March 27, 2005

The doctors of tomorrow will be more or less glorified quacks who would take tuitions from OT technicians

A NUMBER of MBBS doctors are being produced in Pakistan who are neither well educated and nor well trained. Majority of them lack all the necessary skills and talent that one would expect off a qualified doctor. So much so, the many of the postgraduate doctors aren’t even trained to work as senior registrar or as junior consultants.

With the exception of one private medical college, all medical colleges in the public and the private sector are not functioning as per rules and regulations of the Pakistan Medical and Dental Council (PMDC). And it does seem that the “authorities” aren’t interested in correcting the prevailing situation. Postgraduate training is equally worse in the majority of postgraduate training centers. With the exception of a rare few, majority of the departments do not have structured training programmes.

TRAINING DURING HOUSE JOB: Every medical graduate has to work as a house officer in the field of medicine and surgery and its allied departments, as per the rules of PMDC. The purpose is to train the novice doctor in basic surgical and medical methods that are practised on patients under supervision.

The doctors learn the day-to-day management of patients in the ward, minor procedures, passing a urinary catheter to IV line and so on. They assist in invasive procedures. If they are lucky, a good professor (which is a rare commodity) will also teach them about ethical practice of medicine and social responsibilities of a doctor. Not only with the professor be a teacher, but he or she will also be a role model to the young doctors.

After the house job a doctor should be able to call himself a trainee or a learner in medicine or surgery. At this point in time, he decides about his future actions, which field of medicine or surgery he would like to go to. However, if a doctor decides to remain in Pakistan, the he or she would most probably live a life a second-class doctor for postgraduate training in those departments where part time training is provided by part time professors to part time trainees.

Unfortunately the situation is same in every branch of medicine and surgery in teaching centers all over the country.

TECHNICIAN DEPENDENT SURGEONS: A doctor who has opted for surgery, (obstetric gynaecology, ophthalmology, neurosurgery, ear nose throat, thoracic surgery, plastic surgery, urology etc.) will end up getting training in these centers where he will work unsupervised most of the time.

He will be dealing with emergencies in the late-hours of the night. If he blunders in anyway, he will seek help and will be guided on the telephone by his senior colleagues.

If some of the trainees are lucky then they will be trained by some junior consultants for dealing with emergencies. For example, in obstetrics and gynaecology, the trainees will be trained to perform caesarean section and evacuation of uterus. They will not be able to perform elective cold surgeries. In the field of surgery, they will be able to deal with acute appendicitis, gut perforation and bullet injury, but will not be trained in dealing with gall bladder, major bowel surgeries, renal stones, spinal surgeries, elective orthopaedic, ophthalmic and ENT procedures.

The person who trains these future surgeons are the theatre technicians. After all, these are the people who have been working at the hospital for many years. All teaching hospitals have experienced OT technicians who can perform minor and major surgeries without knowing the pathology of the disease and are least bothered about the post-operative complications. Some of them are definitely better surgeons than professors and it is a well known fact that many professors need their help in their private and public practice.

Because of this existing situation, trainee surgeons across the country depend on experienced operation theatre technicians for their training in every branch of surgery. During their attachment at teaching hospitals, majority of postgraduate trainees start their private practice at small peripheral hospitals, that have mushroomed all over the country. They admit patients with or without diagnosis and perform surgeries with or without indications, with the help of technicians. The ‘hard working’ young postgraduate trainees pass their FCPS, MS or MD exam and declare themselves specialists. They work in private sector health centers as consultants while at the same time, some of them get jobs in public sector hospitals.

These technician-dependent-surgeons are increasing day by day. Every day we hear about the mismanagement of patients by these TDS and unfortunately there is no mechanism to control this epidemic. The TDS are ready to work in periphery. They are cheap and in majority of the time most of the patients are satisfied as well. At the same time, they are good for the hospital’s revenue stream. But they cannot provide a quality care to the patients because of their dependence on technicians and total lack of understanding regarding ethical practice.

MEDICAL REP DEPENDENT PHYSICIANS: Young medical graduates who want to be physicians also go through a rough deal. After the completion of their house job, they are selected to work in the specialist field where they complete their requirement for FCPS Part II, MS or MD examination.

