November 1997, Volume 47, Issue 11

Original Article

Problems of Medical Education in Pakistan

Arshia Samin Naqvi  ( Centre for Medical Education, Baqai Medical University, Karachi. )

Abstract

Inspite of being the products of present system of medical education in Pakistan, the faculty members of Baqai University are generally dissatisfied with it. They have raised their concern on present medical education at various forums, This paper discusses the problems of medical education in Paldstan as elicited by the faculty members of Baqai Medical University. The importance of this study lies in the growing concern over deteriorating standards of our medical education and the strengthening belief that a change in the system of medical education is inevitable (JPMA 47:267,1997).

Introduction

Present system of medical education in Pakistan is the one which has its roots in the colonial era. Since independence in 1947, medical education in Pakistan has witnessed very little or almost no change at all. As a result of the rigid attitude of our policy makers, lots of problems have appeared which need to be sorted out and remedial actions be taken.

Methodology

With the aim of developing a scientific approach to medical education, Centre for Medical Education, Baqai Medical University organizes workshops on various aspects of medical education. In the workshops on Educational Planning and Evaluation and on Problem-Based Learning, participants are invited to discuss the problems of medical education in Pakistan. Then with the help of the facilitators each problem is properly phrased and listed down. This study includes the problem census ofa total of thirteen workshops on Educational Planning and Evaluation and Problem-Based Learning that have been organized by Centre for Medical Education, Baqal Medical University from Januazy, 1994 to April, 1996. They were attended by faculty members from Basic as well as Clinical Sciences. Participants included faculty members of all levels i.e. Professors, Associate and Assistant Professors, Registrar, Senior Lecturers and Lecturer/Demonstrators. Maximum number of participants was 26 and minimum 8. The common problems identified in these workshops were selected for discussion in this article (Table).

Problems that were similar or inter-related are listed under one broad heading. Total number of participants in all the 13 workshops were 176 with an average of 13 per workshop.

