Are you a young doctor in Pakistan? Run.

Are you a young doctor in Pakistan?

Underpaid, overworked, and with surprisingly few options available the best financial decision for young doctors in Pakistan is to leave

By Bakht Noor

Are you a doctor in Pakistan? Have you just graduated and are about to begin your house job? Or are you possibly in your last couple of years of med school? For that matter are you even a mid-career young-doctor working as a PG Trainee or an MO? If any of these apply to you, we have a piece of advice: run. Give whatever test you need to, find whatever opportunity you can in a different country, take your skills, and leave.

Young doctors in Pakistan are being robbed blind. As one of the most highly skilled professionals in the country, they are overworked and underpaid. And unless you have either the right connections, a wealthy background, or access to the correct institutions setting up a private practice (which is where the money is at) is next to impossible.

A bad financial decision

There are two kinds of medical students. Those that go to government medical colleges and those that go to private ones. While the private ones are dreadfully expensive, costing on average Rs 5-6 million for a full ride through five years, the pay-off is far from immediate and difficult to achieve. And even for those studying on subsidised rates at government colleges the path to financial stability is paved with uncertainty.

After MBBS, a student starts working as an HO (House Officer)- what is commonly known as House Job. A fresh graduate isn’t licensed to be a medical practitioner. The Pakistan Medical Council (PMC) issues a temporary licence. An HO becomes an MO (Medical Officer) if they begin working immediately after the completion of their House Job. In case they pursue further training (i.e. specialisation), they’re known as PGs — post-graduate trainees.

“The stipend for an HO is fixed at 65,000 PKR. This is morbid given the amount of labour they’re required to put in. Not only are they training as doctors but also providing care to patients”, explains Dr Syed Maarib Iftikhar, who also runs advocacy group Reformistan.

Compare this starting salary to other less skilled professionals. A fresh undergrad from LUMS with no experience has an average salary of Rs 75,000 per month. If you compare their skillset to that of an MBBS graduate, their salary seems ridiculously high. A fully trained doctor has a fixed stipend of Rs 65,000, and this too they don’t get entirely or get cut in smaller cities. On the other hand, a fresh grad from LUMS that has studied marketing might

be able to land a job with very little experience at a consultancy and make twice or even thrice that as a starting package.

While abysmal starting salaries are a regular feature in the medical profession all over, the prospects of this rising are also bleak. The pay scale only improves once they become consultants — which may take up to 10 years. And even the path to becoming a consultant is uncertain. It requires a certain degree of specialisation that requires time to study. For a young doctor that does not have family money, the salary that an HO or an MO gets is not enough to live sustainably and also have enough time to study and improve their standing.

The stipend doesn’t cover anything- the cost of rent, fuel, utilities, absolutely nothing. HOs who don’t immediately opt for specialisation become MOs (medical officers). This is basically a non-trainee job without specialisation. “They’re the most severely underpaid. Their salary varies according to the hospitals they work at and the number of hours they put in, but a general estimate would be 60-65K.”

This is also a gendered domain as mostly female doctors work as MOs. Due to societal pressures of marriage and homemaking, women feel restrained from pursuing specialisation and often settle as MOs. Women doctors in Pakistan are more handicapped in terms of personal finances. They mostly lack the luxury of time and are permanently deterred from becoming consultants. Despite the rigorous training and education, 60-65K is the extent of their finances in the field.

Many PGs (post graduate doctors) opt for specialisation, which is the process of gaining expertise in a particular medical field such as neurology, hepatology etc. Training PGs are better off at government hospitals, usually receiving a monthly salary of Rs 100,000. However, private hospitals pay considerably less. In fact, many PGs are unpaid. The stipend for PGs is even more appalling. They’re paid a monthly amount of Rs 90,000 in the government sector, and Rs 35,000-45,000 in the private sector. It takes 4-10 years to complete training.

They still continue to work in hopes of building their CVs as trainees and ultimately starting consultancy after 4-5 years. Becoming a PG is also very competitive.

“It is very difficult to find a position here and the pay is as low as 65000 PKR, even less than the HO stipend. It’s a painstaking process too. PGs are required to pass 2 exams, one in the first year of training and second in the last. The second exam is really difficult to pass and many people aren’t able to make it. The system of PG-training is very unfair and limited. Graduate trainees are often not paid and I feel disrespected on their behalf. This gives a clear signal that the country doesn’t value their education. You don’t get the compensation that you deserve,” explains Dr Maarib.

Is money the only problem?