These young doctors, majority of whom are intelligent and hard working, are trained by their seniors, who are usually not available in the wards. Resident Medical Officers (RMO), registrars, senior registrars, medical officers in, out-patients departments are the main trainee of young physicians. They deal and manage emergencies without the supervision of senior professors or faculty members in majority of the wards.

It is routine practice for many professors not to do rounds, organize clinical meetings or even encourage discussions in wards. They come late and leave early, because of their heavy commitments in private practice. Whatever time they spend in the ward, they are busy in activities, other than academic.

Trainee doctors learn the art of prescribing drugs from medical representatives of national and multinational pharmaceutical companies. Because the majority of the patients are attended by these young doctors in public sector institutes, they are obvious choice for the promotion of drugs.

Medical representatives not only teach them about their new and old products, they also make them corrupt by fulfilling unethical and wrong demands. In the absence of a structured postgraduate training programme the networking of the trainee doctors with different medical representatives is a very effective method of promoting drugs and creating awareness regarding particular disease.

These medical reps-dependent physicians (MDPs) are not able to provide quality care as they are not trained to do the job. In fact, they are glorified quacks with postgraduate diplomas and the majority of them are not there to solve the problem or to treat the disease. They are part of the problem and are the cause of drug induced illnesses.

It is interesting to observe that the prescription of some senior faculty members and their students working as junior consultants. They prescribe multiple antibiotics, multiple vitamins and same drugs with different names to one patient. These prescriptions show the loyalty of these doctors, more towards the drug companies and less towards the patients.

At the same time, unethical pharmaceutical companies in collaboration with medical stores, doctors, quacks, laboratories and hospitals continue to work hand in hand, all because our young graduates are not told or taught about medical ethics and simple morality. There are 600,000 such quacks in the country who are causing havoc in the rural areas, city slums and are directly responsible for the deaths and suffering of innocent patients. At the same time, our prestigious institutes are also indirectly responsible for the morbidity and mortality of patients by creating TDS and MDPS who are no better than quacks. But these quacks, since they have their undergraduate and postgraduate qualifications, are more confident about their wrong doings. They are not accountable to anyone.

The responsibility for this mess also goes to the academic councils and faculty members of medical colleges who have played a very negative role in developing the medical education and training system in Pakistan. They have been used by politicians and bureaucrats and have brought shame to the most respectable profession. It seems that present system will continue unless we have a political desire to change it for the betterment of our patient.

WHAT CAN BE DONE ?

• First of all, the PMDC should play its role and make sure that every undergraduate and postgraduate centre is running according to the rules of PMDC.

• The PMDC should act like autonomous and independent body for the standardization of training and teaching in undergraduate and postgraduate institutes.

• The College of Physicians and Surgeons should be very careful about the selection of supervisors and there is a need to change the pattern of exam. FCPSP should be an exit exam. There should be a mechanism for the standardization of training centers. All medical and surgical wards providing training should be inspected and it should be seen how much training is supervised. It is a difficult task but the system need a change in that direction.

• All medical universities with plenty of funds available, courtesy, the Higher Education Commission, should become fulltime universities. All faculty members should be paid well to work from 8am to 5pm instead of 10am to 12pm. It is only by appointing fulltime faculty members that it will be possible to train good surgeons and physicians.

• All medical colleges attached to medical universities and general universities should also become fulltime institutes.

• A system of Continuous Medical Education (CME) is required for working physicians and surgeons to make them aware about the changing world. Accreditation from PMDC is required and a system should be developed for this purpose.

• A system of promotion, award and punishment should be established to pick good trainers and to get rid of incompetent doctors in private and public sector institutes.

• Private sector institutes also need a strict monitoring system. It is better if they developed their own system without interference of government. But, if they fail to do so, then it is the government’s duty to provide good and safe health delivery system with efficient system of teaching and training at private institutes.

• It is also required that our postgraduates should be exposed to real people of this country by developing a mechanism of their posting in rural areas of country. The Basic Health Units (BHU), Rural Health Centers (RHC) and taluka hospitals should be upgraded by affiliating them with medical colleges and universities. Instead of concentrating in cities, the policy makers should also concentrate on these centers for training and providing healthcare to the masses.

It is about time that our people, patients, women and children get better treatment. After all, we are a nuclear power!

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