Results and Discussion

Curriculum
Although, Pakistan Medical and Dental Council (PMDC) has chalked out the outlines of our medical curriculum, yet the irony of fact is that most of the faculty members involved in teaching are not aware of its existence. Hence, teaching is carried out accordingly. Moreover, the course outlines are vague, not clearly defined, resulting in the ambiguity of the situation. In this regard it is important to note that educational programmes designed in the past for one set of circumstances are still being used under changed circumstances i.e., yesterday’s programmes are a misfit for today’s problems. There are recurrent historical examples of programmes that were appropriate for that time but are now out of date because needs and curriculum concepts have changed1. The most important issue and which needs the urgent attention of medical educators is thatof Curriculum2. In the past, a few attempts have been made to revise the existing curriculum but were not successful inbringing any substantial change1. Hence, it is assumed that methods of curriculum supervision may restrict change. The intention may be to maintain standards, but the result quenches the flexibility required for constructive change. The presence of nationally mandated curricula create passive institutions which in turn produce passive graduates4. There is no standard, ready to use curriculum that can be adopted in toto10.
Medical Students
In the countries where selection is on the basis of academic criteria alone, atleast some individuals are admitted who have no real thirst for learning and no deep conunitment to learning those things which contribute to competence as a physician. It is also true that the nature of the educational programme, particularly in early years where the content seems so remote from the goal of becoming a medical doctor is often clearly demonstrative and may even induce passivity and resentment5. As medical curriculum is not well defmed, a medical student is left alone to swim in the vast sea of knowledge. Curriculum overload is a fundamental and increasing problem with medical education, even if learning is enjoyable and the students are capable and apply themselves5. This is rare, while usually the students are under great stress as they lind it clitticult to get through an exam designed out 01 an extensive text. If we debate the extent of our medical curriculum a question arises “Should eveiy medical student learn the detailed anatomy of the skeleton", when only a few will ever make use of this information?6.
In the traditional system of medical education, students are not actively involved in their pursuit of knowledge, rather they have to depend on theirteacherwho plays a pivotal role in the building up of a health team. In such situations, students role becomes passive: taking notes, learning and passing a row of exams in order to get certified for medical practice. Furthermore, there is heavy emphasis in our educational system on learning by rote. This habit is further reinforced by examinations whichare mainly based onrecall of information. There is a definite need to reduce the total teaching load of medical education and give students the time and chance to identify problems and develop their own skills in problem identification and solution. The present emphasis on didactic coverage of courses and selective reading does not provide them the training needed to meet the challenges of the future1
Medical Teacher
There is justifiable concern that the poor learning habits of medical students are frequently compounded by lack of teaching expertise in their teachers1. The mitial selection to the teaching post 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 specialist9. Moreover, a general practitioner sitting in his clinic is financially more secure than a Professor of a basic sciences subject in a medical college. There is no additional benefit in pursuing a teaching career in medical/dental colleges, so most of the teachers do not have enough zeal to bring any meaningful change in the present system. Teaching is a full time profession. The time required for organising and supervising is not available with the medical teachers under the present system. Even if the teacher desires to enter full time teaching, he cannot find time. This is linked with the financial returns and can not be compared with the income in the private practice7. Concept of teacher evaluationis non-existent, neitherby committee norby peer or students. Hence the teachers are devoid of any opportunity to receive feedback for their teaching. Monitoring of teaching performance particularly inputfrom students is lacking. While appointing medical teachers very little or almost no emphasis is given to their teaching abilities and communication skills. There is no standardized cnteria for the selection orprornotion of a medical teacherand their teaching abilities or contribution to educational development are given no consideration. Moreover, the methods of selection, promotion and posting of doctors is beyond the control of departmental head. It is a growing realization that even in a traditional medical school, the role played by a teacher should be more than that of a mere dispenser of information but because generally there is no compulsory/formal training programme for medical teachers, sothey are unable to act as guide to students6.
Teaching in Medical Colleges
Teaching in medical colleges is geared towards passing exams and that too tests only the knowledge part of the subject. Today inPakistan the entire emphasis of the system of medical education is on the passive acquisition of knowledge, much of it to become outdated or forgotten, rather than on its discovery through curiosity and experiment11. Assessment system far more than curriculum or instruction determines the nature of learning. Contempomiy assessment systems pmbe primarily a candidate’s ability to recall or recognize bits of information. Knowledge, competence and performance are independent variables and all need to be assessed both for the puipose of documenting achievement and for exhibiting the quality that is valued by the medical professionals which is unfortunately not being done presently. Skills and attitude are not given due weightage6. Students attach less value to what they learn, rather pay more attention to improving their perfonnance in exams. The whole system of medical education is geared towards passing the exams. There is marked emphasis on teaching while little on learning. Integration between different disciplines is lacking with the result that the whole of pre-clinical and pam-clinical subjects are taught in isolation6. This traditional dissociation between the pre- clinical and clinical parts of the course has been a significant factor in perpetuating the curriculum overload11. Medical students do not have any contribution in the planning of the curriculum or evaluation of the educational process and outcomes of their learning. They are not treated as adult learners and are supposed to follow the age old system.
Present Examination
Within the framework of present system of undergraduate medical examination, the most destructive agent at play is the use of unfair means. These unfair means are used not only by the. students but by the teachers as well. As presently our examinations are subjective in nature, bias and foul play are very common. Examiner’s opinion about a particular student may be biased due to any reason what so ever or a examiner can have a biased view point of a certain topic. Inall such cases student is the suffererand has to bear the brunt of the situation. What is even more unfortunate is that the examinations also test only the knowledge part of the subject. There is no wonder that students put so much emphasis on mugging and cheating. Our present examinations are not designed to stimuates critical self- learning. They are only emphasizing on memorization of facts which is dangerous10. A very regular and hard working student fails to give a good presentation due to any reason at the annual exams. This is a very non-scientific approach and occurs because of the absence of a system of continuous evaluation. Only the result of final exams is given due credit while students attitude, interest and bard woiic during the whole academic year is not considered at all.
General Problems of Medical Education
Educationists believe that information disseminated in mothertongue is easily comprehended. But the situation inour country is such that our mother tongue is not used as a medium of instruction in majority of educational institutions, because of unavailability of textbooks and reference materials inUrdu. English is used as the medium of instruction for all professional as well as postgraduate programmes. So the students with very sound knowledge of science but with some weakness in English find it difficult to understand or express themselves in English. In most of the medical colleges of Pakistan students-teacher ratio is very inappropriate. Usually the number of students in a class is around three hundred. Hence communication between faculty and students in most medical schools has not been one of the strong point of our system6. Moreover with increasing awareness of personal rights, lesser number of patients allow themselves to be examined by medical students, especially so in private medical colleges. In modern world live or mechanical simulators are substituted for patients. But in the absence of any suchfacility medical students inPakistanare devoidof the opportunities to practice their clinical skills and they are left with mere theoretical knowledge of the subject. In Pakistan national politics exerts influences on each and every institution In medical colleges students as well as teachers selection is highly politicized. Merit is no longer the criteria resulting in lowering of standard of medical education as a whole. The standard of medical education is directly related to the standard of teaching manpower, financial inputs and available facilities7. Due to wrong planning and policy making financial inputs for medical education are scarce and the facilities for teaching/learning i.e. reference books, journals, laboratory equipment are not upto the standard and inadequate as well. We do not have the potential of research neither in our undergraduate medical institutions nor at the postgraduate level.

References

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