Money looks ridiculously bleak here. However, it isn’t the only problem. Speaking to Profit on the condition of anonymity, a recent graduate from CMH Lahore said that the Rs 65,000 stipend wasn’t the only issue for young doctors. “You could still make an argument for the low pay because the house job is a part of one’s professional training and is considered an education. But the amount of work that HOs are expected to do is insane — a lot of hospitals only run on the basic labour that HOs provide which is very much skilled labour,” they explain. “This involves 100-120 hours of work per week, which is unheard of anywhere else in the work. It obviously can’t be justified financially. However, people don’t really care about the stipend here. It’s seen as a part of education, one really can’t practise medicine without this.” This, of course, is part of the problem. A lot of the private students that go to colleges like CMG go after completing their A levels and come from families that can afford to pay the fee for a private college. For them, it is possible to treat the stipend as extra pocket money and bide their time until they can specialise and open their own practice and then make a lot of money. But consider for a moment a young doctor that does not have those kinds of resources. Made to work over 100 hours a week, they will not have enough money to make any savings and not enough time to prepare for examinations that may allow them to specialise and make more money. They regularly thus get stuck as MOs or PG Trainees making very little money for the amount of highly skilled work they do. According to Dr. Maarib, the main problem is the culture that you find in med schools and hospitals. “It’s extremely regressive and exploitative. It’s ironic how people who claim to take care of your mental health are the ones to mess it up. Junior doctors especially face a hostile environment. There is no sense of mutual respect and they’re expected to keep their heads down and be okay with the extremely toxic work environment. This adds to why many young doctors are adamant on leaving the country,” he says. “The hours that they’re expected to work are gruesome, and that too without a break. The doctors are severely overworked and underpaid. You’ll run into doctors who haven’t slept in 40 hours. This is unfair, particularly in a profession that caters to human life. It explains why doctors in outpatient departments are often impolite with their patients. They’re in a constant state of stress and anxiety. This creates a negative cycle which directly impacts patient care.”

The system of PG-training also thrives on people-pleasing and running favours for seniors. “It’s a deeply exploitative system. The trainees need letters of recommendation from their consultant to set up their own practice. The LoRs depend on how much the trainees can keep their consultants happy. This gives consultants the blank check to exploit junior doctors and get away with it. The junior doctors are trapped essentially. They’re always trying to please their seniors and run extra favours for them. This isn’t professional and shouldn’t be there. Slander and abuse is casually thrown at them. They’re basically helpless as they need to complete their training. There’s no one they can report to and reporting itself is a career suicide for them as it’d jeopardize their LoRs. Junior doctors have to endure a lot, and none of it is worth it.”

“The work environment is much kinder abroad. The NHI (National Health Insurance) already grants you leave for a multitude of reasons. You can call in sick and not be questioned. Other countries are far more generous in taking care of employees’ mental health. You don’t find that here.”

Moreover, training isn’t uniform here either. According to sources, “the Central Induction Policy (CIP) was applied to the central body, PMC. It entailed that merit would decide where people would go for training. However, some points were very absurd. In order to promote doctors in BHUs (Basic Health Units in rural areas), MOs would get extra points. Bribery was rampant here. MOs would pay 20 lacs to work at BHUs to earn extra points. These points would guarantee them a training spot later. All of this was a big mess. Principally, it’s good that the government is facilitating you to work at BHUs. Yet, it’s fundamentally wrong if one has to pay to get there.”

“The place where you train is what you’ll be essentially. Med school isn’t that important as it doesn’t teach the practical stuff. You basically learn to become a doctor in your training- and training isn’t uniform. It varies across institutions. You’re left at the mercy of trainer doctors. They tend to have inflated egos, which is a huge put-off for me. “Then there’s of course the financial aspect. The country is ravaged by economic turmoil.”

A saturated profession?

An HO (house officer) at Shalamar Hospital in Lahore reported that medicine has become a deeply saturated field in Pakistan. It’s extremely difficult to find admission without contacts and/or money. Even after admission, the merits are so high that students are unable to find seats at the department of their choice. “Only 1-2 seats were available for surgery this year.”

However, according to the CMH graduate, medicine as a profession isn’t saturated in Pakistan. “There’s an infatuation with medicine at large at a social level. People would go to any and every length to become a doctor. The problem is that the infrastructure isn’t developed to that extent. It can’t cater to so many people. Pakistan still has a strikingly low number of doctor to patient ratio.”

An added layer to this is that doctors are concentrated in urban areas. According to Dr. Maarib one doctor would be catering to an entire village. “Even hospitals in Lahore such as Mayo Hospital are inundated with patients coming from all over Punjab. Patients in critical conditions often have to wait for months to get their surgeries done. New hospitals haven’t been built to accommodate the population increase as well as the growing number of doctors. In fact, many doctors remain unemployed.”

