Diary of a Young Doctor Archives

I have worked in one of the largest public hospitals in Punjab for almost a year. I chronicled the routine of young doctors and my observations regarding the public health system as I saw it for The Friday Times. I have collated all those pieces in one page here. I call it The Diary of a Young Doctor.

Part 1

I felt as if I could not move my legs. It was as if my body was disobeying my mind.It was 4:45 a.m. and my alarm bell was piercing my eardrum. I did the only thing I could do at that time: I pushed the snooze button. I knew I had to get up in a few minutes and by then my legs probably would have enough energy to crawl out of bed and move. It was a Saturday morning and I had to be in the 'Accidents and Emergency Department' for my 12-hour duty from 6 a.m. to 6 p.m. I had returned the previous day after doing a 28-hour ward duty which included very little sleep and quite a bit of leg work. The reason my body was temporarily refusing to obey my mind was my tiredness and lack of energy. In the end, I made it to the emergency department and performed my duties as a House Physician for 12 hours straight. This is how the life of a young doctor unravels.

A lot of patients visit the emergency ward because they want "urgent" treatment of things that can be easily dealt with on a regular schedule.I am a medical graduate undergoing my first year of medical training known commonly as House Job. Being on the junior-most rung in the ladder of the public health care system, we are the first point of contact for the people coming to public-sector hospitals. We have to perform emergency duty once a week and twice every other week. In the emergency department, we treat the patients who require urgent consultation with a physician. The patients come in, we examine the patient and write medications for them accordingly, their attendants get the free medications from the medical store located inside the department and those drugs are then administered to the patients by the nursing staff. This chain is the usual protocol followed in most public sector hospitals. In some cases, some drugs are not available in the medical store inside the department so the attendants are asked to get them from any nearby store.In the hospital where I work, we have the Hospital Management Information System through which we enter medications for patients using laptops and they can get their medication from the medical store without any hassle. On a regular basis, we treat patients suffering from gastroenteritis (caused mostly by unhygienic food and water consumption), fever and body pain, and patients who are already on medication for chronic conditions like diabetes, kidney failure, liver disease or heart disease. Patients are charged only for the minimal admission fee; laboratory tests and radiological investigations, including X-rays, ultrasound and CT-scans, are done without any charges. 
I return home with an aching back, an empty stomach and pain in the balls of my feet.|

Emergency Duty is mostly spent by us while moving from bed to bed and not being able to sit for more than five minutes. There are very few seats available in the emergency department and most of the work is done without much respite. During the duty hours, more time is spent by us counseling the patients and their attendants than actually treating people. Everyone wants to get our attention first and it can become hectic very fast, with beds filling up to twice their capacity and still more patients streaming in. Things can get heated as well and incidents of fights between the doctors and patients have been noticed in the last few years. There are no security guards in the emergency rooms, leaving the duty of self-defense to the doctors themselves.Incidents of bullying by attendants led to the formation of the Young Doctors Association 5 years ago.The facilities that I have described above are at par with almost any private hospital in the city. But the only people who tend to visit public sector hospitals are of the lower-middle class or the lower classes. One reason for this is that there is a shortage of both space and personnel in public sector hospitals. We cannot refuse treatment to any patient and this puts a strain on our already scarce resources.

A lot of patients visit the emergency ward because they want "urgent" treatment of things that can be easily dealt with on a regular schedule. I have personally seen patients of sinusitis, occasional headaches, acid peptic disease and increased blood pressure in the emergency ward while all of them are theoretically out-door department cases.In the emergency room, a house officer examines patients, takes blood samples, passes nasogastric tubes or folley's catheters, checks blood sugar levels and blood pressure and has to write prescriptions on discharge of the patients. These few tasks are repeated from the start of the duty till the duty finishes after 12 hours. There are times when the inflow of patients is very high and it becomes extremely difficult to shuttle between patients based on the severity of their symptoms; and there are times when most patients are stable and the doctor can catch his or her breath for a while.Apart from fulfilling our duty, we also receive many prayers and good wishes from patients who are successfully managed. The road is not full of roses, though, and patients complain if the treatment is not working. The toughest aspect of the job is to face the incidents of mortality in the emergency. In most of the cases I have seen, attendants raise a hue and cry at the death of their loved one, and that frightens the rest of the patients. In those moments of grief, all the doctor can do is to inform the attendants and get signatures from them on the death certificate.As for me: at the end of the 12-hour duty, I return home with an aching back, an empty stomach and pain in the balls of my feet. I try not to walk much after I reach home and after a few hours of rest and some dinner, go to sleep, ready for another day at work.

Part 2

There was a frantic knock on the door of the doctors' room. A half-asleep lady came in abruptly. It was 2 o'clock in the morning and there was absolute silence in the rest of the ward. The lady gasped and said, "Dr Sahib, the condition of my patient is serious, can you please come and check her?" I had no option but to get up from the couch I was lying on, get my stethoscope and accompany her to the bed of that patient. As it turned out, the lady was a patient of liver failure and was having pain in the abdomen. After a brief checkup, I wrote down a simple ant-acid and asked the patient to take some water. Problem Solved. Sleep be damned.

