Recently, I read an article in a local newspaper in which the writer said that Pakistan does not have enough doctors. ‘Enough’ is, of course, an entirely subjective term. So I looked up some numbers about doctors per a certain amount of population in several countries.

Interestingly it wasn’t developed countries that had the most number of doctors compared to their population. Cuba heads the list with almost six doctors for every thousand people. Developed countries like the United States and the United Kingdom had a little more than two doctors for a thousand people and Pakistan has about two thirds of one doctor for the same number of people.

If it makes my readers happy, India has fewer doctors per thousand people than Pakistan. As far as the numbers suggest, even if we bring back all doctors of Pakistani origin who are working in other countries, we might not get the number up to one doctor for every thousand people.

As I looked through the list of countries and the number of doctors they have, it became pretty obvious that the number of doctors was not necessarily directly related to the quality of healthcare available in a particular country.

Based on the numbers provided by the now defunct Pakistan Medical and Dental Council (PMDC), as of 2018, Pakistan had about 190,000 non-specialist doctors and another 46,000 specialists. However, there was no breakdown into different specialties.

Looking at the numbers for Pakistan a bit more closely, the Punjab has 83,000 doctors while Sindh has 66,000 doctors. Sindh has less than half the population of the Punjab and almost three fourths the number of doctors as in the Punjab, but nobody I know will insist that medical care in Sindh is better than that in the Punjab because it has more doctors per thousand people.

Coming to the Punjab, reports suggest that there are as many as 40,000 non-formal medical practitioners (quacks) and a lot more practising alternative medicine like homeopathy, traditional Greek medicine (hakeems) and others such. The reason why these non-formal medical providers exist is simply because regular physicians are either not available or are too expensive for the poorest segments of society.

As I have said before, good healthcare depends on availability, accessibility, quality and, perhaps most importantly, the cost. Recent introduction of the Sehat Cards is a good beginning but unless some money is set aside for doctor visits rather than just hospital care, the endeavour will be less than successful.

As far as the distribution of doctors all over the Punjab is concerned, there is one ‘guesstimate’ I can make. The total number of doctors working in Mayo Hospital as house physicians, specialist trainees, medical officers, registrars and consultants is probably greater than the total number of doctors working in one of the poorer and more rural districts in the province.

Before I get into a discussion about providing adequate number of doctors where they are needed, let me address the interesting issue of medical specialisation. My MBBS degree, issued to me after I passed my final professional examination, states that I was now ‘authorised’ to practise medicine, surgery and obstetrics. In actuality at that time, I did not even know how to give an intravenous injection.

The problem with medical specialisation is that all specialisations are not equal. With the advances in technology certain non-surgical specialties have become much more ‘invasive’. As an example, 40 years ago, cardiology was about determining the problem and then deciding whether open heart surgery was needed or if the patient could be treated with medicines.

Cardiology is now a group of sub-specialties that include diagnosis as well as complicated forms of treatment. Of these forms of treatment, the best known is of course the use of ‘stents’ to open up blocked heart arteries.

And the problem here is that this form of cardiology specialisation (interventional cardiology) is very lucrative and so we have more cardiologists putting in stents than we have the ones trying to treat heart patients with medicine. As somebody once said, asking an interventional cardiologist if a person with chest pain needs a stent is like asking a barber if a person with any hair needs a haircut.

How many specialists are needed in a particular specialty is often decided in the US by specialty boards and the ‘learned’ societies of that specialty. As interventional cardiology became popular (meaning more lucrative), the years of training required to practice this sub-specialty were slowly increased to almost six years after doing three years of internal medicine. Forty years ago it took just two years after internal medicine to become a ‘fully’ trained cardiologist.

In my specialty of cardio-thoracic surgery, as coronary bypass surgery became common and very lucrative, the number of training programmes in the US that could offer training in this specialty was cut down by half the year I started my training.

So those responsible for certain specialties make sure that the new trainees do not flood the market and that the ones produced are adequately trained to perform the complex procedures being done. More importantly, manpower surveys are performed to decide how many new specialists are needed as the specialty grows (or shrinks) and present specialists retire.

In Pakistan, medical specialisation is a free-for-all. Taking the example of cardiology, we have the Dip Card (-diploma in cardiology) and then we have the Fellow of the College of Physicians and Surgeons (FCPS) and finally the foreign-trained specialists from UK and the US. I do not know if any of our medical universities are offering a Doctor of Medicine (MD) degree in cardiology.

The question then is whether all these different types of training produce similar or even relatively equivalent experts in any specialty like cardiology? As a US-trained surgeon I am biased. I believe that US-trained cardiologists are generally better trained and qualified. However, there are individual variations.

My bias is strengthened by my experience in Pakistan. As the chair of the department of cardiac surgery in King Edward Medical University, I had the opportunity to work with and be involved in training FCPS as well as Master of Surgery (MS) candidates. In my opinion, it will take a few generations before specialty training in Pakistan can compete with US training.

And that brings me to the question of why our teaching hospitals are so full of medical trainees. The answer to that question is that though there might be a minimal number of years for training, trainees can just stay on in the hospital for as long as possible, getting a monthly stipend and working in private hospitals during off hours to make more money.

During my time in KEMU, there were trainees for FCPS cardiac surgery that were already there when I joined and were still there when I left almost seven years later. In stark contrast, I started my training in cardio-thoracic surgery on a July 1, and exactly three years later I was given a farewell dinner and sent into the world to fend for myself. That is what should happen in Pakistan as well.