Medical Education in Pakistan


Medical Education in Pakistan 

We need competent full - time well paid accountable
medical teachers devoted to academics

Prof. Emeritus Lt. Gen. Mahmud Ahmad Akhtar
Former Surgeon General Pak Army/Principal Army Medical College,
Dean Medical Faculty Quaid e Azam University

Teaching is a profession that creates all other professions. It is an art and science. Art is the oldest and most enduring. Teacher plays the key role in imparting education therefore the quality of teacher is most important in successful outcome of education. Teacher’s continuous assessment, evaluation, training/education is essential for the professional development of teacher, thereby progress of education. All over the world, teachers’ assessment, evaluation is regularly carried out involving students and accordingly teachers training is carried out. During my tenure as the principal of Army Medical College, teachers’ assessment was regularly done involving the students and teaching results were excellent. It has enormous importance for the medical education. Teaching profession needs passion commitment devotion and dedication, honesty, trustworthiness and loyalty too.

Lt. Gen. Mahmud Ahmad Akhtar

Teacher not only develops the professional/vocational capabilities but also intellectual and spiritual values of the students. Teacher has to possess sterling qualities of head and heart to become the role model for students.  In the past, medical teachers were devoted to patients and their care. They did not indulge in unethical medical practice, entertained a few private patients not affecting teaching. They helped poor patients with medicines and financial aid, set good examples for the students. With the spread of virus of corruption, many teachers have become money minting machines and students emulate them resulting in wide spread malpractice. Teaching needs creation of knowledge by doing research. It is well known adage that without research teaching is barren. There is a well-known phraseology ‘publish or perish’. Publications play an important role in the assessment and development of teachers- shows teacher’s updating of knowledge and skills. Research enriches teaching, contributes to learning and by its discoveries improves health care. The critical, analytical thinking ability, power of imagination and originality in teaching is inculcated by research activities.

Research: There is a scope for improvement by research in every field of medicine even in general practice/family medicine/ primary care by using simple methods. A postgraduate degree/diploma in clinical subjects means a selection for further training for specialization. A research degree is essential for wholesome knowledge in a particular field- essential for an academic career. In the British system in earlier stages, the British had combined qualification i.e. clinical cum research at Doctorate level) MD/MS etc., later the British adopted separate research qualifications like MD, DM, MS, DS, etc.

Other countries of the world, European Union, Japan, China, Soviet Union etc. have combined clinical/ research degrees. Pakistan is not following any system with the result that the research output is practically nil even less than the tiny Islands. Many of our medical teachers just become glorified technicians without any worthwhile flow of publications-originality. In UK one cannot get academic job without also possessing an academic research qualification. Students have to learn from their teachers at bed side, therefore medical teacher has to be a role-model. Patient care is in caring for the patient and has to be learnt at the bed side.

Medical teachers also need to acquire knowledge in humanities and social sciences in addition to professional knowledge. They should be imbued with the spirit of humanism, intense desire to serve the humanity. Likewise in the selection of medical students, humanistic values should receive top priority. Now a days in Pakistan this aspect is totally ignored. In the earlier days, admissions were based purely on merits- now a days many wealthier students get admissions on making hefty payments. Many doctors move to police, customs and other services in Pakistan-a phenomenon unknown in other countries- an enormous loss of money and time spent on education/training. Furthermore, in addition to good qualifications, aptitude for teaching and all other criteria, attributes of good teaching should be considered for selection, which is not done in Pakistan.

Teacher should be a good communicator, have command over language, teaching skills and have good administrative abilities. Teacher should be a lifelong learner. These attributes need continued focus and development. As medical education is concerned with creation, saving, preservation and promotion of human life of the patient, that is the heart and soul of holistic medicine. Man is more emotions than tissues, has biological, socio-economic and spiritual aspects. Medicine belongs more to humanities and social sciences than to biological sciences. Medical education is about patient care- should be patient centered -patient is the VIP. The most important aspect is the attitude, behavior followed by knowledge and skill of the treating doctors. Appropriate attitude and behavior is quite often found lacking due to poor selection of students and teachers.

At independence Pakistan had 87 yrs. old King Edward Medical College and newly started Balak Ram Medical College at Lahore in the private sector and Dow Medical College Karachi in the public sector.

King Edward Medical College’s MBBS standard was equivalent to MBBS London, its degree was recognized all over the world. Its post graduate degrees MD/MS were recognized all over the British empire rated equivalent to Royal Colleges qualifications was given precedence in seniority (Regulations Indian Medical Services 1937(RMSI). Medical education had first set back in 1959 when Martial law authorities appointed Army Medical Corps administrators (MBBS with field Ambulance Experience)/ in charge of colleges. Regimentation was imposed in the colleges, unions banned, many teachers and bright budding professionals left for foreign countries causing medical brain drain. The major setback occurred when the Prime Minister Bhutto by an order increased college admissions from one hundred to over three hundred students without providing adequate facilities. Agha Khan Medical College was established in 70s with 50-100 students’ admission, had controlled institutionalized private practice, the only medical college to keep up international standards to date. The Army Medical College was established in late 70s with 100 students affiliated with Quaid e Azam University. It attained high standards. In mid 1990s, the college was affiliated with ‘NUST’ a private university. For commercial reasons, the students’ entry was increased to 200, resulting in steep fall of standards.