The above-mentioned scenario is one of the many that we have to endure during our 28-30 hour long ward duties, also known as "long calls". After a regular day at work, the whole ward becomes the responsibility of 4-5 doctors who are said to be "on call" while the rest of the doctors go home. This duty has to be done once a week and at a weekend once a month. The regular tasks that we are required to perform during our calls include noting down blood sugar levels of diabetic patients, monitoring blood pressures of any serious patients, doing a routine checkup of patients in the ward, dealing with occasional complaints (like the one mentioned above) and lastly, to oversee casualties that occur on our watch. We are required to be present in the ward at all times during duty hours, and it basically means little rest and little to no sleep.

After every 5-10 minutes, there are knocks on the doctors' room and one attendant after another barges in to get the required "attention" for their patients. In many cases, the condition of the patient is "irretrievable" and it is difficult for both the doctor and the attendant to see the patient suffer. Most of the patients admitted in medicine wards are suffering from either chronic liver disease (due to very high prevalence of hepatitis in our population), tuberculosis in its various forms, stroke (known as 'brain hemorrhage' in popular culture), kidney failure, meningitis (infection of the coverings of brain), chronic pulmonary disease (due to long-term smoking) and fever due to infections. Patients are checked twice daily, once in the morning and once in the evening.

In a country with so many health-related issues, negligible amounts of money are being spent on patient care in public hospitals. A lot of patients can be saved by provision of simple ventilators but the number of ventilators across hospitals in Lahore is no more than 100-150! Similarly, dialysis units and liver transplant facilities, which are considered routine in developed countries, are not easily available in most tertiary care hospitals in our country.

The human aspect of being a doctor can be seen during ward duties, as doctors give their best efforts and energies to save the patient without having any relation with the patient. In many cases, young doctors work out of their comfort zones to treat the patient as well as is humanly possible. Young doctors are the wheels upon which the health care system is working.

The culture of attendants in our country is not only cumbersome but also problematic at times. Due to socio-cultural beliefs, more people are willing to stay with the patient than is necessary. The problem arises when doctors are inconvenienced by attendants craving attention, leading to neglect of other patients. Even when forced to leave the ward during rounds, the attendants are back as soon as the restriction is over.

Last year, a team of doctors were visiting from the United Kingdom for a project and they were surprised to see so many attendants in our wards. They recounted that in the UK, attendants are allowed to visit the patients only during scheduled hours and even at those times, so many attendants were not allowed to visit the ward, ultimately avoiding the mess that we have to face.

At this juncture, I would also like to point out that the running of emergencies and the wards is primarily done by the young doctors and they are the wheels upon which the healthcare system is working, despite all glitches. It is an unfortunate reality that most doctors working in public sector hospitals are not even paid for their jobs, making their work more worthwhile than it already is.

As I wrote earlier, there is acute shortage of bed space in public sector hospitals. Last year, during the dengue outbreak, when the Chief Minister visited many hospitals including the one I work at, he was appalled to note that two and in certain cases three patients were present on one bed. Based on his instructions, patients were adjusted but it was a short-term measure and the situation remains the same. I personally have had to discharge patients at times because of acute shortage of space. I felt extremely bad doing that but the patients themselves wanted to go home and be comfortable.

The toughest aspect of ward duty I found was the time of casualties. The usual scenario goes like this. Doctors are mostly aware of the patients who are having a really bad time and they try to counsel the relatives beforehand. When a distraught attendant comes running in, calling for attention, the concerned doctor rushes to assess the patient. When the patient is critical, the doctor calls his batch mates for help and combined efforts are done to resuscitate the patient. If the patient can't be revived, the protocols are followed and the attendants are informed about their patient's demise. The response of the attendants to the news depends on various factors including the age of the patient, disease of the patient and the quality of counseling done previously. In case of young patients, the reaction of the relatives is quite severe and I have seen my colleague's collars ripped off by an angry relative. Due to their inability to cope with grief, many attendants blame the doctors for the casualty of their patient, without acknowledging the work done by the same doctors when that patient was alive.
At the end of the day, it is not a fair world and a doctor can do only as much.

Part 3

"Please guide us, doctor. We have come back because the local dispenser [quack] refused to administer the injection you wrote for our son, saying it is too 'heavy'."

