Over the years I have expended much time and ink criticising the state of medical education in Pakistan. Perhaps it is time to offer some constructive advice. I will concentrate on King Edward Medical College/University (KE) where I graduated from many decades ago and where more recently I served as a member of the academic council and the chair of the department of cardiac surgery. Over the four decades since the time I graduated, KE from being arguably the best medical college in Pakistan has now reached the point where it is teetering on the brink of utter mediocrity.

There was a time in the seventies when as members of the training staff at medical programmes in the United States we could get a new doctor from Pakistan admitted as a resident just on the strength of the fact that he or she was a graduate of KE. Frankly after a period of medical acculturation KE graduates competed very well with locally educated physicians. Sadly, today if a KE graduate applies for a training position, or for a local license to practice medicine, the first thing they ask for is ‘un-forged’ description of subjects studied and grades obtained (transcript).

What has changed besides a generalised seeping corruption in our work environment? Much has changed but before I go there, KE was a victim of its own success. In 1969, as the editor of the KEMC Students Union Gazette, I wrote a poem of which I remember one line. Addressing KE I called it: "the aged Matriarch subsisting on tradition". Sadly tradition goes only so far in the modern world. Among many others, three important things happened that have really had bad effects on KE.

First is the increase in class size. The largest lecture theatre in KE can only hold at maximum 150 students. The class size these days is around 275 students. This means that roughly one third of the students have no place to sit during a lecture. This problem goes on even after graduation when the clinical departments get inundated with house officers they cannot even provide a place to sit down.

Second change is the quality of physicians that join the academic ranks. In 1970, the year I graduated from KE, the best and the brightest of medical graduates from the Punjab on getting their foreign training would return to Pakistan and literally fight over getting an academic position in KE. Also, the senior most professor automatically took over as the principal. Seniority and ability were valued and respected.

Today seniority has been put aside and the whim of the ‘appointing authority’ reigns supreme. This has done two bad things. First, the senior faculty has lost interest in what they do and their teaching function has suffered as a consequence. Second, young doctors that receive excellent postgraduate training no longer want to join a system where neither ability nor seniority counts anymore.

The other problem is remuneration. In the public sector the pay would be hilarious if it was not so sad. As an example, when I joined KE in 2004 as a ‘grade twenty’ professor and head of the department of cardiac surgery on contract, my starting pay including housing and transportation allowance was all of 36,000 rupees a month. If I performed just one open heart operation in the private sector every month, I would essentially double my monthly income.

Even for those that decide to join the academic ranks out of a need to serve, outside practice is necessary to pay the bills. I realise that the bureaucrats that control health departments will tell us that they have the same pay scales, but then they have the use of big houses, many servants and chauffeured cars for free. And I would not even mention ‘Allah’s bounty’ that rains upon them in immeasurable amounts.

The third thing that has changed for the worse is that KE became a University. The first VC was the previous principal. He was fired as soon as the present chief minister of the Punjab took over. The next two VCs, the first the senior most professor and the second one an unmitigated sycophant proved the Peter Principle of management absolutely correct, that managers get promoted to their level of incompetence.

One of the bad things that happened when KE became a university was that an institution already overburdened with more medical students than it could handle added on to itself the responsibility to train a large number of paramedical and postgraduate medical students. My rather moderate sized department of cardiac surgery was forced to take on the training of eight students that wanted to do a four year B.Sc. Honours in cardiac perfusion technology. Without going into the details of what it means, let me just say that my workload and my ancillary staff was barely adequate to train two such students a year at best.

At the same time I was also forced to take on four postgraduate students for a Master of Surgery (MS) programme while four surgeons pursuing a Fellowship of the College of Physicians and Surgeons of Pakistan (FCPS) qualification were also my responsibility to train. Fortunately, three of the MS students fled after they realised that they might actually have to do some real work in my department. Seven years later, two of them are still wrestling with clinical requirements at the premier heart centre in Lahore. Only one managed to complete his training at KEMU.

Finally, the matter of ‘curriculum’. In basic sciences they were, until a few years ago, teaching students the brilliant art of making ‘purryas’ (folded paper to hold powdered medicine, sort of like origami). But nobody was teaching students important things like genetics. I do not think that there is any faculty member at the basic science level in KE to teach such subjects. As a matter of fact there is no faculty member in the basic sciences with a doctorate in any relevant discipline from a well-considered university.

So, just talking of KE what do I think should be done to improve the quality of medical education? The most important thing is to make KEMU truly autonomous. Academic staff hired for KE should be for KE unless they are fired or choose to resign and the selection of such staff should be entirely up to the institution. Pay scales should be flexible enough to attract exceptional teachers and clinicians. The institution should be allowed to raise separate funds from private sources to pay for ‘named’ chairs and ‘named’ departments. And attached teaching hospitals must be brought under control of the university.

Second, the number of students should be cut down to less than 150. Yes it will mean that 90 per cent of the class will be made up of women, so be it. Frankly, for most specialties women make better doctors than men! Third, proper curriculum development that is in line with modern medical concepts should be implemented. And improving the state of the attached teaching hospitals might not be a bad idea.