In Pakistan medical education has become unethical commercial activity. Medical and Dental colleges, institutes and universities have haphazardly mushroomed in the country. Many of them are functioning without adequate facilities of teachers, hospitals, labs, equipment, sports facilities etc. For the wholesome development of a student, co-curricular activities are a must. It has been aptly said that the battle of waterloo was won on the playing grounds of institutions like Eton, Harrow etc. Physical exercises are most important to develop and nourish the physical and mental faculties of the students and plays an important role in the prevention and treatment of physical and mental disorders, promotion of health. Indoor and outdoor sports facilities should be provided and sports should be compulsory- an important part of education and health care of the patients. For good health, good learning, health friendly diet, good sleep and physical exercises are must.

Many medical colleges have teachers who travel to out station colleges for one day, a week, fortnightly, even monthly. These teachers are dubbed brief case teachers/professors. Many private medical institutions are governed by their own private universities, dishonest, fraudulent examinations are held to pass the students in order to obtain maximal financial gains. Wide spread corruption has been reported in the Pakistan Medical and Dental Council in nexus with Govt departments in granting permission to establish new colleges without basic infrastructure facilities. The teachers produce doctors of their own image.

The sub-standard colleges are producing poorly educated/trained self-centered doctors with substandard qualifications. Medical institutions should produce doctors of integrity. They should be imbued with spirit “what they give to their country/patients i.e. more important that what they get”. Doctors should be concerned with what is left in the patient’s pockets rather than with maximum extraction. Cost effective strategies should be adopted. Health economics including pharmaco- economics should be taught and practiced. Prevention is most cost effective therefore preventive medicine should be given utmost importance at all levels, individual to community, particularly in the developing world with poor resources. Real Pakistan lives in the slums of cities and towns and in the rural areas. About sixty percent of Pakistan’s population lives below at or just above the poverty line. Clinical medicines i.e. history taking (most important 60%) efficient physical examination (30%) investigations carefully chosen (10%) should be practiced. The strategy should be to treat maximum number of patients with minimum cost. If history taking and physical examination is done masterly and conscientiously, the need for tests is minimized, that is the soul and beauty of ethical medical practice. For treatment, natural life style therapies should be used, simple remedies should be used, for drug therapy cost effective “Essential Medicines” recommended by the expert group of WHO should be used. An essential medicine is defined as the efficacious, relatively safe, affordable, cost effective medicine needed by the large majority of the population i.e. over 90-95% of population- it says for itself. Unfortunately Pakistan is the only developing country in the world which is not using the Essential medicines System- the reason is rampant corruption- lust for money. Though the Pakistan’s 1st list of Essential Medicines formulary was prepared in 1987 but never implemented for a single day. This is the major cause of Pakistan’s highest still birth rate in the world. 40 per 1000 deliveries while the world’s average is 14/1000- the highest new born infant, child mortality (below 5 yrs.) maternal mortality and adult mortality and the shortest life span in the world barring two to three sub Saharan countries. Nepal and Bhutan are far ahead, even the newly emerged Bangla Desh has taken enormous lead. Sri lanka has reached nearly developed world statistics with universal health care and universal one education system for everyone. All these countries are robustly following essential medicines system. On the other hand Pakistan’s markets are flooded with irrational harmful medicines robbing the people of their health (toxicity) and meagre financial resources of the people and country. It is pertinent to point out that the British National and Nordic countries health services run on generic medicines. The need for health economics is supreme for Pakistan- medical education and practice should be geared towards this end.

Pakistan is flooded with bogus qualifications like fellowships, doctorate etc. - openly sold all over the country, people displaying, and practicing, cheating, playing havoc with people’s lives with impunity. Even many doctors holding basic qualifications displaying fake post graduate qualifications openly practicing as super specialists charging enormous fees. PMDC and the Govt. is least concerned about the dangers patients are exposed to. It appears that the PMDC’s only job is to harass genuine qualification holders – issuing notices etc. even to octo-gerian doctors to stop medical practice if renewal is not done in time.

All over the world doctors holding teaching appointments are not allowed private practice so that teachers devote full time to patient care and to academic activities. In Pakistan teachers are allowed unrestricted/ unregulated private practice. Many teachers spend most of their time in the unethical medical businesses owning hospitals/diagnostic centers doing only part time work in the teaching institutions. Unrestricted unethical medical practice rather business is a cancer destroying the very foundation of medical education and the patients’ lives. It has earned a bad name to the noble profession, some doctors are accused of acting worse than dacoits even plundering the wretched poor patients which dacoits spare, and bringing bad name to the profession- No wonder Pakistan has got the worst health indicators in the world. Tragically our rulers are least concerned about people’s pathetic plight and deeply engrossed in luxurious living and elitist projects serving the elites only. Health and education has the least priority and even in the health sector luxurious tertiary projects forming 1% of the health care system gets the top priority while the primary cum secondary health care gets the least priority.