I was busy making the 'discharge form' of a patient when that couple came towards me and said those lines. Their teenage son had been discharged yesterday upon their request, and I had prescribed an injection that he needed every day for the next week. The couple said they would get their son the shot through a dispenser in their locality. And they were back the very next day.
A doctor can, just by clicking on the computer screen, get free medicines for needy patients

This is not a unique situation. Apart from managing patients feigning abdominal pain in the emergency ward and waking up during the "on call" nights after every hour to change a transfusion bag, this is what young doctors do in "routine". A routine day comprises duty of about 6 hours, from 8 in the morning to 2 in the afternoon. We start the day by checking patients on the beds allotted to us and by writing down the DPNs (Daily Progress Notes). This is followed by a survey of our work and additional examination by our immediate seniors, the Medical Officers. After that, there is the ward round by any one of the designated consultants/specialists. During the round, the consultants listen to the medical history of patients from house officers or medical officers and look through the investigations carried out previously. Then, according to the situation of the patient, investigations or different drugs are advised which are added later to the charts by House Officers. 

If the patient is newly admitted and can't buy medications on their own, there are two ways of getting them free medicine. There is a list of medications that are provided to our wards every day by the hospital. They include most of the commonly required drugs, and a doctor can, just by clicking on the computer screen, get free medicines for needy patients. Another way is through the Medical Superintendent (MS) of the hospital. For that, the patients' file has to be signed by the MS himself, which is not a hard thing to do. Then there is the problem of urgent investigations. For that, house officers have to counsel the attendants and sometimes have to get involved themselves to get those tasks done through the emergency department. At times, the bureaucracy of it all can get in the way and frustrate patients.
I have seen patients who think they are not being treated fairly threaten the doctors by mentioning political figures or members of the bureaucracy

As in the rest of Pakistan, a patient is likely to get sufficient attention (which mostly means more than normal) if they know someone in the hospital hierarchy. This doesn't mean that doctors don't care for their patients; it's just that we find it difficult to divert our energies where they are not required.

This 'protocol' business can turn ugly. Many a times I have seen patients who think they are not being treated fairly threaten the doctors by mentioning political figures or members of the bureaucracy. It happens particularly frequently in the hospital where I work because we have to deal with all kinds of government employees and their kith and kin. According to one of my seniors, even if the gardener of CM house brings a patient to the hospital, he expects to get 'protocol' equal to that of the CM himself.

Hospitals are great places, not only for learning medicine but also for learning about the different shades of life. I would like to mention some of the most interesting cases I have seen in my brief clinical career.

The fiancee with the headache before her FA exams brought to the emergency by her very concerned fiance, the CA student who had not eaten anything for a month due to some kind of love affair; the 65 year-old woman patient who insisted on smoking despite the disease in her lungs; the helpless relatives of a 70 year-old woman who had to get dialysis but couldn't find the hospital where it was urgently available; the 50 year-old woman with tuberculosis of the meninges (brain coverings) and an untiringly colorful vocabulary; the madrasa student who sat for his Dars e Nizami exam while he was admitted in the hospital; the women loudly reciting Quranic verses around a very sick patient and freaking out the doctors; a 15 year-old boy spending most of his time around his ailing mother in the ward and running around taking her samples for laboratories; the young patients (mostly girls) with acid/bleach intake for suicide purposes and the attitude of their families towards them; and all those patients who are never satisfied when they are prescribed pills and demand injections and drip infusions just to feel medical; and all the drug mules who are accompanied by police or custom officials and deny any wrongdoing until the last minute.

There are also issues among various departments in the hospital that cause unnecessary delays in diagnosis and treatment of patients. The Radiology and Pathology departments provide services to all the rest of the Hospital, and are indispensable in the management of patients. If the same tests are to be done from private labs, the cost is not affordable for most of our patients, who belong to the lowest strata of the society economically.

I would also like to mention that there are almost no holidays for young doctors during their house jobs. In the department where I work, we only get 2 holidays in a month, both Sundays. Apart from that, we only get one emergency leave per month.

Part 4

"Please give me some money, I'm hungry and don't have any money to buy food," said the beggar.

"I wish I could, my friend, but I earn less than you do," was my reply. And I was not bluffing.

There is a simple basic rule that governs almost all professions in the world: you work and that earns you money. There are strings attached to this simple fact according to different fields but the basic notion remains the same. Soldiers claim to fight for the country, police officers risk their lives for maintaining law and order, public servants work (or at least they are supposed to work) to provide services to their countrymen. At the end of the day, however, they all get paid for it. From the highest offices of the country to the lowest, from generals to chowkidars, from CEOs to clerks, the maidservants that work in houses, sewage workers, technicians, sales boys, they all get paid for doing their job. But in present-day Pakistan we are making one big exception to this rule: doctors.

I have chronicled the lives of young doctors and have described the trials and tribulations associated with their job. It is hard to believe that despite all this hard work, most doctors working in public sector hospitals are not paid. Imagine a person with 17 years of education, working 28 days a month, doing 30 hr/48 hr duties, and earning a grand total of zero rupees per month.

Imagine a life with no pay, no job security and no health insurance (given that we deal routinely with HIV positive and Hepatitis C infected patients). All that keeps us going are the 'thank yous' of patients and a hope that someday, things will be better.

