For years, the foundation of medical education in Punjab has been corroding. Till a couple of decades ago, medical college professors were promoted after years of serving in the trenches, not always in “teaching positions”, and rising through the ranks to eventually earn their promotion to the position of professor. They had spent decades teaching, examining, and managing wards and clinics. They were certainly not all equally learned or equally admirable as teaching doctors, and the system they presided over was far from perfect. But the long years of experience did give these veterans a good, if unstructured, grasp of their subject, teaching, and assessment of undergraduate and postgraduate medical students, as well as a certain familiarity with the scope, deficiencies, and limitations of the system they served.
Then came the realisation that years of experience alone do not make a professor. At the same time, a need was felt that the path to specialisation should not be years of serving in multiple fields and then settling into one, serving that again for years before finally acquiring whatever post-graduation degree was available, usually a diploma or a two-year MPhil or MD/MS degree that did nothing more than certify the already accrued experience. There was no “structure” to this system and no “standardisation”. It could not mimic an assembly line even if it tried. It was just a continuation of how things had been done by human beings for centuries. Go work with someone who is a master of their craft. Keep your head down, work hard, and you will learn in due course. And while you learned, you served.
The Assembly Line of Consultants
The need for "structured" postgraduate training led to the setting up of institutions that offered four- to five-year postgrad programmes, mostly in clinical (and “allied”) disciplines, to medical graduates after one year of “house job”, and the degree awarded to them at the end of the programme qualified them for specialist and teaching positions in hospitals and medical colleges. Thus, assembly lines of “consultants” were set up in the clinical fields.
The “basic sciences” lagged behind, and an attempt was made to add them to the foray of four-year structured programmes, but it doesn’t seem to have worked out. And so basic sciences still made do with the MPhil and now increasingly PhD degrees, but with a difference. MPhil programmes used to be rare in the country, much less the province. The reason was simple. The material and human resources needed to teach and guide a student for an MPhil degree in fields like microbiology, physiology, anatomy, and biochemistry were scarce in the country. And if any kind of a standard was to be maintained, we could afford to award only so many degrees per year, and that is what we used to do for many decades.
For centuries, the path to mastering medicine was simple: work with a master of the craft, keep your head down, and learn while you serve – but today, we have replaced that foundation with a mechanical assembly line
But now there was a mushrooming of degree programmes for basic sciences as many public sector universities set up MPhil programmes, albeit with huge deficiencies in what postgraduate training for a doctor in a basic science discipline actually demanded, and soon even scores of private medical colleges started offering similar degrees, duly accredited by the HEC and PMDC. We were now churning out MPhil and even PhD “scholars” in basic sciences at quite a fast pace as well, though nowhere near matching the clinical sciences assembly line.
At the same time, new service structures were introduced which started inducting these newly minted subject specialists into “teaching positions” in the public sector medical colleges. The initial inductions were based on a postgrad degree in the relevant discipline, which meant two years (in the case of MPhil) and four years (in the case of a postgrad in a clinical or allied field) experience in the discipline, plus a year or two of teaching experience, which was a rather flexible requirement and was never put to any test to see if the experience translated into any kind of skill or not. They also considered your Matric and FSc scores (!!) but even stranger was this brand new requirement: published “research”, and not quality but the number of published papers.
So the new postgrad degree—which was not new at all for the “basic sciences” at least, the same old MPhil but of an obviously reduced quality, but let's just assume it was something new—coupled with “research” was what replaced years of experience that used to be the requirement for any doctor to be promoted to even the most junior teaching position earlier, that of “assistant professor” or, in clinical fields, “registrar”.
The path to progress for the new crop of specialists was clear: they needed to clock a few more years to be promoted to associate professorship and another few to be promoted to full professorship, provided they met the requirement for the number of “research papers” published. And they did.
The Illusion of Research
So one might assume that Punjab became the hub of high-quality clinical and basic science research in this progressive era? But that would be a wholly misguided assumption to make because the facts are quite contrary to that. In fact, Pakistan has become a global centre for predatory journals, fake peer review, gift authorship, data fabrication, paper mills, and citation farms. This non-exhaustive list is cited here not for accusing individuals but to lay bare the general milieu against which we need to examine what is happening to our undergraduate medical education. Because at the centre of the deteriorating standard of medical education sits the newly minted professor.
