Between a rock and a hard place

By Dr ALI MADEEH HASHMI
THE Pakistani medical profession has been in the news for all the wrong reasons lately. Strikes, demonstrations and all kinds of wrongdoings on the part of the ‘healing profession’ seem to be the norm, if the media is to be believed.

But what do doctors themselves think about this?

In Pakistan, as elsewhere in the world, becoming a member of the ‘professions’ (medicine, law, etc) has traditionally (and in most cases, correctly) been considered a path to upward social mobility. In rural and semi-urban areas, where opportunities for employment are limited, sending one (or all) of their children to medical college is the dream of poor families. Even in relatively comfortable middle-class families, the medical profession has traditionally been viewed as a desirable vocation for studious children who perform well in school.

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A young doctor after graduation is faced with a stark prospect: find the money to migrate abroad or face a lifetime of frustration in Pakistan.

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As a result, there is massive competition for admission to medical colleges. In Punjab, more than 30,000 bright youngsters compete for admission to around 3,000 slots each year, an admission rate of around 10pc (as a comparison, the admission rate to American medical colleges is around 50pc).

Those who are admitted to medical college face a rigorous five-year curriculum with lectures, practical demonstrations, hands-on work and a huge (and ever expanding) body of knowledge to master.

After graduation and a one-year ‘house job’ in whichever hospital their medical college is attached to, newly minted doctors find that they are basically cast aside and left to fend for themselves. There are few job opportunities that pay enough to marry and raise a family and even fewer which would allow a young doctor to save money to educate themselves further. The lure of the West is a constant presence but Western countries have their own system of licensing and certification which can be a time-consuming, expensive process. In addition, most Pakistani doctors, especially from outside the bigger cities, lack basic English language skills and are thus poorly positioned to enter the medical profession in the English-speaking world.

In more advanced societies where educational and social research is the norm, there is at least some effort to link ‘higher’ (ie college or university) education to the existing job market. In the US, this guides efforts by educators to channel students into vocations which are expected to be in demand in the near to medium term. In addition, in most Western countries, ‘technical’ or ‘vocational’ education is better organised and does not carry the social stigma that it does in Pakistan. Jobs for electricians, plumbers, car mechanics, etc require specific technical skills but no college degree and pay a livable wage.

The only sector of Pakistani society that has benefited from the mania for ‘higher education’ is the education sector itself with private schools and colleges and recently private ‘universities’ sprouting like bamboos after the rain. Many of these institutions offer dubious curricula with minimally trained faculty churning out thousands of graduates with low-level skills that would have been better acquired in high school.

In the medical profession, the same model operates except that the minds being thus wasted after graduation are some of the best and the brightest in the nation. A young doctor after graduation is faced with a stark prospect: find the money to migrate abroad or face a lifetime of frustration with no opportunities to better his/her education or find stable employment.

There are solutions available but they require some political will and vision. Starting immediately, the government can incentivise doctors to serve in semi-urban and rural areas. They should be offered jobs at above the prevailing wage immediately after their house jobs and asked to serve in their chosen posts for at least three years. This model is very common in the US where fresh medical graduates can serve in federally designated ‘Health Professional Shortage Areas’ in exchange for the government paying off their (substantial) student loans. While they work, they receive the prevailing wage — in essence, being paid ‘double’ for this duty.

In Pakistan, those who complete their three-year service and pass their entrance exams into higher medical education should immediately be given paid positions in academic teaching hospitals for the duration of their training. This will require a couple of things. New public hospitals will need to be built. The last large public hospital in Lahore was built over 20 years ago. The city’s population has since expanded exponentially with no new public hospitals being built to accommodate this increase. In addition, the government must mandate that in order to maintain their accreditation, all hospitals attached to private medical colleges have to start offering paid, post-graduate training positions.

This would immediately open up huge new opportunities for recent medical graduates as well as start to provide much-needed, trained medical manpower for semi-urban and rural areas. While the government cannot mandate where a doctor sets up his practice, many of these doctors originally from smaller towns would choose to eventually return to their roots to be closer to families and to take advantage of the opportunities in smaller towns and cities where there is still a critical shortage of qualified doctors.

The way a society treats its educated citizens is indicative of its priorities. The ‘educated intelligentsia’ (also known as ‘civil society’) is the ideological leader of a society. Without its active support, no government can hope to last very long, let alone bring about any lasting change. This will not happen unless political leaders start paying attention to the grievances of doctors, lawyers, teachers and all those who form the core of civil society. Without a consensus on basic issues, we cannot move forward.

The writer is a psychiatrist and teaches at King Edward medical university in Lahore. He taught and practiced psychiatry in the US for 15 years.

Published in Dawn, July 27th, 2015