After the doctors' protests last year, pays were increased. This does not mean that everyone is getting that pay. In the department where I work, there are 28 people working as House Officers and around 30 as Medical Officers/Post Graduate Trainees (PGRs). Out of 28 House Officers, only 8 are on the paid seats while the remaining 20 are working on 'honorary' basis (there is not much honor involved; it is a euphemism). Similarly, out of 30 Medical Officers, only 15 are getting paid. The situation is similar or worse in other departments and hospitals across Punjab. People working on honorary seats perform equal duties, do everything as others do, the only difference is that they are not paid for doing that work. This is a unique and frankly disgusting way of treating a professional, and there is no precedent for it anywhere in the world. Apart from interns at offices, everyone gets paid for their jobs. At times, even the Senior Registrars, after 10 years of medical training, have to work on honorary basis.

There is an inside story to this practice. Theoretically, the seats in wards of teaching hospitals are preferably given to the graduates of the institute that the hospital is attached to. This results in inequality at times because graduates of other institutes opt for institutes in bigger cities. In the case of Punjab, graduates from all over the province prefer to do their clinical training in either Lahore, Multan or Rawalpindi. There is also the issue of non-residents. If a resident of Lahore got admission in Rawalpindi Medical College or Nishtar Medical College, he/she would prefer to complete his/her post-graduate training in the native town. Due to this shuffling, there are more candidates for less seats and departments employ different people on honorary basis. The merit list for giving a job for post graduate training starts from graduates of the same institute. Second on the list are graduates of other government institutes and lastly, the graduates of private medical colleges, including the ones in China and Russia.

There are ways that people bypass the merit system, because in Pakistan there is a single key for every lock: Sifarish. If you have the requisite Sifarish, you can bypass the merit and get a paid seat in your desired department.

To cope with the economic pressure due to lack of any pay, doctors from public hospitals look for jobs in the private sector which forms 80% of our health sector. As a result, most of the unpaid (and in some cases, even the paid ones) do jobs at private hospitals in the evenings and in public hospitals in the morning. After living for more than 25 years on the largesse of your parents, if you still do not earn anything on your own, it reflects poorly on you. Also, during post-graduation, a lot of doctors are tied in the knot of marriage and it is difficult to ask your parents for sustenance of another person while you earn nothing. I personally know some people who delayed their marriages because they did not have the means to support a new member of the family. In some other cases, the young doctors were the only source of income for their families and had to wait till completion of their post graduation to marry.

This system of 'honorary' jobs should end as it is nothing but a kind of slavery.  

Part 5

"I am really thankful to you doctor sahiba, you saved my daughters' life today," said the mother of a young woman to one of my female colleagues.

The very next day, another attendant had this to say,

"You doctors are murderers. You don't know how it feels when your loved ones die. You have killed our young brother. We will never forgive you."

Both of the above-mentioned statements reflect a common misconception in our society, that doctors are supposed to be messiahs who save lives. I may have to face the wrath of some of my fellow professionals for saying it out loud, but this can't be farther from the truth. During the five years of medical school, followed by countless years of medical training, all we learn are a set number of protocols to follow. There is no subject or even a chapter dedicated in any of our books on 'How to Save a Life' (excuse me for the reference to a song with the same name by the band The Fray). The main problem with this assumption is the immense responsibility it places on the shoulders of the attending physician/surgeon. Doctors, in general, safeguard the best interests of their patients but having the mantle of 'saviour' placed on their shoulders is more than a little unfair.

As a result of the 'messiah' label, doctors become the automatic fall guys when a tragedy occurs. Doctors are obliged to do their best, regardless of the expected results, and when their efforts fail, the first impulse of the attendants is to blame the doctor for the demise of their loved one. I am not saying that medical science is guesswork; but why is the medical profession considered a "calling from God"? It is high time we learned to differentiate between a profession and a calling from God. Doctors are "working" in hospitals. They aren't on a divine mission to save everyone who comes their way. They provide a service and in return expect to get paid for it. (And we know how that's gone done in our country.)

When doctors announced a strike to demand for a better service structure, the widespread reaction was that doctors should be philanthropists who put others before themselves and don't ask for a compensation package in return for the time they have invested.

To quote the columnist Ayaz Amir: "The young doctors' strike was not about doctors versus ailing and suffering humanity. In the Islamic Republic suffering humanity is a handy cliché, readily invoked to score a political point and as readily consigned to the upper layers of forgotten memory when the need passes. If anything, this strike was doctors versus a hidebound bureaucracy, one of the most ossified bureaucracies in the lands which can claim descent from the British Raj."

During the strike by doctors, one of the major objections was that doctors were supposed to provide health services in any condition, as they have taken an oath to do so. Let me make it absolutely clear that in the original Hippocratic Oath that was formulated around the year 425 BC, there is no provision that makes it mandatory for a doctor to provide health services to anyone who wants them. In the revised Hippocratic Oath, constituted by the British Medical Association, one of the points declares: "I will do my best to help anyone in medical need, in emergencies. I will make every effort to ensure the rights of all patients are respected."

