There was a time not long ago that medical colleges in Pakistan were respected institutions. There were few medical colleges, all public. Admission was solely on merit. Tuition fees were minimal. Standard was so high that doctors from Pakistan did not have to pass any qualifying exams. They were registered by the general medical council of UK and were eligible to apply for jobs in UK hospitals.
However in the last few decades there has been a catastrophic decline in the quality of doctors. The first two private medical colleges were first established in Karachi and their financial success opened a flood gate of private medical colleges in the country. Soon there was a mushrooming of private medical colleges from Karachi to Khyber.
Pakistan Medical and Dental College (PMDC) with which medical community had least interaction became an influential organisation. Its long serving Registrar virtually became a king maker. Colleges of inadequate structure and grossly deficient minimal faculty were approved to start classes. These medical institutions did not meet even the elementary requirements. Some of them made agreement with private and public hospitals to use their hospital for teaching purposes the so-called public–private partnership. Millions were exchanged between greedy owners, corrupt officials of PMDC and incompetent bureaucrats.
The tragic consequence of this exercise was proliferation of more than 150 private medical institutions. The sad part of all this is that there is not sufficient medical faculty for these colleges for teaching purposes. Certain basic sciences subjects were in such demand that they were changing their colleges every month. They were offered lucrative packages before inspection by PMDC. However after successful inspection and recognition it was a different story.
Role of PMDC: The deterioration in medical standards has much to do with the functioning or rather malfunctioning of the regulatory body. It has sadly not lived up to the high moral, ethical and academic standards expected of an august body. Making an impressive high rise building from its own resources does not bestow credibility. It is plagued by nepotism, cronyism and non-accountability. The Registrars of this institution have behaved like Czars. Not surprising that several of the previous Registrars have faced or are facing cases in the NAB.
PMDC was a non-entity. The only encounter doctors had after graduation was for registration, a requirement necessary for working as a doctor, a kind of license to practice. The proliferation of medical colleges in the country was a golden opportunity for PMDC. Dubious feasibility reports were given to owners aspiring to open medical college for a handsome amount. Inspections were done by a team of inspectors from basic and clinical sciences before commencement of the academic session. Performa for inspection was cleverly crafted to make the task easier to start the college. A team of inspectors mainly professors from different subjects will visit the premises to verify the ground realities. Inspection was mostly like a pre-scripted drama. The college to be visited was given sufficient advance notice to hire faculty, the necessary equipment, library books, furniture and all the necessary paraphernalia to be displayed on the inspection day. Most of these accessories were later taken by the supplying contractor for use in the other colleges to be inspected. After inspection a report is prepared about the state of the institution, signed by the convener and all the inspectors and submitted to the PMDC executive body for action. Envelopes, gifts and even Ummrah tickets have been offered to the visiting team of inspectors to facilitate the decision making.
Faculty: There is disproportionate emphasis on the availability of the teaching faculty. My observation is that there is not sufficient faculty in the country for all colleges, public or private. Specified, qualified experienced faculty is an integral part of a proper functioning medical college. A strange species has evolved in the teaching faculty, the so called foreign faculty. This terminology baffled me initially. These are honourable members on the strength of a medical college as faculty members, but may actually be working anywhere in the country or even abroad usually Gulf countries. It is a mutually beneficial, symbiotic relationship. The doctor gets the necessary teaching experience from the institution and the college shows the required faculty without paying a single penny. They do however come at the time of inspection for verification and claim travelling expenses.
Part time faculty: If the concept of the so-called foreign faculty is intriguing, there is another sub variant of this species, the so called part time part time faculty. These are professors who are on strength of a Private Medical Institution (PMI) but visit the college or hospital once or twice a week only. Off course, they are paid less but they get the teaching experience letter for promotion. Most of the time they are busy practitioners.
