DefinePK

Abstract

This question can only be answered after we know what is the setting in which most of the undergraduates are supposed to work after graduation. If the aim of the present medical education in Pakistan is to produce graduates, the majority of whom will in the future work only in hospitals dealing with indoor patients, then, the answer to the above question is “YES, the only place for Clinical Training of undergraduates is the “Hospital”. If there is any hesitation or qualification about where the future graduates will work then we should critically analyse the prevailing undergraduate training programme.
Presently Pakistan is producing over 4000 new medical graduates every year. By far the majority of them will either set up a private practice of their own, or join service as a Medical Officer in a Dispensary. In both these situations they wifi be working outside the hospital surroundings. As a matter of fact most of the time they will be far removed from a Hospital. The undergraduate training they have received has been entirely in the hospital surroundings. That is the only medical care they have seen being practiced. This is also the only setting in whjch they have seefl their teachers work. No wonder the fresh graduates do not want to leave the hospital surroundings. Hence the demand for house jobs for everyone and hospital based postgraduate training for everyone. Should we blame them if they do not want to go to peripheral areas. When and where have we given them any training or exposure of work in settings outside the hospital.
If we want that the bulk of our graduates should work in Dispensaries and in rural areas then we should also train them to work in those surroundings. If the needs of the nation are that physicians should look after the health needs of the population then we have to train the graduates to perform these duties. The answer to the question posed above, then is “No, hospitals are not the only place for Clinical training of undergraduates”. As a matter of fact they are not the best place for the training of a physician who will eventually work in the Community. Hospitals are the place for training of specialists i.e. postgraduate training.
A perusal of the preamble to the MBBS course prepared by the Pakistan Medical and Dental Council shows that the main objective of the programme is “to produce a general purpose community oriented- doctor, capable of doing good work independently”. Further on it states “should be able to diagnose and treat the common medical problems”. The plan documents and other government publications also emphasize the need for a physician capable of working in the Community and not in the Hospital alone. Pakistan along with other members of WHO is a signatory to the Alma-Ata declaration calling for Health for All by the year 2000. The main plank of the strategy for achieving this is the Physician trained to look after the needs of the population. The Pakistan Medical Association realising the importance of this programme made it the theme of its XVI Conference held in Karachi in 1984. The above targets can not be met unless the curriculum and the teaching strategy is totally community change. Unfortunately in Pakistan, despite the stated objectives in the preamble, PMDC sticks to a rigid, outmoded curriculum which was followed in United Kingdom in late 1930’s. The entire clinical training of an undergraduate according to this system is in the hospitals. revamped. All around the world the medical curriculum has changed to meet the needs of the community.
The curriculum of a Medical College should be designed according to the percieved needs of the people, its graduates will serve. It should be a dynamic document which is adjusted as and when the health needs of the
The teaching potential of Health Centres, Dispensaries, Out-patients and offices of Family Physicians has been consistently ignored. They provide the ideal settings for training undergraduates for the job they will be doing after graduation. Even in highly advanced countries like United States there is a move to increase the component of training in Ambulatory Caie1,2
The idea of doing some of the Clinical teaching outside the hospital is not new. It is being done in different forms in many countries. In Pakistan the major objection to any proposal to have the medical students go for training out. side the established Medical College affiliated Hospitals has been that there is no one to teach the students outside these hospitals. The existing teachers do not want to teach outside teaching hospitals, while those who are working outside the teaching hospitals are not considered eligible to teach.
If it is considered that the training of medical students outside hospitals is essential then a solution has to be found to this dilemma. If the needs of such training can be best met by having the existing teachers teach outside as well, then ways and means of taking them outside will have to be found out. Alternately, the eligibility of physicians outside the teaching hospitals to teach medical students should be re-evaluated. After all, the Clinical teachers presently working in Medical Colleges have acquired their teaching skills after their appointment. The initial selection to the teaching posts does not require any previous teaching experience. The sole criteria has been a postgraduate qualification in the given speciality, or in other words the ability to function as a specialist (Consultant) in the hospital. The teaching title came as a part of what is essentially an hospital appointment.
If the basis of the appointment of present clinical teachers is only proven ability to perform clinical duties in hospital settings then there is no reason why proven ability to perform clinical duties outside the hospitals should not be the basis of appointment of teachers outside the hospital. Just as the specialist working in a hospital is the best person to teach that speciality the Family Physician is the best person to teach the practice of medicine outside the hospital. Not evely Family Physician would be capable or interested in teaching medical students and some criteria will have to be established to select the right ones, but wholesale condemnation of non hospital based physicians is not justified. Inducting a selected few into teaching will provide a solution to some of the existing contradictions and dilemmas facing medical education in Pakistan.