Similarly, according to PM&DC (Pakistan Medical and Dental Council) Ordinance of 16th July 2011, Section 9, Sub-Section 2 (a) : "A medical or dental practitioner shall be free to choose whom to serve, with whom to associate and lay the timings and place of professional services to be provided."

While Sub Section 2(b) reads: "A medical or dental practitioner shall not be bound to treat each and every person asking his/her services."
In my opinion, one of the underlying causes of outrage against doctors during the strikes was the "messiah" proposition. How can someone who is supposed to "save lives" go on strike? As a nation, we are prone to miracles and magical rescues; we are always hoping for some messiah to come and save us from the "mess" we are in. This messiah complex has in the past led to acquiescence to dictators and demagogues. We, as a nation, need to mature and start believing in processes and institutions, not saviours.

Bottom Line: Doctors are not messiahs; they are ordinary professionals doing the best that they can. 

Part 6

Medical Science, like other disciplines of science, is a constantly evolving subject. New discoveries are being made, new ways to treat and look at diseases are being researched and newer drugs are being introduced on a daily basis. But the medical profession in Pakistan is lagging far behind the rest of the word in innovation and research. Very little, if any, research is being done by public sector hospitals and medical colleges. Apart from the Aga Khan University and Shaukat Khanam Hospital, there are no recognizable research centers in the country. Due to this issue, most of the books we consult during MBBS are written by Western or Indian authors.

It may come as a surprise to the reader that doctors in Pakistan are required to do research as part of their curriculum, both at the undergraduate and post-graduate levels. The ground realities, though, are very different. Very few of the "researches" done by Pakistani authors are published in international publications. On the undergraduate level, the research is mostly very basic and does not require much critical thinking, nor is it up to an international standard. The Community Medicine departments (responsible for overseeing research) ask students to choose from a particular list of topics on which research can be done. No funding is provided for the purposes of research. Students usually take shortcuts just to fulfill the academic requirement, and the matter is over after the final exams.
On the post-graduate level, where research is an important tool in the rest of the world, Pakistani doctors do not spend enough time on research topics. Most of the topics are re-hashed versions of the same old 'traditional' things. A grand sum of Rs 2,200 can get you a good synopsis on your chosen topic. Plagiarism is not thoroughly checked, so liberties can be taken in that regard. I questioned some of the senior doctors about this trend and they pointed out a few factors responsible for this problem.

The foremost issue is financial. Most post-graduates do not have job security and often have to work at multiple hospitals. In addition, they do not get any kind of funding for the sake of research. In such conditions, all they do is look for shortcuts to fulfill the academic requirement. In Shaukat Khanam Hospital, doctors are paid handsome salaries and have job security, resulting in some serious research work being done there. The proposed Service Structure that was the demand of doctors during their recent strikes is a much-needed step as it would at least provide job security, if not lavish pays.

The second most important reason for lack of research is the absence of critical thinking from our curricula. Research is borne out of questions about persisting problems and requires finding solutions to problems. We, on the other hand, learn and see throughout our academic life that 'he/she who crams the most, achieves the maximum marks'. From nursery school all the way to the final year of MBBS, we learn how to rote-learn particular texts and then regurgitate them in our exams. Questions are discouraged at almost every level and many teachers think it a disgrace if they do not know the answer to a student's question. In addition, there are almost no research societies working in medical colleges. The only one that I encountered was a small society working out of Punjab Medical College, Faisalabad.

The third factor in this regard is the lack of teachers and instructors who can guide students about research. This problem is present both in medical schools and in the College of Physicians and Surgeons, the premier body that awards specialization degrees in Pakistan. In many cases, the supervisors for research are not well-versed in the art of evaluating a research paper as it is very different from an examination paper.

Despite all these problems and glitches, there are still some success stories. Pakistani doctors, particularly surgeons, have developed many indigenous solutions to the problems they have faced over the years. The need of the hour is to promote critical thinking and research among the medical community so that Pakistani doctors can compete on an even keel with their international colleagues.

Part 7

Dr. Adnan was the best graduate of his MBBS session three years ago. He had achieved the highest marks in almost all the annual exams during his five years of medical school. He completed his house job of one year and spent almost 6 months in preparing for the entrance exam to a Residency program in the United States (the USMLE or United States Medical Licensing Exam). He cleared the first two stages (it's a three-stage exam) with ease and applied for a visa, so that he could visit the United States and take the third and final exam of USMLE. But he was denied a visa for the United States. He has spent almost 300,000 rupees in fees for the tests, and it has taken him a year for him to reach this stage. But his efforts have been in vain.