Admission: In good old times after the announcement of FSc result, admission notices appeared in the national newspapers. Candidates filled and submitted the admission forms. Merit list with name and numbers were displayed on the college notice board. Now with these commercial enterprises it is not that simple. Initially, every PMI held their own entry tests as well as an interview. However actual admission criteria are donation. Lower the merit, higher the donation. Weightage is also allocated to the interview. It is a farce. The real aim is to explore the financial standing of the client, the students’ father or guardian is willing to pay. I have seen and heard sobbing parents and wailing girls when despite being on the merit list could not be admitted because their parents could not pay the hefty donation and were denied admission. Recently there has been change in the admission policy but the PMI are desperately trying to revert to the old corrupt system of admission.
Mission statement: Every PMI has a mission statement displayed at a prominent place usually at the entrance. Beautiful, idealistic high sounding words. Most of these are cut and paste from other institutions and have nothing to do with the realities. The real mission of all PMIs is to make money and more money, by whatever means. It would be interesting if the FBR looked into the assets of owners before and after setting up of the medical institutions. Some PMI have set up trusts mainly for the purpose of tax evasion or avoidance. Most of the trustees are owners or close relatives of the owners or their business associates. A financial audit of these PMI will alleviate the financial health of the country.
Patient occupancy: PMDC stresses that at least 50% of the beds should be non-profit beds. It is also mandatory that there should be 60% occupancy. However most of these PMI do not even achieve 30% occupancy. In fact, most of these PMI do not have the necessary logistics to care for 500 patients. Water supply, sanitation and even paramedical staff is not sufficient to cater to the needs of three hundred patients. At the time of inspection, fake patients are admitted to enhance the occupancy rate to meet the 60% criteria of PMDC. Fake files of fake patients are prepared diligently. Fake lab results, treatment sheets and clinical notes are entered in files to give semblance of genuine patients. These fake patients are given free food, transportation and token money for their co-operation. This arrangement works for these poor individuals and of course for PMI. It is surprising that wise and experienced inspectors are unable to differentiate between the genuine and fake patients.
Medical Education: Recently, a bewildering development has occurred in the field of medicine. A new class of doctors has evolved calling themselves medical educationists. It has been revealed to them that the old, rotten, decayed education system is in need of change, in this climate of change. They have answers to all the problems in the medical field. Whatever has been taught before and the way it has been taught is not applicable to the present times. In the disguise of medical education, amateurs and recruits in the field of medicine have become specialists in teaching methodology. All the legends that have taught generation of teachers are now irrelevant. They did not make their students self and lifelong learners.
PMDC with its customary lack of vision and procrastination in collaboration with the PMI has become partner in this venture or crime. Overnight PMIs have started medical education courses. Most of these diplomas and courses are financially motivated. PMDC in order to facilitate PMI has made these degrees and diplomas a pre-requisite for promotion. Methodology is mostly distant learning, assignments and off course financial benefits. Doctors who have not taught or delivered a single lecture are now education specialists. It is easy to give solution when you have no idea about the problem. Most of the PMI boast ad nauseous the state of art of their tertiary care hospitals and their dedicated and qualified faculty. However if they themselves or any close member of their family needs medical treatment, they do not trust their own hospital or staff for treatment. Alexander Flexer, guru in chief of medical educationist when he reviewed the state of medical of medical colleges in USA recommended that half of all medical colleges should be closed. If a Flexner criterion was applied to Pakistan, more than 80% of the medical college will be closed for good.
Solution: The problems of PMDC are innumerable but can be solved if there is will. Solution requires a holistic approach. There are three stake holders of this system; PMDC, students and owners. The first and foremost step is overhauling of the PMDC. Members of the PMDC should be carefully selected and elected. A well defined criteria should be applied and representation given to all sections of medical and dental community. The members should be senior professors with at least ten years experience or general practitioners with twenty years after graduation. The number of nominees should be limited. Teaching and general cadres doctors and dentists should elect their representatives.
