Medicine is one of the key professions wherein life and death decisions are made fairly regularly. Training to be a doctor is both expensive and essential. Social, political and economic factors often determine how healthcare is provided and how it is delivered. Training for doctors requires careful attention, as in these days of globalisation the movement of doctors across international boundaries is even more frequent and, therefore, a degree of international homogeneity and understanding of educational and training standards is required even though cultural variations must be taken into account. It is crucial for a nation’s reputation to ensure that its medical workforce is able to match, if not surpass, international standards. The global scene requires that there be certain standards in the selection and education of medical students. The reputation of the exporting country is at stake if its doctors are not adequately trained and are not able to compete well in the international market. In 1905, Abraham Flexner was tasked by the Carnegie Foundation with the advancement of teaching to evaluate standards of medical education and medical colleges in the US and Canada. Some 150 medical colleges were visited and the report had far-reaching recommendations that led to a major overhaul of medical education and many medical colleges were closed down. Some of these observations have a pertinent role to play in medical education at the present time in Pakistan.
Over the past two decades or so, there has been a major expansion of medical colleges in Pakistan, both at the government and private levels, perhaps more so at the latter level. The most recent figures suggest there are a total of 94 medical colleges in Pakistan, 39 of which are public and of these 55 are private medical colleges. The media recently voiced concerns about a number of issues related to alleged corruption in medical colleges and also about poor regulation and quality control through the Pakistan Medical and Dental Council (PMDC). The role of the regulator needs to be expressed, expanded and evaluated clearly and carefully. In the speed to develop more medical colleges, some colleges in the private sector are lagging behind in terms of resources-both human and material, and also less than rigorous evaluations in both the entry and exit of medical students. The standards of admission vary considerably and so does the output. The task is to educate the public too so that it can differentiate between well-trained and poorly trained doctors. Currently, the relationship between medical schools and universities is not very clear. The first step towards such a clear understanding is to ascertain the relationships and study the components of medical education.
There are raised concerns that include shortage of faculty, inappropriate training, lack of appropriate materials and lack of patients leading to inadequate clinical exposure. Additional factors noted are seeing these medical schools as profitable businesses. The shortage of postgraduate residency places for training also leads to doctors moving abroad to train and then not coming back. The education system in Pakistan is generally based on rote learning rather than didactic teaching. Old fashioned methods of teaching and learning hold sway, assessments use essays rather than other methods and learning is by and large passive.
Most of the private and some of the public medical colleges do not keep up to date with new methods of education, learning and training. Fewer medical schools with better education and better equipment may produce fewer doctors but the quality is likely to be far superior. Therefore, the challenge for Pakistan and the PMDC is to be certain whether more ill-trained doctors are produced to make up the numbers or whether having fewer better quality doctors is better. This debate is to be heard everywhere and educational patriotism on the part of institutions of learning and professional patriotism on the part of the medical profession is required. Educational patriotism is about a mission greater than the attainment of institutional completeness, demanding and delivering ideal education. Professional patriotism is about the honour of the profession and the responsibility that comes with it for the efficiency and efficacy of the rising of personal gain. If the Higher Education System (HSE) and medical systems do not respond to poor quality wherever present, a gross disservice will be done to the population and future generations.
Development of medical education depends upon the creation of public opinion that discriminates between ill-trained and rightly trained physicians. This also means that all medical practitioners are grounded in medical science fundamentals. The second factor is the role universities play in their attitudes towards medical standards and, thirdly, the attitudes of the medical profession itself towards the standards of their own practice and their sense of honour towards their profession. Of these three, the latter two factors as more moral rather than educational. In modern society, the ratio of people going into a profession meeting the needs of the population also means that if there is an oversupply of professionals without any quality control it is the most vulnerable who will suffer, especially if the healthcare system is largely private.
I do not believe that private medical education is all bad or has poor standards but the huge variability in standards remains a matter of major concern. As Flexner observed, it is the quality of teachers and their teaching that makes a lot of difference; there is a likelihood that in many medical schools that is indeed the case and the output will be excellent too. On the other hand, it is clear that a national set of assessment tools should be agreed upon and used to overcome the differences.
It is critical that safety of the patients and the public be the paramount consideration and remain so. The way forward is that selection of the right student with the right aptitude and right attitude for medical education is crucial and innovative strategies to revamp medical education with updating of the curriculum and regular updating is considered seriously. Problem-based learning and joined learning across different subjects need to be encouraged. E-learning and use of social media can help deal with faculty shortages. Simulation laboratories may be needed to teach students. Finally, the moratorium on opening new medical colleges until proper human and physical infrastructures are in place with regular and frequent assessments by the PMDC for a gradual and well-planned expansion of medical colleges must be seen happening. Newer models of teaching and learning are easy to develop and deliver.
The writer is a professor of Psychiatry and consultant Forensic Psychiatrist in the UK. He can be contacted at [email protected]