126,931. That is the number of Registered Medical Practitioners (people who have obtained MBBS degrees and have completed a house job of one year) in Pakistan, according to the Pakistan Medical and Dental Council. Every year, some 8,000 fresh medical graduates join this list. A vast majority of Pakistan's medical graduates want to move to either the United States, the United Kingdom, Australia, the Middle East or other green pastures in the world beyond Pakistan. According to a report aired on Geo News on 8th August 2012, Pakistan has become the largest exporter of young doctors to Britain's state-funded National Health Service (NHS). The number of Pakistanis registered on the GMC (General Medical Council) data stood at 8,552 on 7th of August, 2012. Similarly, according to a research paper titled 'Pakistani Physicians and the Repatriation Equation', published in the New England Journal of Medicine, Pakistan has contributed approximately 10,000 international medical graduates (IMGs) to the United States. In a research conducted in 2007 titled 'Reasons for migration among medical students from Karachi', it was revealed that Over 95% of Aga Khan University (AKU) and over 65% of Baqai University (BU) final-year medical students intend to go abroad for their postgraduate training.

And all this while Pakistan is facing an acute shortage of trained doctors, according to reports by the World Health Organization (WHO).Pakistan cannot meet its needs for healthcare, given the current levels of production and dependency on physicians in the organization of the system. Although out-migration contributes to the problem, it is the growing demand for healthcare from increases in population and adverse conditions that generates ill-health. The most important question to ask about this mass migration is: Why are all these people leaving their country?

The answer is manifold and, speaking as a health professional myself, painful to state.

The survey done on medical students of Karachi's elite Aga Khan University and Baqai Medical University revealed that the two most important factors behind this intent as pointed out by the students are poor salary structure and poor quality of training in Pakistan. I can vouch from my personal experience that as soon as a medical student enters the medical school, the next big question regarding his/her life is the "plan" or path he/she intends to take after graduation. Even during the one-year training of the house job - something I am currently pursuing - the queries about the "future" are among the most frequently asked questions by one's seniors and family members.

It is an absolute travesty that in Pakistan the practice of "Career Counseling" for medical professionals is practically nonexistent. Most middle-class parents only have three or four career options for their kids: Doctor, Engineer, Banker/Accountant and if all else fails, Army. In a similar fashion, when a medical student enters medical school, it is from his/her seniors that guidance about any future plans is acquired. Traditionally, there are four ways to pursue post-graduation for Pakistani students. The first one is the FCPS (Fellow of College of Physicians and Surgeons, Pakistan) route, which involves four years of clinical training at a tertiary care hospital in Pakistan. After completing four years of training and passing the FCPS exams, you are considered a specialist in whichever field you chose to pursue. The second and most attractive option is that of obtaining a residency in the United States, where the training standards are the highest in the world. For that route, a candidate has to go through the three stages of the USMLE exam (the examination fee for each step is more than 1.5 lakh rupees), the third of which can only be done in the United States.

After the residency and an exam, the candidate becomes "Diplomat American Board" for the chosen specialty. It should be noted that the ratio of people who get their desired residency after passing the exams is around 50-60%, which means that despite getting excellent marks, you are not guaranteed to get your favored specialty (for example Anesthesia or Neurosurgery) in 50 to 60% cases. The time required to complete this whole process ranges between 3 to 5 years.

The third option is that of pursuing post-graduation in the UK. To follow that route, one first has to pass the PLAB (Professional and Linguistic Assessments Board) exam, which is a two-stage test. The examination fee for each stage is also more than one lakh rupees. After completion of PLAB, post-graduation courses are taken, based on available spots in the preferred specialty. The whole process of completing this route takes around 5-7 years. An alternate route to acquiring British certification is the MRCP/MRCS (Member of Royal College of Medicine/Surgery) route, which is a two-stage route, but the training can be obtained in Pakistan while exams have to be taken in the UK.

The fourth and latest addition to the options is that of post-graduation in Australia. For that, a candidate has to pass the entrance exam of the AMC (Australian Medical Council), which also has two separate tests. The examination fee for each step is in the range of the fee for USMLE. There is no guarantee of getting a post-graduate education in Australia even after getting excellent marks in the first entrance exam.

Most medical students in Pakistan don't know which path they will take, even whether they will be able to work in their desired field or if they will get a job where the salary is adequate after about ten years of medical training. And this, I am sorry to say, is the primary dilemma of the medical community, the so-called "cream" of the Pakistani nation. 

Part 8

10 year-old Umar was playing with his elder brother, 14 year-old Adnan, in the street of his muhalla. Their parents were unaware of their activities. Adnan hit upon a fun idea: let's try out our father's new motorbike. Umar joined him in the adventure. 

