Inam Muhammad Baig ( Pilgrim Hospital, Boston, United Kingdom )
July 2020, Volume 70, Issue 7
Short Communication
Abstract
Undergraduate medical education in Pakistan appears to be in turmoil due to various problems. One of the main reasons is the rapid growth of private medical colleges in a short period of time to meet the increasing national demands of doctors but without proper measures for standard maintenance and quality assurance. However, original research verification of a gross decline in standards is lacking. Efforts to reform the system cannot find credibility in the absence of evidence. We can begin with simply interviewing senior consultants in tertiary care teaching hospitals in Pakistan to see if they perceive differences in standards of medical graduates from various medical colleges to obtain such evidence. This short communication aims to provide a brief literature review of the perceptions about the standards of medical graduates and undergraduate medical education already published in the last two decades in less validated forms.
Keywords: Standards, Medical education, Medical graduates, Pakistan.
DOI: https://doi.org/10.5455/JPMA.20867
Introduction
The overall perception of a decline in the standards of medical graduates in a developing country like Pakistan clearly indicates that undergraduate medical education is in turmoil facing many challenges.1 There are no proper measures in place for quality assurance and quality improvement2 to ensure that medical graduates are of an adequate standard to be safe and competent doctors. This situation has worsened with the rapid growth of private medical colleges. These institutions are contributing to meet the increasing national demands of doctors but without enough mechanisms for standardization and good quality education in place.3 The outcome is that fresh medical graduates from various medical colleges, joining tertiary care hospital medical teams, demonstrate a disproportionately large range of medical competencies and performances, from being totally incompetent to having excellent clinical competencies. Concerns about this crisis of medical education were raised frequently in the national media and highlighted repetitively by many educationists through editorials, opinions and short communications ( see table) but rigorous scientific research studies wwhich could have provided authentic evidence were not done.
Therefore, unless substantial evidence of substandard medical education leading to substandard graduates is available, recommendations for reforms cannot find credibility. Qualitative research projects can explore experiential and phenomenological evidence regarding variation of standards and existence of alarming low standards in the medical education of various medical colleges by studying their medical graduates though the experiences of their senior mentors. This is a part of the writer's commitment to work towards improving the quality of medical education in Pakistan; where there was one medical college in 1947 at the time of its inception, eight were added by the government with proper planning in the first decade4 and until 1990 there were only 22 (including only one private) but in the last two decades the number of medical colleges has increased to 132, more than 65 percent are private.5 This situation should invoke all the stakeholders reminding them of their social responsibilities.1
Literature Overview
There is a scarcity of literature about medical education in Pakistan in general and about standards of medical graduates in particular. It was very difficult to find any original works simply because no original research has been done so far regarding standards of medical graduates. A thirteen-year audit of medical education publications in Pakistan (2001-2013) which produced quantitative results, did not show a defined category of manuscripts about standards of graduates among the total of 118 publications.6 However,16 (13.6 %) manuscripts were not placed in any category and no papers about perceptions of standards were mentioned therein. This simple audit however, included publications from the four indexed medical journals of the country and excluded the 71 other local medical journals. Only one original research paper,7 a qualitative study about the problems of medical education in Pakistan, provided indirect evidence towards the low quality of medical education. Most of the other evidence consisted of opinions, editorials, short communications, commentaries and letters to the editors etc. The aim of study was exploring the problems of undergraduate medical education to understand the causes of deteriorating standards of medical education and medical graduates in Pakistan.7 A qualitative design was the appropriate method as it was based on opinions and perceptions of 178 faculty members but instead of interviews or questionnaires their opinions had been recorded by facilitators in 13 workshops. The results relate to the original aim and listed in place of enlisted the problems of medical education under headings of deficiencies in curriculum, faculty, students, teachers and assessment systems. The validity of the results is difficult to comment on as no other evidence was provided to verify them. However, being the only one in its category, this 20-year-old paper is very valuable local evidence. There is however a reasonable amount of evidence in the form of expert opinions to