Doctors in the dock

By Zubeida Mustafa
Source: Dawn

The woes of the health sector in Pakistan are unending. It is strange that given the large number of people affected by the government’s health policy – the people, the medical practitioners, the pharmaceutical manufacturers, the health institutions, the local bodies, the civic agencies responsible for primary and community health – the various issues of concern which crop up from time to time are not taken seriously.

We are constantly being told that a new national health policy will be announced soon. But, (although Sindh has announced a provincial health policy) that beguiling document does not see the light of day. And the masses continue to suffer.

Standard health care is not available to the people at affordable prices. Those who are affluent and can afford it have access to excellent health services in the private sector.

In fact, with increasing privatization people can also exercise their choice in deciding on the treatment they want to take. But those who are of modest means can be doomed.

Not only are they fleeced for whatever treatment they receive. Their condition might actually deteriorate because of the wrong treatment given to them by a careless or an ignorant health professional.

Although from the public’s point of view, both access and affordability are as important as the quality of care a patient receives, here we will focus on the quality factor.

This matter has emerged as a subject of debate in public forums for two reasons. First, since November the accrediting body of the medical sector, the Pakistan Medical and Dental Council, has come into the limelight for what is perceived to be the government’s interference in the Council’s composition and working.

The second event which should have drawn public attention to the standards of health care being provided in the country was the “alternative national health policy” that was unveiled by the Pakistan Medical Association (PMA) in January.

Its emphasis, among others, was on ensuring the quality of medical education and health care provided to the people. It is a telling verdict on our health system that the president of the PMA expressed strong concern about the 600,000 quacks allowed to practise freely in the country but more than that about the “glorified quacks” being produced by many medical colleges.

All this just confirms that the PMDC has fallen short of its responsibilities. At present it is a top heavy body with a governing council of 53 members, most of whom are ex-officio government officials (principals of public sector medical colleges, health secretaries representatives of public sector universities).

All that these worthies have been doing is to issue licences to the doctors who graduate from the recognized medical colleges in the country and to prescribe the requirements of space and staff of a medical college, the curriculum, time of examinations, qualifications of teachers and examiners and so on. It is assumed that if quality medical education is ensured the products of that system – the doctors – will also be competent. But this approach has not safeguarded the interest of the public as the PMA’s alternative health policy confirms. Simply licensing a doctor to practise does not ensure that he will continue to upgrade his education and knowledge as the concept of continuing medical education expects him to do.

It also does not ensure that he will be ethical, will follow safe methods and observe the Hippocratic oath he has supposedly taken at the time of graduation. It is said that the primary function of the PMDC is to safeguard public interest. Given the chaotic conditions in the public health sector and the sufferings of the common man, it is plain that the primary interest of the patients is not being protected.

The impression is that the PMDC has emerged as a body to protect the rights of the health professionals, even at the expense of their patients. This is deplorable. Similar regulatory bodies in other countries are assigned a different role altogether.

The General Medical Council of the UK defines its function as maintaining “the standards the public have a right to expect of doctors. We are not here to protect the medical profession – their interests are protected by others. Our job is to protect patients.”

The Accreditation Council of Graduate Medical Education of the US states, “Our system of medical education relies heavily on considerable public funding. We, therefore, need to be accountable to the public in terms of both meeting public needs and preparing well qualified new physicians in the most effective way possible”.

Isn’t it time the PMDC reviewed not just its composition but also its functions? Apart from some entrenched elements in the public health sector, no one disputes the need to include representatives of the private medical colleges on the council.

It is also important that some members of the lay public, the users so to say of the health system, are also taken in the council. The General Medical Council of the UK, the model on which PMDC was set up in 1948, has changed.

Today 14 out of its 35 members are from the lay public and appointed by the Privy Council, 19 doctors are elected by the doctors on the register and only two academics are appointed by medical colleges.

The PMDC should now also be more concerned about the competence and ethical behaviour of the individual health professionals. Prof S. Naeem Jafarey, a senior member of the medical profession in Pakistan and Adviser at the Ziauddin Medical University, proposes, “to ensure a uniform standard among graduates from different universities, the PMDC should hold a national licensing examination.

A licensing examination is not a novel idea. In most countries the right to practise is not automatically granted on acquiring the basic qualification. For the last 15 years PMDC has been holding a licensing examination for foreign graduates. It already has the expertise of holding a licensing examination.”

Prof Jafarey – there are many other doctors who share the same view – is also concerned that “at present there is no monitoring of the quality of medical practice and there is no mechanism to redress complaints of ‘poor’ quality of care”.

The fact is that the press reports the malpractices that are rampant in the medical sector only when a major scandal occurs. The day-to-day behaviour of the medical professionals is never reported – though people who have suffered at the hands of their physician/surgeon do grumble about it.

It is not known whether it is the PMDC’s responsibility to provide protection and redress to patients from doctors who are “dysfunctional and who, by reason of their misconduct, ill health or poor performance, put patients at risk of harm” – to borrow the terms used by the GMC of the UK in a report.

If the PMDC’s ordinance does not empower it to receive complaints from the public, investigate them and cancel a doctor’s licence if he is found guilty, it is time this amendment was made. If this provision is there, we do not have much evidence to prove that this responsibility is ever taken up.

Here it would be timely to point out that the health professionals’ role vis-a-vis their patients is not to be taken lightly. They should every day before they begin their work recite the Hippocratic oath which they were supposed to have taken when they graduated because many of them have forgotten them.

They should specifically remind themselves of this clause: “I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.”

It is also pertinent to remind them of a new version of the oath which says, “I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability.

My responsibility includes these related problems, if I am to care adequately for the sick.” It also reads, “I will prevent disease whenever I can, for prevention is preferable to cure.”