And what makes a professor here? Publications. And what do we know about publications in this system? The above, with extremely rare exceptions. This new professor had not spent twenty years in the trenches learning in an unstructured, unstandardised way how to teach and examine medical students, learning the ropes of the system, and, very importantly, cultivating a sense of loyalty and ownership. They moved on an assembly line, got a degree, clocked the minimum required years, managed the exact number of publications in journals of questionable standing, and they got promoted. Fast. Click. Click. Click. Eight years from the first induction as “assistant” to “full professor”, provided you can churn out the “publications” fast enough. What does that give us? At best, professors with bare minimum teaching experience and very suspect “research” credentials, who do not take ownership either of the system they serve or their own subjects; products of an assembly line who have landed the cushiest job fast and can now rest on their laurels, the “success stories” of a system that does not know what its ends are.
Before we go further, let us be clear about what a professor is supposed to be. A professor is not just a lecturer. A professor is a gatekeeper of the subject. That means they must know their subject deeply enough to teach it, answer unexpected questions, and correct misconceptions; design and deliver a full course, write meaningful examination questions, take vivas and judge whether a student truly understands, fail students when necessary, defend the subject from dilution, speak up in academic meetings, resist administrative pressure to lower standards, and model the profession for the next generation. But the system we have put in place is designed to select for professors who can produce papers (of a questionable quality) at a fast pace, not doctors who can teach and examine students up to a desirable standard.
Modernisation Without Foundation
And against this background, we decided to adopt modern Western assessment and teaching protocols. Where were we at this point? We had already undone the foundations of the old system we had, an old-fashioned 20th-century system, but which rested nevertheless on solid foundations that the old, wizened, difficult-to-the-point-of-unreasonableness professors provided. Instead of studying our own needs, defining the goals of our medical education system, and implementing reform accordingly, we decided to “modernise” under pressure from foreign licensing bodies and the desire to look modern, and adopted the "integrated block system." It was supposed to connect subjects, deepen understanding, and make learning clinically relevant.
This system is designed to transition MBBS education from traditional, subject-based (Anatomy, Physiology, Biochemistry) teaching with subject-wise time blocks (e.g., 2 hours Anatomy, 1 hour Physiology) and a heavy reliance on full-class didactic lectures with a static yearly timetable for each discipline, to a system-based, organ-centric modular model grouped into blocks. It relies on small group discussions (SGDs), skills labs, case-based learning (CBL), self-directed learning (SDL), directed self-learning (DSL), self-study time, and early clinical exposure (ECE) integrated into timetable slots starting in 1st/2nd year, alongside dynamic block-based timetables that change every module (one, two, or three per block).
It looks very good on paper, of course. We will train our students to reason clinically and solve practical problems from day one instead of making them learn laborious, boring theory for the first two years without knowing how it relates to their eventual clinical practice. But a system is only as good as the quality of its implementation. Bear with me.
This model was developed in the affluent, technologically advanced West. It assumes small group teaching; sufficient, comfortable physical infrastructure, including well-cooled and heated classrooms; no shortage of dedicated, well-trained, well-paid subject specialists; strong English language skills in both teachers and students; faculty who can design cases and tutorials; students who can read and reason independently; functional libraries and IT support; time for discussion and reflection; and separate medical education departments that handle the enormously increased paperwork.
What we had in place were over-enrolled, overcrowded medical colleges, most of which do not even have lecture halls large enough to accommodate their students for lectures, much less sufficient numbers of smaller classrooms for small group discussions. We had senior faculty inducted and promoted based on the number of “research publications” of questionable academic rigour, and junior faculty largely made up of generalists or specialists in other fields who are thrown into “basic sciences” because of a gross inadequacy of the service structure. We perhaps had moderate language skills among the faculty, but mostly poor among students; no more than very basic experience in designing curriculum in the senior faculty, meaning they can follow the textbook and make a list of its headings and subheadings but scarcely more; poor reasoning skills in the students (our high schools do not teach students to reason); non-existent or poorly maintained and poorly funded libraries; at best, poor IT support; and medical education departments that are not equipped to do more than keep a questionable record of student “attendance”.