There can be limited members from PMI not more than 10% of total strength of PMDC. They can be co-opted with no voting rights. PMI nominees must not be below the rank of professors with at least ten years teaching experience. The president of the council shall be the most senior member for three years only, non- renewable. There is no need to have nominees from CPSP or armed forces. There shall be a chief administrator preferably retired bureaucrat from ministry of health of grade twenty or above. His term tenure will be three years non- renewable. Under him and reporting to the chief administrator there should be two officials, one looking after the academic activities and the other administrative affairs. There should be clearly defined SOPs for all their activities.
Inspection of the colleges is the most important and corrupted aspect of PMDC. A team of inspectors consisting of senior professors from basic and clinical sciences be appointed for two years and if there are no complaints can be renewed for further two years only. Before inspection, a team of architect, finance and legal member should visit the college. Its task should be to study the maps design, capacity, location and approach of the hospital. The structure should be carefully assessed for safety and security. After the satisfactory report from this team, the college will be intimated of the date of inspection.
Staffing: PMDC has stringent well defined rules for the number of faculty required. Initially for the first two years there is relaxation in the number of faculty in the clinical departments. However at the time of first inspection, disproportionate weightage is given to the basic sciences. Most PMIs go to great length to lure professors in the basic departments as they are a precious commodity. The distribution of marks should be rationalized and equal marks be given to basic and clinical sciences at the time of inspection. Hospital is 70% of a medical college. Running of the hospital is dependent upon junior doctors and nursing staff. No marks are allocated for these vital staff of the hospital. They are low in priority of the owners of the PMI; they are only interested in marks required for recognition.
Structure should be very carefully scrutinized. There are certain very good points in the previous performa regarding structure of the premises. They need improvement. The college building and hospital building should be purpose built, designed by experienced architects and approved by the NESPAK. Safety especially regarding earthquakes should be compulsory. Some colleges are set up in buildings originally built for some other purpose and later modified. Easy spacious entrance, easily accessible for patients and visitors is essential. Adequate parking facility for at least 100 cars should be provided in hospital and college premises. Instead of modified rooms shown during the inspection, proper lecture halls should be part of the college. College must have a large play ground for extra-curricular activities instead of rented ground. A 500 seat purpose built auditorium is a must for a medical college for various functions and activities. Hospital must have open clean and green spaces.
Canteen: A proper hygienic canteen for seating capacity for 100 persons should be an integral part of the hospital. It should be able to cater for patients, visitors, students and faculty. It should be supervised by the college community medicine department. They will be responsible for ensuring the quality and quantity of food served to the patients and hospital staff. Adequate weightage should be given to these facilities in inspection. Most of the public medical colleges and all of the PMIs have no department of nutrition. Every hospital must have a qualified dietician and marks allocated.
Solid waste management system in these tertiary care hospitals is pathetic. During most of the inspections, I was informed that it has been outsourced. It is pity that such an important aspect of hospital is neglected. Adequate allocation of marks should be given to solid state management. Pakistan medical license examination in Medical College admission test was introduced few years ago. If there is an entry test at time of admission, why there cannot not be an exit examination at the end of MBBS. Similar examination should be done to assess the efficacy of the system. It is a maxim of education that you assess what you teach. A PMLE examination should be held twice a year, theoretical examination of clinical subjects only. It can be organized by any one of the numerous medical universities in turn. Result of all colleges should be displayed on the PMDC website. Any college, whose more than 50% of the students fail to pass the exit examination should be warned. If it fails to improve, its performance, it should be barred from further admission. Further, the college should be fined heavily for not maintaining the minimum required standards. College performing well should be given incentives if form of extra seats or increase in tuition fees. Student selection admission should strictly be on merit. MCAT conducted by the provincial government should be accepted. No college or university should be given liberty of holding its own admission test. A central merit list should be prepared for each province and strictly adhered to. These are few suggestions for improvement of functioning of PMDC.
The writer is a doctor and convener/ inspector PMD, convener/ examiner CPSP