Teachers holding professional appointments should be paid enough so that they whole heartedly develop their full time energies to medical education. There should be vigorous accountability- continuous audit and appraisal.These days there is emphasis on integration of medical sciences i.e. basic and clinical sciences and also with humanities and social sciences to achieve holistic medical education and health- care.

Unfortunately these days many specialists are practicing as mono organists and not as whole some doctors. A doctor studies 5 yrs. plus 1 yr. house job to become a basic doctor i.e. primary health care doctor, then spends a few years to do internal medicine/ general surgery/ family medicine/gynae and obstetrics to become a specialist i.e. has more general knowledge. Those doing sub specialty/ super specialty like cardiology/ gastroenterology/ pulmonology attain further specialization. The basic degree i.e. MBBS should be the strongest degree so that a doctor has good knowledge and acumen of primary care. Mental health and mental disorders have become very common. In fact most of the patient’s carry two physical  and one  mental disorders like anxieties, depression, emotional distress, etc. Common mental disorders should be diagnosed earlier with physical disorders and treated. This helps in overall treatment even of physical ailments. Unfortunately in Pakistan this aspect is badly neglected at patient’s peril. There should be complete integration at the primary level, medical care facilities.

In most of the countries physical and mental medicine is fully integrated otherwise patient does not get effective treatment. It is also cost effective. Even in the Sub Saharan countries, mental health has been fully integrated with physical medicine with excellent results. Only complicated patients should be referred to specialists. In this way Pakistan’s medical education is very defective. This aspect needs full attention and action. Unfortunately many of doctors do mal-practice for extreme lust for money, just see a patient not as a whole human being but as a mono-organ, perform expensive procedures, charge massive fees, neglect many ailments patient is suffering, or unnecessarily refer patients to other specialists for minor general ailments and many tell the patient there is nothing wrong as they do not find any positive finding in their organ of super specialty. This is a serious crises of malpractice, neglect of patients and robbing of patient’s finances. History taking (mainly) and physical examination the basic pillars and soul of medicine are ignored-many consultants even do not, touch the patient.

A doctor should be humane to the patient and scientific to disease, should be a good communicator should be endowed with empathy and humility- mother of all virtues.

Recent studies have shown that the Noble laureate have a lot of interest in arts, humanities and social sciences- have a wide base of knowledge- this is a common factor in their careers successes. Dr Abdul Salam used to edit Govt Colleges Urdu and English magazines and wrote prose and poetry. Successful physicians have also excelled in art and poetry etc. In these days this aspect is being badly neglected. In the earlier days of Pakistan, many medical doctors excelled in literature- pros, poetry, arts etc. Before independence Prof M. A. Peerzada won an all India debate contest “doctors versus lawyer’s profession”. After partition Dr GM K Baloch used to play a leading role in the proceedings of the literary society Halqa- Arbabe- Zauq and excelled in literary pursuits. General Shafiq ur Rehman excelled in Urdu humour literature and General Mahmud ul Hassan has published Urdu poetry.

The most important thing the teachers have to offer students is themselves- longer and deeper relation with the students is the hall mark of learning. Student should be taught to be lifelong self-learner. The quest for education is a continuous never ending endeavor. The journey of knowledge knows no limits. Hippocrates said life is short and art is long, occasion instant, experience perilous, decision difficult.

In Pakistan there is deficiency of competent teachers. We should utilize the experience of old academia. During my tenure of principal ship of the Army Medical College, the experience of old academia like General Shaukat Hassan, General Mahmud ul Hassan and others was utilized producing excellent results. We should accumulate the wisdom of the older academia and codify it to serve and guide the present and future faculty. In foreign countries the old teachers are appointed as Emeritus Professors. Unfortunately this is not done in Pakistan.

Pakistan’s education landscape should be result oriented. The recent report by the Quacquorel Symonds global rating organization on ‘higher education’ put Pakistan at the very bottom of nations with shamefully 9.4 while India is 60.9, we are even behind the war torn Lebanon in spite of spending billions of rupees of the poor debt ridden nation.

In Conclusion to bring Pakistan’s medical education to the international standards there is dire need to have competent whole time well paid accountable teachers devoted to academic activities with appropriate number of merit based attitude selected students adequate infrastructure facilities and transparent evaluation system has to be introduced. Limited institutionalized private medical practice as is done at Agha Khan University at Karachi and other countries may be done. Teachers tenure, promotion should be based on their sustained performances. This is do-able- being done in Pakistan at the Agha Khan Medical College and in the SAARC countries. Pakistan should become a social democratic welfare state as envisaged by the founder of the state, enshrined in the Pakistani constitution and the cardinal principles of our religion. Commercialization of education, particularly medical education is lethal for the people- the present health indicators have proved it. Unregulated, exploitative, capitalistic state, Pakistan is called the ‘Islamic Republic of Pakistan’- it is neither Islamic, nor Republic, nor Quaid’s Pakistan, ideologically or geographically.