substantiate the existence of the issue. It was rightly portrayed by Amin et al.8 that the current situation of a deteriorated state of medical education in Pakistan and India resembled what was happening in USA a century ago due to enormous growth of substandard private medical colleges in that region of the globe. They arrived at the conclusion that a century later almost all that described by Flexner9 in his report 'Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching' regarding the state of private medical colleges was being repeated in a different region of the world. This paper presented a comparative analysis of the situation of medical education comparing it to similar situation in a different part of the world a century ago. It provided lessons to learn either by following the report and changing our systems or writing a similar report in a new context with the demanding needs of current times. Although Naqvi7 had produced a large list of problems of medical education, Nasim10 in her short communication thought that the main reason of decline in quality is that most of private sector medical colleges in Pakistan were lacking departments of medical education and their faculties were untrained. This observation was based on her personal experiences as a teacher in medical education. In an editorial in the journal of college of Physicians and Surgeons Pakistan, Biggs1 raised concerns that there is an ongoing unchecked growth of medical colleges in the private sector and the medical colleges in Pakistan seem to be indifferent towards their social responsibilities. He wrote that in ten years' time (between 2001 and 2011) 18 medical colleges (4 public, 14 private) had been established only in the Punjab Province of Pakistan. The main challenge, he thought the medical education in Pakistan faced was the absence of a system to keep a check of standards of individual medical colleges. Similarly, in an opinion article Awan3 very honestly exposed the current state of medical education highlighting the kinds of medical graduates being produced and how focusing more on quantity rather than quality and standards could be dangerous to the health system of a country in the long term. Although, this article was based on the author's opinions and his personal experiences, it provided a very honest picture of the situation. Several other educationists have also raised such concerns in their editorial opinions or commentaries.2,10-16
Conclusion
This short communication informs the reader of the meager, accessible local evidence about the standards of undergraduate medical education in Pakistan. Based on this information, It would recommend more extensive qualitative research to provide robust scientific evidence regarding the standards of newly qualified medical graduates in Pakistan. This authentic evidence is in fact urgently needed to acquire credibility and empowerment for the many voices asking for drastic reforms in undergraduate medical education in Pakistan.
Disclaimer: The literature review was part of an assignment submitted to the university of Edinburgh during my master's in clinical education course, an assignment is an educational activity and not published. However, it was submitted through Turnitin and scanned for similarity and cleared.
Conflict of Interest: None to declare.
Funding Sources: None to declare.
References
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2. Tariq M, Ali SA. Quality assurance and its application in medical education. J Coll Physicians Surg Pak 2014; 24:151-2. doi: 03.2014/JCPSP.151152.
3. Awan AK. Trading-off quality for quantity: Mushrooming of Medical Institutions and Quality of Medical Education in Pakistan. [Online] 2016 [Cited 2017 December 06]. Available from URL: http://jpathology.com/wp-content/uploads/2016/06/Opinion- Article1.pdf
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6. Rathore FA, Waqas A, Zia AM. A thirteen year audit of manuscripts related to medical education published in leading medical journals of Pakistan. J Pak Med Assoc 2016; 66:439-41.
7. Naqvi AS. Problems of medical education in Pakistan. J Pak Med Assoc 1997; 47:267-9.
8. Amin Z, Burdick WP, Supe A, Singh T. Relevance of the Flexner Report to contemporary medical education in South Asia. Acad Med 2010; 85:333-9. doi: 10.1097/ACM.0b013e3181c874cb.
9. Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. [Online] 1910 [Cited 2017 December 06]. Available from URL: http://archive.carnegiefoundation.org/pdfs/elibrary/ Carnegie_Flexner_Report.pdf.
10. Nasim M. Medical education needs to change in Pakistan. J Pak Med Assoc 2011; 61:808-11.
11. Ali SM, Shamim MS. Way forward for Departments of Medical Education in Pakistan. J Pak Med Assoc 2014; 64:732-3.
12. Gadit AA. Professional competence assessment: is it a wakeup call for Pakistan? J Pak Med Assoc 2010; 60:965-6.
13. Rajput AM. Medical education in Pakistan. J Islamabad Med Dent Coll 2012; 1:154-5.
14. Shaikh SH. A reform agenda outline for medical education in Pakistan. J Coll Physicians Surg Pak 2009; 19:331-2. doi: 06.2009/JCPSP.331332.
15. Syed S. Medical education: Dangerous doctors. [Online] 2015 [Cited 2017 December 06]. Available from URL: https://www.dawn.com/ news/1224144/medical-education-dangerous-doctors
16. Siddiqui FG, Shaikh NA. Challenges and Issues in Medical Education in Pakistan. J Liaquat Uni Med Health Sci 2014; 13:91-2.
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