In my previous article, I had discussed what seems to have gone wrong with King Edward Medical University (KE) and what could be done to make things better. Even though I had suggested that KE was tottering on the brink of mediocrity, I did not quite realise how bad things had become. More than mediocrity what seems to be threatening KE is chaos.

Over the last week or so, there have been physical confrontations between certain members of the Young Doctors Association (YDA) and senior academic staff of the medical university. Investigating teams have been established to determine cause and culpability for these confrontations. The end result will as usual be nothing.

This in essence is a total breakdown of the medical hierarchy and end of whatever little prestige is left attached to the idea of seniority. There was a time when being a professor at KE commanded respect. It meant that the person had reached the pinnacle of academic achievement. Today being a professor is like being an ordinary government employee whom any two bit bureaucrat can humiliate at will. The reason why this can happen is because members of the teaching staff of the KEMU are employees of the Punjab government. The Punjab government can transfer them, promote them or make them ‘inactive’ (Officer on Special Duty-OSD).

From the looks of it, it would seem that things are beyond repair. But things are rarely as bad as they look. The academic staff of KE has three primary roles. First is to teach undergraduates, second to teach and train post graduates and third to provide or rather ‘supervise’ patient care in teaching hospitals. These three roles are intertwined. The last role is limited to ‘clinical’ departments only. The problem is primarily with postgraduate (PG) trainees. And these problems can be fixed by the university on its own. I will avoid delving into other relevant ‘solutions’ I have recommended previously.

Clinical departments in hospitals are run by members of the academic faculty of the university. These ‘consultants’ oversee three types of medical staff that works under them. First and the most straightforward are the ‘house officers’. These are fresh medical graduates that need to complete a year of house job to get full accreditation by the Pakistan Medical and Dental Council (PMDC). After completing their year they are history. The next cadre is that of the regular and permanent departmental employees. These include medical officers, registrars and senior registrars. This group comprises career physicians that might continue in that path or might choose other career options.

The position of PG trainees in the medical hierarchy of a clinical hospital department is quite flexible. They are students but they also have to perform clinical duties since that is an intrinsic part of medical learning. So, they are often inappropriately treated like regular hospital employees. The major problem is that there is no time limit on PG training. The situation has been made worse by the fact that PG trainees get a regular stipend from the government for as long as they are trainees.

A trainee position is like a ‘gold mine’ for the unscrupulous young doctor. There are no fixed clinical responsibilities, there is a decent monthly ‘stipend’ and subsidised ‘board and lodging’ at the medical student hostels. The trainee can work in a private hospital on the side to make extra money and take an occasional ‘night on call’ to keep the trainee charade functional. This makes the PG trainee position so desirable. And that evidently was the basic reason for the confrontation between the YDA and the academic staff -- getting a PG trainee position for a YDA member or sympathiser.

Here I would like to iterate most forcefully that the academic staff of the university has the absolute responsibility to train PG students. In my opinion the quality of PG students trained in a particular clinical department is the best evidence of how good that department is and how well patients are taken care of in that department. That said. Teaching is a two way street. Here again the reputation of a clinical department often determines the quality of PG students it attracts. And yes, respect for any individual irrespective of academic rank has to be earned.

Without taking a position on the recent confrontation in KEMU between YDA members and the teaching staff, I do wish to point out the major contradictions in post-graduate training that create problems. First is the one I mentioned above that there is no effective time limit on the period of PG training for particular PG qualifications. There are minimum time requirements but no effective maximum time limits. This exposes the entire PG trainee programme to misuse. The first thing that needs to be done is fix a time based upon specialty for which a PG trainee will receive a stipend and subsidised room and board. Once that period is over, the trainees must leave the department and prepare to take PG examinations on their own.

The other major problem at present is that there are two disparate pathways to getting a PG qualification that clutter up the situation unnecessarily. There is the fellowship programme of the College of Physicians and Surgeons of Pakistan (FCPS-CPSP) and the Doctor of Medicine (MD) and the Master of Surgery (MS) programmes run by universities. These university based degrees more often than not are a sham. Almost appropriately, the MS degree is referred to as My Son degree and the MD degree as My Daughter degree.

In short there should be only one path to post graduate specialisation in medicine and that is the FCPS. All other degrees can be additive and signify the desire of a particular physician to pursue a career in academic medicine. That said, even the FCPS training needs to be improved upon and also be time limited. However, the single most important part of post-graduate training is determination of the ‘clinical’ responsibilities of a trainee.

When it comes to administration and the actual day to day running of a clinical department, it is the permanent staff that is responsible. However, trainees must also be given some idea of management of a department. The more important aspect of training is gradually increasing clinical responsibilities appropriately supervised by the teaching staff. However, all training programmes must be monitored by the CPSP. In my personal experience as the chair of a training department, the CPSP persistently failed to play its proper supervisory role.

There is one final recommendation. That is to limit the number of trainees based upon the ability of a particular department to provide them with appropriate training. As an example in my own training in cardiac and chest surgery while in the United States, I went through a very busy clinical programme in terms of volume of surgical cases but it had only one trainee position per year for a two-year training programme. At the end of the two years, I was given a small going away party along with a pat on the back by my ‘chief’ that gently but firmly led me out the door.