So what is the inevitable aftermath? A reduction in the time allotted to lecture-based teaching which, given our facilities and resources, is the only form of teaching we are capable of delivering reasonably well. Most of the students’ time is now allotted to activities that we are, to put it very simply, unable to conduct in any meaningful way. These include activities like SDL, DSL, self-study, and “mentoring” sessions for “professional development”. The faculty is constantly busy making and remaking colourful timetables which are essentially meaningless. The only teaching that is happening is still the lecture, which is still largely subject-based. The “integration” that was supposed to happen in the small study groups simply has not been possible because we lack the physical infrastructure and trained manpower to make it happen. This is not rocket science. It is very simply the failure of a system that was set up to fail when it was burdened with tasks it was not equipped to perform and goals it was not built to achieve.
Asking the Right Questions
The question then arises, why was this allowed to happen? The simplest answer offered is that US licensing bodies insisted that we “modernise” or our graduates would be barred from appearing in US licensing exams. One might accept this at face value. But then one might also ask, do we spend our tax money on medical education to train doctors to export to the US, or do we do it to train doctors because we need to provide our own people with some acceptable standard of healthcare? One might further ask why this new system was imposed without asking some very basic questions first:
- What are the assumptions of this model?
- What resources does it require?
- What will happen when it meets our class sizes, our physical infrastructure and faculty shortages, our language barriers?
- What evidence is there that it will improve student understanding and future practice in our context?
- What are the risks?
- Who will implement it?
- Who will “facilitate” small group sessions?
- Who will design the cases?
- Who will facilitate “professional development”, and are they trained to?
Were some of these questions asked? Certainly not with any conviction. These are not administrative questions. They are academic questions. They are precisely the questions a professor is supposed to ask because they know the subject and the system. The old professor, for all his faults, would have asked them. They would have been difficult. They would have delayed the implementation. They would have demanded answers.
The new professor asked nothing. Perhaps not out of negligence, but because they did not know what to ask. They had no framework for judging whether the new system would work. So they accepted it passively, because they had no intellectual or professional foundation from which to resist. And the system was implemented in one push without any preparation involving human resource and infrastructure development, without a single pilot “block” ever being run to try and answer any of these questions.
What is happening now, after a few years of implementation of this new “modern” pedagogical system? We have talked about assessment elsewhere, and that really illustrates the broken spine of the system. But equally, so do students who attend lectures only to mark attendance and the “small group” sessions that are hardly organised at all. Attendance is marked, though. The most important part of their day in college is to know where to go to get themselves marked present next. And colourful timetables continue to be minted each week; attendance is marked electronically in many places, so students have to be meticulous about that, but nothing more.
The good students—we still have some—would still go home and read their books. Most, though, rely on the slim volumes that deal with older university questions and other available low-quality question banks which are quite enough for them to pass and make it to the next block at 50 percent aggregate passing. The tableau is complete. You will hear no complaints because the system serves the professional elite. But the question we need to be asking is what have we destroyed and what have we built in its place to pass down to the next generation. And in another decade, what would be the quality of the doctor serving in our wards and clinics? Left to its own devices, the system will inevitably crash sooner or later, and perhaps it is the ECFMG which might eventually complain that we are sending them poor raw material.
Redefining the Goal
What is reported here is not grist for the mill of an “accountability” bureaucrat who knows nothing about medical education and has never given a thought to what the medical education system in the province is for. It is also not to feed the hunger for scapegoating individuals that goes for governance in this country. The first thing to recognise here is that this is a structural problem. It cannot be solved by punishing individuals. Any solution that one might think of today would take at least a decade to implement. We need to think about how to make the transition in a way that does not dismantle the system altogether and does not lower the standard of medical education to the point where it endangers future patients, which is what is happening now.
The bottom line is that the system as it existed before this copy-paste “reform” did not have the material and human resources needed for it to even have a minuscule chance of success. And those deficiencies cannot be rectified by the stroke of a pen by shuffling around individuals or even by hiring and firing. Even though individuals in positions of authority and responsibility, including professors and health planners in the province, bear responsibility, penalising them will not resolve the issue. What is needed is a wholesale rethink of what the system is for and what goals we want to achieve through it, and what changes we need that justify reform.
The goal of our medical education system certainly cannot be meeting the requirements of a foreign licensing body at whatever cost. Because our medical education is not and cannot be a cheap pipeline to produce doctors for the affluent West. It is also not and cannot be one more pathway for upward social mobility for the middle classes who then insist on degrees that will enable them to move abroad. So the planners need to ask the question: why do we train doctors in Pakistan? And let the answer to that question be the guide to reforming medical education in the province and the country.