Columns are written often enough about money-hungry doctors. Indeed money-hungry doctors are as much a cliché as money-hungry bureaucrats and money-hungry politicians and money-hungry businessmen. And that is indeed a problem I have with some of the vituperation doctors have to face in Pakistan. Are Pakistani doctors not a part of this culture where everybody and his or her aunt are doing whatever they can to make as much money as possible? So why should doctors not do what everybody else is doing?
Aha! You want to talk of oaths and stuff and that doctors are messiahs. Well I suppose before I go any further it is important to point out that every messiah in history, real or pretend, sort of ended up rather badly. As far as the ‘oath’ thing is concerned, I never took any Hippocratic Oath when I graduated from King Edward Medical College all those years ago. And would it even be appropriate to take a ‘pagan’ oath? Also I might point out that we in Pakistan have been ruled for most of our life by generals that violated oaths sworn in the most Islamic fashion possible.
So oaths clearly have little importance as far as Pakistan and its people are concerned and the people of Pakistan obviously include the doctors of Pakistan. That then brings me to some of the problems that we have in the delivery of healthcare. The big question is whether doctors in Pakistan are worse than in other countries or is that just the usual gripes that all unhappy ‘customers’ have of services they pay for but are not satisfied with? Based upon my experience in one of the ‘most advanced’ medical care systems (United States) and then that in Pakistan, I can say with some assurance that doctors in Pakistan are as good or bad as those in the US with some important differences based upon the legal and professional environment they practice in.
Members of the Pakistani ‘intelligentsia’ are always bemoaning the fact that in Pakistan we do not have ‘the rule of law’. That is the primary reason for the difference in the quality of healthcare delivery at all levels between an advanced country like the US and Pakistan. Nobody in Pakistan observes laws unless they have to. In the US there are laws that govern almost every aspect of medical care and these are enforced. In Pakistan also we have laws that govern much of medical care but these are rarely if ever enforced and the only time they might be enforced is if somebody in the ‘food chain’ forgets to pay off the person responsible for enforcing the law.
In an environment where neither hospitals nor doctors nor even the ‘pharmacies’ that dispense medicines are under any oversight, to receive appropriate medical care must be a miracle. And yet as far much of medical care in Pakistan is concerned, the fact that most people actually get treated appropriately must be considered a miracle. And that miracle is based upon one simple fact; most doctors in Pakistan do the best they can even under the most difficult circumstances.
Yes, there are ‘bad eggs’ among Pakistani doctors as there are among all other professions. But there is one important difference between doctors and most other professions. We as doctors are trained to make people feel better and if possible cure them from whatever ails them and that is all we can do. So, for all practical purposes a doctor can either treat a patient or not treat a patient. In the private sector if people go to a physician seeking help and do not get it, that physician will not survive in the marketplace. And that is true even of the ‘quacks’.
All those in the ‘business’ of providing medical care, unless they can ‘satisfy’ their customers (patients), will be driven out of business and in Pakistan being driven out of the medical business can also be accompanied by serious physical harm. Like all businessmen, doctors and hospitals have to do at least to survive financially.
The exception to that rule are hospitals or medical ‘practitioners’ especially in smaller towns where there is little competition from qualified physicians or from properly staffed government clinics. Anybody that has ever driven from Lahore to Rawalpindi on the GT Road must have noticed that in almost every small town on the way there are many ‘storefront’ shops with a big board proclaiming them to be a hospital or a medical clinic. One can well imagine what sort of medical care might be available in such a place.
In the US which is the only other country I have practiced medicine, every area of medical practice is closely supervised. For physicians there are three major reasons that force them to stay current with the latest developments in medical care. First, every physician must spend up to one hundred hours in ‘continuing medical education’ (CME) before reapplying for state license, and you cannot practice without a state license. This forces physicians to attend conferences and educational seminars to keep up with the latest developments in their area of medical expertise. Sadly, the ‘licensing’ authority in Pakistan, the Pakistan Medical and Dental Council (PMDC) has no such requirement for physicians being ‘re-registered’.
The second reason why doctors are forced to stay up to date is that every board certified physician (like FCPS in Pakistan) has to recertify the boards every ten years. This means that they have to study and prepare for a rather strenuous examination. Also, more recently almost all the specialty boards have instituted a policy that all those certified by the board have to provide yearly proof of activity and education to maintain board certification.
Finally and perhaps most intimidating is the system of ‘medical liability’ where any dissatisfied patient can sue any doctor. The basic requirement for getting out of such cases is the defence that the doctor was following the ‘accepted standard of care’within that community. To prove that a doctor committed malpractice the plaintiff has to prove that the doctor behaved in a manner that was not within the accepted standard of how his or her peers would behave. And that then forces doctors to keep up with the ‘guy next door’ in terms of education and practice standards.
In Pakistan the well off, the well-connected, senior bureaucrats, and politicians rarely have difficulty in getting good medical care. The problem is for poor patients that have to depend upon government hospitals and clinics for medical care. The state of medical facilities run by the government are in such a bad way that most poor patients end up relying on ‘quacks’ and unlicensed practitioners for help. Every now and then the provincial government mutters a few words of concern about the public healthcare system but then forgets all about it to concentrate on the latest highway project. Sadly the public healthcare system is rarely a priority for any government of the Punjab. That sums it up.