june issue 2011

On a typical hot and humid afternoon in Karachi, Ahmed Sher, a resident of Mirpurkhas, waits for his turn to see a doctor, along with hundreds of other patients and their families in the compound of Civil Hospital, Karachi. This is his third trip to Karachi in the last eight months to seek treatment for his two-year-old daughter who has chronic pain in her stomach. Despite the medication the doctors have prescribed, she has not had any relief. “The treatment is not working but I have no choice other than to come here,” he says.

Sher’s troubles are a manifestation of one of Pakistan’s healthcare system’s most basic problems: many doctors can’t help the public with basic health issues.

In fact, it was reported recently in Dawn that the WHO’s regional director, Dr Hussein A Gezairy, at a workshop on public health said, “The impact of medical education can be gauged from health indicators such as infant mortality and maternal mortality rates. It is therefore important to produce doctors who have skills and abilities to promote public health.” He also called for the replacement of the three-decade-old medical curriculum in Pakistan with one that takes into account the country’s changing health needs.

The problems with the medical syllabus are explained by a WHO report. The report entitled, “The Teaching of Medicine in Pakistan and the Emerging Role for Community Oriented Medical Education: The need for broader Partnership,” says that if the traditional syllabus is followed “basic and clinical sciences are studied separately; students are exposed to patients after several years and education is primarily discipline-, teacher-, lecture- and hospital-based.”

Thus, the WHO is promoting a syllabus in which “basic sciences are taught throughout the study parallel with clinical subjects, related disciplines are often taught concurrently and teaching is student-directed, problem-based and/or community-oriented. The predominant outcome of this change is the endorsement of problem-based community-oriented education, where educational institutions take account of the epidemiology, vulnerability and the needs of the population.”

In fact, the WHO has been advocating a community-oriented approach for a long time through its Community Oriented Medical Education (COME) programme, not only in Pakistan but also worldwide.

The WHO is not the only one pushing for reform. Medical education has been an ongoing issue for years and for the last several months, the Pakistani press has been raising the inadequacies of Pakistan’s medical education system again.

Clearly there is a crisis at hand. But who is to blame? Non-governmental organisations such as the Pakistan Medical Association (PMA) and the Young Doctors Association (YDA) along with individual experts are all pointing fingers at the Pakistan Medical and Dental Council (PMDC). The PMDC is the statutory, regulatory and registration authority for medical and dental education and practitioners in Pakistan and is responsible for the monitoring and standardisation of medical education.

While speaking to Newsline, the registrar of the PMDC, Dr Ahmed Nadeem Akbar, agreed with the WHO’s analysis of the curriculum issue. In fact he went on to say that the PMDC has done nothing to improve medical education in the last 30 years — until recently. He said that this changed three years ago — which is when he became the registrar — and the council formed a national committee for formulating a new curriculum. The new syllabus is now in place, but only in seven universities, including Aga Khan University and Dow Medical College.

Dr Akbar added that the reason it hasn’t been launched on a national level is because the PMDC wanted to approach the matter in a scientific and methodological way, “fine-tune it. These changes can’t be brought about overnight,” he said. “We have been working for three years it will take time, several years maybe, before the new curriculum is launched nationally.”

But skepticism abounds given the slow changes in the curriculum and the growing number of universities.

Dr Sher Shah Syed, in a recent column for a leading daily, describes what he thinks the problem is: “In the last two years, the PMDC recognised all medical and dental colleges that applied for registration. There was only one exception, which by the looks of it, lacked the ‘right’ political and financial connections. While we have as many as 92 PMDC-recognised medical colleges in the public and private sectors, the majority of them struggle to meet even the minimal PMDC requirements as regards to faculty, space and facilities. It is also a fact that the PMDC has allowed several of these colleges to increase their induction quota. The least expensive of medical colleges in the private sector charges at least Rs 400,000 per student per annum, making it one of those rare businesses in which millions can be earned without having to make a proportionate investment.”

He is not alone in his criticism. Dr Salman Kazmi, the secretary general of the YDA, condemned the PMDC by calling it a “white elephant.” He said that the council had no interest in reform and people with “vested interests” have taken over. The very restructuring of the council, according to him, has led to the current crisis.

If the PMDC wanted to take drastic actions to protect students and the public, it could. The PMDC has the authority to give accreditation to a medical college and to take it back, but it seems as if it has only been doing the former. Not even a single case of a medical college being stripped of its accreditation has been reported in the last two years even though Dr Akbar claims that if the weaker colleges don’t reform themselves they are shut down.

Here the issue of monitoring comes up. How is the PMDC making sure that colleges comply with its guidelines not only during the accreditation process but also beyond it? Dr Akbar, the registrar of the PMDC says that the curriculum is monitored on a five-year basis. When asked if that is enough, his answer is yes. “While the curriculum is monitored every five years, the annual exams of all the medical colleges are monitored by the PMDC inspectors annually.”

The General Medical Council (GMC) in the UK, just like its Pakistani counterpart visits each medical school at least twice within every 10 years along with annual monitoring. However, there is a difference in the process. The GMC carries out a more comprehensive review of its medical colleges as is illustrated by the details of its Quality Assurance of Basic Medical Education (QABME) Annual Return Process. This means that “every year, each medical school must provide a return to the GMC that identifies significant changes to curricula, assessments or staffing; highlights risks or issues of concern, proposed solutions and corrective actions taken; identifies examples of innovation and good practice; responds to issues of interest and debate in medical education, including promoting equality and valuing diversity; and identifies progress on any requirements or recommendations arising from the QABME visit process.” In Pakistan, only examinations are monitored annually and detailed reports are not sought every five years during visits.

Meanwhile, as far as the actual curriculum is concerned, the YDA Secretary General Dr Salman Kazmi toldNewsline that the curriculum and syllabus for undergraduates has not been defined. He said it was “unfortunate” that medical students and young doctors are not offered career counseling nor are they taught medical ethics, which he said were the cornerstones of a sound medical training and education programme.

Some say it is not what is being taught that is the big problem.

The PMDC syllabus is fine, says an official of the Aga Khan University’s curriculum department. “It has all the subjects that need to be taught to an undergraduate medical student but we raise the bar with a student-centred approach: problem-based learning; smaller classes; group discussions; integrated teaching (teaching related subjects together); and finally a community-based approach.” Students practice not only at the well-renowned Aga Khan Hospital but are taken to NGOs like Edhi and outpatient clinics.

It is clear that the problem is mostly of methodology.

What all the organisations are calling for is to integrate the aforementioned aspects of teaching into the syllabus itself so that the quality of medical education may be improved in the country. And when the registrar of the PMDC, Dr Akbar, talks about the new curriculum he says that the PMDC is doing just that. However, Dr Akbar is more keen on integrating problem-based learning, teaching related subjects together and adding ethics into the curriculum as opposed to the community-based approach.

Pakistan’s medical education is at a crossroads: while the medical curriculum issue is just one of its many crucial ones — such as the lack of faculty and research, and inadequate infrastructure — it is one that if solved can lay the foundation for a sea-change.

Meanwhile, it is the people of the country who suffer as cases of neglect and negligence rise and government inaction continues. The pyramidal cadre of doctors in the country means that those on the upper level are accessible only to people who have the financial resources to reach them. The less fortunate have no choice but to go to any doctor they can afford.

Ahmed Sher has returned to his village with new medicines and little money left. He did finally get his turn but, only time will tell if this time the doctors were able to diagnose Sher’s daughter’s illness correctly and give her the treatment to end her drawn-out suffering.

This article originally appeared in the print version of Newsline under the shorter title, “Expired Medicine.”