Medical Education System In Pakistan

Reforms Necessary To Halt Ruination

The medical education system in Pakistan has become highly regressive over the years, and its quality has raised many a questions following the recent sacking of hundreds of  Pakistani physicians by the Saudi Commission for Health Specialties. Dr Sohail pleads the case for reforms and how they must be brought about.

 recently published my analysis of the rapidly deteriorating condition of medical in Pakistan (1). My focus in the recently published article was to highlight the deficiencies that exist in the policies, procedures and infrastructure of Pakistan Medical & Dental Society (PMDC) and the Higher Education Commission of Pakistan (HEC); the two accrediting bodies that do not seem to function in a concerted and collaborative manner. Independently and collectively, the arcane policies and procedures of these two entities have done more harm to the medical education and training system in Pakistan than all other factors combined. If the practice of medicine is to remain relevant in Pakistan and continue to be of benefit to the community than we have to think differently…the current model has failed and it will only get worse with the passage of time.

In this communiqué, I would like to focus on issues that are more relevant to individual medical colleges and to reaffirm the differences between medical education and training system in the United States, undeniably the best in the world, as compared to that in Pakistan. The ultimate hope is that this would spark an interest to reform the delivery of medical education and training in our country.

Medicine is an art whose practice requires many skills, which extend well beyond the technical expertise of the practitioner. It demands empathy, compassion, hard work, honesty and moral and spiritual purity. A good physician is not only a healer but also perhaps the most trusted companion for the patient and the caregivers in their time of need. It remains incontrovertible that despite the many advances in medicine, it still has a strong influence of “apprenticeship”, which it was at the turn of this century. From the teacher in basic sciences to the attending in the clinical domain all play a very important role in shaping the personal and professional attitude and behavior of the medical student, which only gets fortified during their postgraduate training.

I trust it is evident from this table (Table 1) that we have a system of selection, training and evaluation of medical students, residents and fellows and continuous post-certification monitoring of physicians in Pakistan that is not only dissimilar to that in the US but also informal and totally ineffective. Instead of having national level competition to secure admission/selection in a medical school/residencies/fellowships, we depend mostly on individual institutional policies and procedures, which while to some extent are dictated by the relevant accreditation bodies, are nevertheless interpreted and implemented with wide variability. We have to create a very competitive process to enter this noble profession, which in addition to academic performance, should also take into account applicants’ social and behavioral development.

 

The Need For Maturity 

It is a well-documented fact that the “learning readiness” of students is highly dependent on cognitive and social maturity. While age is not a measure of maturity, in most individuals, it does endow them with the experience to use good judgment, comprehend cause and effect and other thought processes that go along with reasonable and acceptable behavior. Maturity plays a role in an individual’s ability to accept responsibility for his or her own thoughts, feelings, actions and behaviors. Maturity governs personal responsibility, shared communication, openness to new ideas, and ability to find solutions to problems. It is, therefore, very perilous on our part to expose students with only high school diplomas to withstand the rigorous curriculum of a medical school and to shoulder the responsibility and the seriousness that this profession demands. It is therefore recommended that we seriously consider adding a pre-med undergraduate degree program for students aspiring to gain admission in medical schools in Pakistan. Interestingly, this recommendation was put forth by Flexner in 1910; a series of recommendations that changed the face of medicine in the world (2).

 

Future Ready?

The practice of medicine today and most certainly in the future is and will be very different from that in the past. Artificial Intelligence (or Intelligence Enhancement as it is called in more sophisticated circles), genetic mapping, 3D printing, telemedicine, advancements in informatics, etc., are radically changing the way we will be practicing medicine in the future. The advent of personalized medicine is also rapidly transforming the practice of medicine and yet, in medical schools in Pakistan, we have poorly qualified teachers who are still imparting the knowledge of yesterday to practitioners of tomorrow. Student-centered pedagogy is acutely lacking in our medical curriculum. We are not making any attempt to create life-long learners, as our process for evaluation of students’ knowledge is largely dependent on memorization and recall. Abraham Lincoln once said and I quote “I do not think much of a man who is not wiser today than he was yesterday”.  Unfortunately, our existing curriculum as well as the system for student evaluation is designed to trounce creative minds and to reward those who have perfected the art of regurgitation. A thoughtful, longitudinal and targeted professional training program must be developed and effectively implemented for faculty in medical schools endowing them with the knowledge and the tools to develop and deliver a medical curriculum that has the plasticity to acclimatize to rapidly changing landscape in medicine.

 

Re-certification

There is ample scientific evidence that suggest that re-certification of physicians (called Maintenance of Certification in United States) at regular intervals dramatically improves patient care (3, 4, 5). Not only that it decreases the like hood of disciplinary action against the physician, it also improves the care of patients with chronic disease such as diabetes, coronary arty disease, cancer and mammography screening in women. It is vital that we re-certify the practicing physicians at regular intervals in Pakistan to improve the delivery of quality patient care and to insure that the physicians continue to possess the most current advances in their specialty. An independent system of re-certification for medical and surgical specialties and sub-specialties must be established in Pakistan that adopts international standards for Maintenance of Certification. I do not believe that we have this expertise at the moment in Pakistan and it is therefore imperative that we work closely with the American Board of Internal Medicine and the American College of Surgeons to learn from their experience and get a select few visionary leaders in medicine in Pakistan trained by these entities.

It is time that we wake up and accept the fact that medical education and training in Pakistan is on life support and is vortexing into an abyss. It has deteriorated in the past two to three decades and the product that we are producing today to cater to the burgeoning healthcare needs in Pakistan is not prepared to help us meet our objectives. Instead of self-gratification and mutual commendations, which have always been an integral part of failing endeavors, we should make an informed decision to ratify this prevailing catastrophe. Seeking assistance from Pakistani physicians in the US, is also not a very promising alternative. Most of these physicians have shunned the life of academic medicine and have embraced the model of private practice. It is, therefore, recommended that we actively seek the assistance of relevant organizations such as Association of American Medical Colleges, Liaison Committee for Medical Education, Accreditation Council for Graduate Education and other similar entities to ensure that our next step(s) towards reformation are informed and have clear milestones that we individually and collectively have to achieve.

 

REFERENCES:

 

  1. Rao S. The State of Medical Education & Training in Pakistan – An Outsiders’ Perspective. Academic Magazine. 2019; 09-10
  2. Duffy TP. The Flexner Report – 100 years later. Yale J Biol Med. 2011; 84(3): 269–276
  3. McDonald, FS, Duhigg LM, Arnold GK, Hafer RM, Lipner RS. The American Board of Internal Medicine Maintenance of Certification and State Medical Board Disciplinary Actions: a Population Cohort Study. Journal of General Internal Medicine. 2018; 33(8): 1292-1298
  4. Gray B, Vandergraft j, Lanson B, Reschovsky J, Lipner R. Association between American Board of Internal Medicine Maintenance of Certification status and performance on a set of Healthcare Effectiveness Data and Information Set process measures. Annals of Internal Medicine. 2018; 169(2): 97-105
  5. Holmboe ES, Wang Y, Meehan TP, Tate JP, Ho SY. Storkey KS, Lipner RS. Association between maintenance of certification examination scores and quality of care for Medicare beneficiaries. Archives of Internal Medicine. 2008; 168(13): 1396-403

Sohail Rao, MD (Dow), MA (Boston), DPhil (Oxford)

Executive Vice President for Research & Development

DHR Health System

President & Chief Executive Officer 

DHR Health Institute for Research & Development

Texas, USA

He can be reached at drsohailrao@gmail.com or s.rao@dhr-rgv.com