Don’t worry about what’s ahead,

Just go as far as you can:

From there you can see further.

--Anonymous

It’s fall, the evenings are getting cooler, there’s a nip in the air and that must mean it’s ‘match’ season. Every year, beginning on September 15, medical graduates from the United States and all over the world (including Pakistan) send in their electronic applications for the ‘match’ in pursuit of a coveted ‘residency’ position in a United States hospital. The ‘match’ or more appropriately the ‘National Resident Matching Program’ (or NRMP) is an algorithm that ‘matches’ hospitals with trainee doctors who want to work there.

In the United States, following completion of medical college, all new graduate doctors must complete a period of post-graduate training before they can be licensed to practice medicine. This training, referred to as ‘residency training’ or simply ‘residency’ (because it is fulltime and often requires trainees, especially in their early years of training to spend most of their time in the hospital, including nights) can last from a minimum of three years (for specialties such as Family Medicine (General Practice), Internal Medicine, Pediatrics etc, to as long as seven years or longer for some surgical specialties.

Doctors can also choose to pursue further specialist training following completion of their residency called fellowship. Upon completion of their residency and after passing an exam, doctors are certified as specialists and can obtain a medical license to practice medicine in the United States. This system has been in place since the early part of the 20th century after publication of a ground-breaking report in the USA in 1910 called the ‘Flexner Report’ (more on that another time). This system guarantees some of the best trained doctors in the world and economic arguments notwithstanding, the medical system in the US ranks as one of the best in the world.

For medical graduates in Pakistan, some of the best and brightest minds in the country, finishing medical college opens up a whole new set of challenges. Post-graduate training is fragmented and finding a position is by no means certain. Bureaucratic hurdles, a mismatch between the number of medical graduates and available training positions, low pay during training and many other obstacles mean that a training position in the United States is the ‘Holy Grail’ of all freshly minted doctors.

A residency position in the USA pays a salary adequate for renting an apartment, buy a modest car and pay your daily expenses from day one with the promise of a much more lucrative salary and bright career prospects at the completion of training. But many hurdles lie between medical college graduation and the beginning of residency training for Pakistani medical students.

The first is completing a set of grueling examinations that certify your basic medical knowledge. In addition to the study and effort required to write these exams, the cost can, many times, be prohibitive for students from less than affluent families. At the public medical institution that I teach, we admit around 330 medical students each year. Our university is ranked number one in the Punjab so only students with stratospheric grades have a chance of being admitted. In 2016, the last student admitted in our university had an aggregate score of over 92 per cent.

Unfortunately, we still follow a curriculum which is a mish-mash of parts left over from the British Raj era with some Pakistani sections grafted on to it. It has changed little since I was a student here in the late 1980s and it does not prepare our students for the US entry examinations. As a result, our graduates have to take 1-2 years off after graduation to prepare for the US exams. In addition to the time required, the money to pay the exam fees can also be an insurmountable hurdle. Each exam (there are 4 in all) can cost close to $1000. Two of the exams have to be taken in the USA which means the expense of traveling to and staying in the USA. An additional requirement nowadays is that all applicants from countries outside the USA must show some ‘US clinical experience’. This means they must have worked at the US hospitals for 3-4 months or longer to be eligible to apply. This is an additional cost.

The total for this academic journey, from graduating medical college to landing a residency position, can easily amount to around Rs18-20 lakh, a prohibitive sum for a young man or woman from a family with modest means.

Ours is a public university which means the bulk of our students belong to middle class families or lower. We have a fair share of students whose parents are daily wage labourers, rickshaw drivers, share-croppers on rented lands or low level government servants. Rs20 lakh is far beyond their means (and in fact, as soon as they graduate, most of our students are under pressure from their families to earn and contribute to household income).

With the fall season, I start getting calls and emails from these very bright young men and women to help in their journey to the US. As the only US trained faculty member in my institution, it’s natural that they gravitate towards me and it has been my privilege to work with some exceptionally talented young men and women in the last few years: the young man with a serious expression who came to see me and told me he was ‘stuck’ in a medical career when what he really wanted was to be a philosopher; the attractive young woman who cried her eyes out in my office because she had been ‘cyber-stalked’ by a class fellow for months; the brilliant young man introduced to me by his friends who was on the verge of clinical depression because he had failed to secure a ‘match’ position the previous year; the frail young woman who had been forcibly married off by her family to an abusive man while still a medical student and who had tried to commit suicide as a result.

They all come to see me with one thing in mind: they want to go to the United States to study and work and they want my help with it.

(To be continued)