There was one little glitch: neither of the brothers knew how to drive a motorcycle. That was where the fun part ended. Adnan sat at the front, Umar at the back. Adnan somehow managed to kickstart the bike and steered it towards the main road. At that very moment, the motorcycle swung out of control and crashed straight into the wall at full speed. Fortunately, a pedestrian saw the accident and called Rescue Services. Within a short span of 30 minutes, two innocent teenagers had gone from having fun to being in critical care. Adnan succumbed to his injuries, despite the best efforts of the rescue team. Umar was brought to the emergency with multiple fractures on the face and fractures in the left arm and right leg. He spent a week in the Intensive Care Unit, where his face took on a different shape due to the fracture of his nasal bones. He couldn't speak or eat for a week so he was fed by a tube and communicated by writing. The first word he uttered was "Home". 

Underage driving is a problem that is never taken seriously by the authorities in Pakistan. There are annual drives against this by government departments but the steam goes out soon enough. People don't bother getting driving licenses or turning up for any "actual" tests. Almost everyone who is someone has their "guy" in the Traffic Police Department, responsible for issuing licenses. Unless you are on the Lahore-Islamabad motorway and have violated a law, no one will ask for your license. There is no societal concern about this issue and parents themselves encourage young children to have a go at driving. 

Figures from the Pakistan Beauru of Statistics reveal that from 2010 to 2012, 9,723 traffic accidents were reported, out of which 4,280 were fatal, causing the loss of 5,271 lives. As per a report by National Road Safety Secretariat, Ministry of Communications, titled ROAD SAFETY IN PAKISTAN:

"The economic cost of road crashes and injuries is estimated to be over 100 billion rupees for Pakistan. Pakistan has spent $0.07 per capita (0.015% of GDP/capita) on road safety in 1998 whereas road safety spending comprises a greater share of public spending in countries such as the United Kingdom (population 56 million) where the government spends roughly £1 billion per year."

Burning needs

Two year-old Musab was playing in the kitchen near his mother. He was the first-born and was thus the star of the house. His mother went to their living quarters to get her phone and left Musab unattended. There was a large pot in which milk was being boiled. She was away for only a few moments when a loud shriek caused her heart to plunge. She ran towards the kitchen to find the boiling milk spilled over her only son, who was crying out loud for help.

She was dumbstruck for a few minutes and hurriedly called her husband to inform him about the accident. By that time, other members of the family had heard the shrieks and had rushed to the kitchen. They pulled Musab out of the muddle and settled him in a safer place. It took the family another four hours to transport the little boy from Renala Khurd to the Burn Unit at Mayo Hospital in Lahore. They were told that more than 60% of Musab's body was burnt. Theoretically, the chances of survival decrease significantly for burns above 40% body surface. He was kept there for two weeks, mostly on sedatives. Musab was taken to CMH Kharian but he couldn't live for more than a week. 

For more than 600 burn patients every year, there are only three specialized burn centers in the vast province of Punjab. While billions of rupees can be spent on essentially useless activities such as getting into the Guinness Book of World Records and advertisements extolling the incumbent government, the peoples' representatives are least interested in improving the public health of their constituents. In this amazing land of people, the rulers have got their own private hospitals and they don't care if the downtrodden burn to death or thrash in agony for days and nights on end.

Part 9

'Kindly admit our patient, Doctor Sb. We have talked to the Medical Superintendant and your head of department. They have sent us here'
I was sitting in the ward, making discharge slips of patients when someone got my attention by uttering the above mentioned words. I checked the papers and he was right. He had been sent to our hospital by a top office bearer of the ruling political party in the Province. I was reluctant to oblige with such commands as I don't personally think political workers are any more deserving of a doctors' attention than the down trodden people who frequent government hospitals. By sheer luck, there was no vacant bed available in the ward. I explained the situation politely to him and the hospital employee sent by the 'Protocol Office'(designated to oblige the 'influential' people, their relatives or lackeys). They tried to reason with me by pointing out that the M.S had talked to our Professor twice and he had written it on a slip that these people should be accommodated. I asked my immediate superior about it and he was also of the view that we have no spare beds and thus we can’t accommodate someone just because they have better connections. He talked to the guys himself and at the end, they left without the bed. This was one of those rare times when we “resisted” the protocol patients. Most of the time, anyone designated as a protocol case gets preference over ordinary patients.

At the hospital that I work, there are special VIP and VVIP wards specified for senior bureaucrats, political figures, Judges and their respective families. In spite of that, countless patients are referred by political figures to the hospital with small slips on their letter pads. This is true for almost every public hospital in the country. As we are based in Lahore, we get most of the ‘slips’ from party officials or government officials from the ruling party of Punjab. In other provinces, only the names change, the ‘slip system’ remains the same. Underlying this whole culture is the belief that unless you are influential enough, you won’t get good treatment from public service providers, be they doctors or engineers or policemen. This understanding breeds more nepotism than what is healthy for a society.

The worst abusers of public service systems are the public servants themselves. Senior bureaucrats consider government property as their personal fiefdom and act like it. To ensure that every whim of the Politicians and bureaucrats is fulfilled, most appointments on the post of Medical Superintendents are politically motivated. Subservience and acquiescence are the requisite qualities desired by the higher ups for the highest posts in public hospital administration.  

