In my last article, I had complained about the quality of doctors available in our government hospitals. My personal experience is limited to the doctors working and being trained in one of the biggest and the oldest government-run teaching hospitals in Pakistan.

This hospital provides all levels of training to hundreds of doctors in all specialties preparing for qualification as Fellows of the College of Physicians and Surgeons of Pakistan (FCPS) as well as for the university-based degrees of Master of Surgery (MS) and Doctor of Medicines (MD). Many of these doctors then proceed to take up specialist positions in both teaching as well as tehsil and district headquarters hospitals.

Before discussing the quality of medical training, it might be worthwhile to mention that according to a newspaper report (Daily Times-August 1, 2016-on line), "959 positions of specialist doctors lie vacant in the Punjab". Even during my time on the academic council of King Edward Medical University (KE) some five years ago, more than 40 faculty positions could not be filled. These included both basic science as well as clinical departments. What both of these pieces of information suggest is that there is a shortage of trained specialist doctors in the country. This could be due to the possibility that not enough trained doctors are being produced or that many trained doctors prefer to work in the private sector or else leave the country to serve usually in the Middle East.

Working in government hospitals is definitely not a preferred career choice for most recently trained doctors. The major reason is money. Government jobs do not pay a living wage or provide a career path that is worth pursuing. The need for a career ‘structure’ with appropriate remuneration is and has been a persistent demand of young doctors. This demand has been ignored by the government for at least the last decade.

To put things in perspective, when my contract with KE ran out after more than six years of service as a ‘grade twenty’ professor and chairman of a department in KE, my base salary was less than Rs50,000 a month. If I had joined government service after I completed my training some 30 years ago my salary would probably have been twice as much.

So, the first problem with most ‘trained’ physicians is that even if they join government service they have to augment their income through some form of private practice. And for those that have young families to take care of, private practice becomes a priority. And that usually means work in a major urban area. Such positions are obviously not easily available so many young ‘specialists’ prefer to emigrate to places abroad where they are paid a lot better. And those that stay in the country prefer to find a place in private sector hospitals and medical colleges that pay a lot more than government jobs. Here I must say this with some sadness that the best and the brightest of the doctors that we train these days either leave the country or else end up in the private sector.

Trainees as well as physicians trained abroad, on return to Pakistan, join government service mostly to avail themselves of government hospital facilities to gain experience and obtain the ‘panache’ attached to an academic appointment. Once that is done then their aim is to develop a lucrative private practice while continuing their attachment to a government hospital or medical college.

There is nothing wrong with having a private practice on the side or after hours for those physicians that work in government hospitals as long as they take care of their patients in the government hospitals as diligently as they take care of their private patients. And that idea must also be extended to the ‘training’ responsibilities that academic physicians have for training young doctors.

Many people in the general public and even some supposedly smart and appropriately ‘trained’ bureaucrats still think that a doctor after graduation and a year’s rotating house job in a teaching hospital can go out and work independently in a rural clinic. This is perhaps an absurd idea and is responsible for much of so called ‘planning’ done by our health department that is entirely ineffective. It was true some eighty years ago when my eldest uncle graduated from KE but medicine today is much more advanced than it was at that time.

Mere registration with the Pakistan Medical and Dental Council (PMDC) does not mean that the physician is now capable of practicing independently without appropriate post-graduate training. Sadly, post-graduate training is the weakest link in the process of producing competent physicians in Pakistan. Some teaching hospitals are better than others and some ‘teachers’ are better than others but there is no uniformity in the quality of training being imparted in different teaching environments. This problem is compounded by the present system of awarding MS and MD degrees that have entirely different requirements than those for a fellowship (FCPS) in the same specialty.

The first step in improving the quality of medical training in all specialties is to get rid of the MD/MS degrees that are known for obvious reasons as ‘My Daughter (MD) and My Son (MS) degrees’. There are, as always, honourable exceptions. With a uniform system of post-graduate training, the College of Physicians and Surgeons (CPSP) that awards the FCPS qualifications should become the sole arbiter of appropriate post-graduate training.

The next step must be to break up the CPSP into subsections with independent governing bodies. Broadly, it should be broken up into medicine and medical subspecialties, surgery and surgical subspecialties, paediatrics and its subspecialties and obstetrics and gynaecology. Modern medicine is too complex to be governed by a single specialty organisation.

Once the CPSP has been broken down into its major components then these components should be overseen to assure that they are appropriately monitoring medical training in their specialty. In the United States, for instance, there are all the specialty boards that supervise and provide accreditation for medical training and then there are residency review committees that assure an appropriate level of training is being provided in all the accredited training programmes. Of course, some trainees and some programmes will be better than others. But the primary purpose of this system is to assure a uniformly acceptable level of training. The result is that once a physician gets through such a system, he or she is actually capable of functioning as an independent practitioner.

Where do we find the people within the medical community that can do all these things? I believe they are there but need the proper incentives and ‘official’ support to do the right thing. Unfortunately, the present government treats healthcare as a stepchild and the bureaucracy is mortally afraid of strong and independent medical professionals running the public medical sector.

Finally, honesty, empathy, and caring cannot be taught in a classroom or on ward rounds. These values have to be acquired at an early age from family members, school teachers and role models in society.