling an
instrument or any other task. One examiner will be present
at each interactive station and will rate the performance of
the resident and ask questions testing critical thinking and
problem-solving skills.

FORMAT OF LONG CASE

Each resident will be allotted one long case and allowed 30
minutes for history taking and clinical examination. Residents
should take a careful history from the patient (or relative) and
after a thorough physical examination identify the problems
which the patient presents with. During, the period a pair of
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examiners will observe the resident. In this section the

residents will be assessed on the following areas:

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71
 INTERVIEWING SKILLS
• Introduces one self. Listens patiently and is polite with the
patient
• Is able to extract relevant information.

CLINICAL EXAMINATION SKILLS

• Takes informed consent
• Uses correct clinical methods systematically (including
appropriate exposure and re-draping).

CASE PRESENTATION/ DISCUSSION

• Presents skillfully
• Gives correct findings
• Gives logical interpretations of findings and discusses
differential diagnosis
• Enumerates and justifies relevant investigations
• Outlines and justifies treatment plan (including
rehabilitation)
• Discusses prevention and prognosis
• Has knowledge of recent advances relevant to the case.
• During case discussion the resident may ask the
examiners for laboratory investigations which shall be
provided, if available. Even if they are not available and
are relevant, residents will receive credit for the
suggestion.

FORMAT OF SHORT CASES

• Residents will be examined in at least four short cases for
a total of 40 minutes jointly by a pair of examiners
• Residents will be given a specific task to perform on pa-
tients, one case at a time
• During this part of the examination, the resident will be
assessed in:

CLINICAL EXAMINATION SKILLS

• Takes informed consent
• Uses correct clinical methods including appropriate
exposure and re-draping
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• Examines systematically.

72 FELLOWSHIP TRAINING
 DISCUSSION
• Gives correct findings
• Gives logical interpretations of findings
• Justifies diagnosis.

As the time for this section is short, the answers given by

the residents should be precise, succinct and relevant to the
patient under discussion.

Note: The resident is required to fill a self-explanatory

“feedback form” at the end of examination.

THE COLLEGE RESERVES THE RIGHT TO ALTER/AMEND ANY

RULES/REGULATIONS
Any decision taken by the College on the interpretation of these
regulations will be binding on the applicant.

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73
 Published: 27 December 2023

COLLEGE OF PHYSICIANS AND SURGEONS PAKISTAN

7th Central Street, Defence Housing Authority, Karachi-75500.
Phone No. 9926400-10, UAN: 111-606-606, Fax No. 99266432