Doctors themselves are no less culpable. It is usually said that doctors make the worse patients. I would like to add to this axiom that they not only are the worst patients, they usually are the worst attendants as well. I distinctly remember that one time that a classfellow of mine at medical school brought her grandmother over to our ward for admission. We provided her with the best care that we could. After two days, she passed away. Since then, my classfellow has not talked to me, as if it was my fault. She herself is a doctor.

I have worked in the Intensive Care Unit (ICU) as well and a lot of times, we had patients brought in by other doctors of our hospital to stay there, unnecessarily at times. ICU is supposed to be for patients whose lives can be saved by intensive care and who are on the brink of death. This is true most of the time, unless you happen to know a doctor. Rules and protocols for management are thrown out the window because of nepotism. The tragedy of public hospitals is that unless you know someone working there, you are not awarded any extra care. As a doctor, I have always provided equal care to patients, irrespective of their status. I am not alone is behaving like this. We feel ashamed when resources are diverted for sake of the ‘Sifarshis’. We are sick of tending to the favored ones. We believe that our health care system is already neglected and needs no further roadblocks than the ones already present. It is a request and a plea to the people on top: Kindly stop pulling your rank to get extra care for your cronies, we are already overstretched. Thank You.  

Part 10

I was busy assessing a patient for anesthesia as I heard loud shrieks from a nearby room. It was my first duty in the labor room and I was not yet accustomed to such sounds. I finished my work quickly and rushed to the room from which the shrieks had come. As it turned out, there was a routine delivery going on there. The shrieks by the patient and shouting by the staff are a norm in the labor room. Duties in the Obstetrics department are hectic in routine. I was appalled to see the chronic lack of equipment and attitude of paramedical staff at the place. The mechanical ventilators were archaic and in a dilapidated state, important injectible drugs were hard to find and we didn't even get 5 cc disposable syringes. To make matters worse, there was a power outage, and the backup generators were taking forever to start. Thankfully, no critical procedure was being done and a potential catastrophe was averted due to sheer luck. Mobile torches were required to maintain the status quo. After an interval of 15 minutes, electrical power was restored and the operation resumed. For the regular staff present in the operation theatre, this was just another day at the office. 

My task, as a member of the anesthesia team, was to keep the patients free from pain. The first thing I observed upon entering the operation theater was its untidiness. The only thing I liked about the place was the fact that I could have a look at newborn children even before their parents. The newborns, tightly wrapped in warm clothes, look like angels entering this world. It is an extraordinary thing to behold. 

Sanitation is a bit better in private hospitals, but it comes at a cost. One of my relatives had to get a caesarian section at a private hospital and was charged Rs 50,000 just as operation theater fee and another Rs 40,000 as the fee for the obstetrician. The overall expenditure was more than Rs 200,000! 

Gynecology and Obstetrics are among the most visited wards in any public hospital. Obstetric care and practice is becoming more and more profitable because of the mind-boggling increase in population in our country. (There's an inside joke about how obstetricians will never die of hunger for as long as there are children being born.) Despite trained and untrained midwives plying their trade in rural and suburban areas of Pakistan, the trend of consulting an obstetrician at least once during the pregnancy period is catching up. According to the latest guidelines, a woman with a normal pregnancy should make at least four visits during the nine months that she is with child. Women suffering from diabetes or hypertension and aged above 35 years or with a history of multiple pregnancies require further tests and monitoring. 

There is little emphasis here on educating women about changes encountered during pregnancy, complications, alarm signs, preparations for birth or the medical options available.

As soon as a child is born, it is kept in the "nursery" and if the infant is pre-mature, it has to be kept in an incubator. The distance between the labor rooms and nursery has to be a short one so that the premature child gets into the incubator as soon as possible. In the hospital where I work, that distance comprises at least half a kilometer! Why this is, no one knows. What we do know for sure is that our patients suffer needlessly every day, as do newborns. The condition of the nurseries where incubators are present is a whole other story. Due to lack of facilities, an incubator which is supposed to contain one infant at a time is being inhabited by multiple infants! 

One can't help but think of the recent incident in which a rat ate away at a child in the nursery of a large public hospital in Rawalpindi. The incident, though terrifying, was not the first of its kind. Stray animals (mostly cats) roam the wards of most public hospitals, carrying unknown bugs in their hair. A women and child-friendly atmosphere has to be created to lure more people to public hospitals. There is an acute lack of awareness regarding maternal health during pregnancy and care of newborn children. Education concerning these issues should be imparted by the state as well as civil society using Pakistan's powerful print and electronic media. It cannot be emphasized enough that one of the indicators of the development of a nation is the amount spent by the state on health of its citizens.


  1. Excellent article! Highly recommend for all. Describes in great detail the plight of the 'cream' of Pakistan due to the messianic belief of the population regarding doctors.

  2. hello abdul I am a medical student from India.. no words can express my feelings for your blogs better than this- awosome....

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