It starts very early

It all traces back to the very beginning. Every year, thousands of students from across the country appear for the MCAT (medical college admission test) aspiring to become successful doctors. However, the admissions process is wracked by uncertainty and inconsistencies. “The admission process is problematic as a whole. It’s revamped every year, which creates so much confusion and anxiety. There’s never a fixed date for admission and examinations. There’s never been a single policy. Everything is in a state of limbo. You don’t know what’s going to happen next,” says Dr Maarib. How does the admission process work? “There are all sorts of medical colleges. However, the rate at which Punjab’s population has increased over the years doesn’t match the number of hospitals and medical colleges functioning in the province. The number of government colleges since the 1980s has remained constant. Though private colleges have been emerging, they are limited to a certain financial class. A lot of people can’t afford private medical colleges. Furthermore, even private medical colleges don’t follow a fixed set of policies. They find loopholes within the pre-existing policies despite claiming their accordance with the PMDC. There’s a lot of grey area here too.” A recent graduate from CMH medical college detailed the structural inconsistencies within the PMC (Pakistan Medical Commission). He reported that when he started pursuing his MBBS six years ago, the MCAT used to be administered at the provincial level, “it didn’t account for students coming from the A Level stream, and only benefited students coming from FSC. The admission process was extremely biassed, it only catered to students who had studied the local curriculum.” As a result, a few students filed a case in the court. The court ruled in favour of the students: CMH agreed to accept other scores in lieu of this test. However, the PMC declared that they wouldn’t consider this decision and filed another case at the High Court, which the students lost. Ayesha A. Malik, the first female Supreme Court Judge of Pakistan was the presiding judge at the time. Then, there was an appeal against this at the Supreme Court where Saqib Nisar ruled in favour of the students, “as a consequence of this development, I was accepted at CMH. My aggregate percentage was higher, 94%.”

“Despite the legal battles, the systematic inconsistencies continue to prevail. The PMDC (Pakistan Medical Doctor’s Commission) was abolished and reinstated as the PMC (Pakistan Medical Commission). This created legal issues as the parliament didn’t approve of the ordinance. The PMDC nevertheless became irrelevant and the PMC was championed by the PTI government, under the leadership of President Arif Alvi who himself is a dentist by profession. The PMC decided against a provincial-level MCAT and introduced a national-level computerised test instead. Again, this was marred by issues and led to corruption.”

“The system was rigged. Candidates would pay off the people conducting this test. They’d escort such candidates to separate rooms and provide answer keys for the test. It doesn’t stop here. Colleges were offering seats to candidates in lieu of 30 lac rupees. LMDC would call students, saying that if you pay us, you’d get a seat. The only institutions not accepting student bribes were Shalamar and CMH,” our sources add.

The new government has again reverted to PMDC. These policies indicate that the admissions process has become more classist over subsequent years. Government institutions- very few in number- are already saturated. Private institutions are overly expensive and thereby exclusive to a certain social and economic class. On top of that, irrespective of merit, most require that you pay your way in. The system is deeply exploitative from the get-go.

Issues with the education system

However, getting in isn’t the only issue. The educational system itself is deeply flawed. The curriculum is outdated and nearly obsolete. There are huge gaps between theoretical learning and practical training. A recent CMH graduate presently preparing for exams to pursue medicine abroad says, “once I started preparing for foreign exams, I realised how far behind we are. At med school, we are just rote learning material for the initial years, and then expected to reproduce textbooks in exams. There’s a huge gap in conceptual learning and knowledge application. You can draw a parallel between studying medicine in Pakistan and the local matriculation system. As opposed to the O/A Level system where you’re required to apply concepts in exams, the matric/ FSC system is only fixated on rote memorization. It doesn’t teach you how to apply theoretical knowledge to practical situations.” Not only is medical education highly expensive, it’s also redundant.

The policies regarding the curriculum are in need of drastic change. Dr. Maarib adds, “the increased emphasis on rote learning doesn’t develop clinical skills. In Pakistan, only the Aga Khan University focuses on the development of clinical skills. It operates very differently compared to other medical colleges in Pakistan. Students are introduced to clinical wards from the beginning and start assisting surgery as soon as the third year. You don’t find this anywhere else in Pakistan. There’s an obsession with cramming over clinical work, which wastes time and is simply not practical.”

Furthermore, med schools prioritise the wrong things. “Medical colleges in Pakistan are obsessed with attendance. You don’t see this abroad where most lectures are available online. Attendance is only compulsory for ward hours and clinical rotation. In addition to this, the way in which classes are structured is objectionable. You find 150 students cramped in a classroom, with absolutely no sense of what’s going on.”

A fresh graduate from Shalamar Medical college adds, “working at the field requires much more unlearning and relearning than it should. Training abroad is also therefore significantly better.” The quality of education therefore can’t be justified by education costs.

In discussing the college fee, the CMH graduate said, “the fee was capped at our time. The Chief Justice set the cap at 8.5 lacs for a year. Colleges claimed that it was impossible to budget and carry operations under this amount. This also led to a hike in medical situation, due to which a settlement was reached. The settlement entailed that colleges wouldn’t charge through bribery and adhere to the amount they’d negotiated on. Now the per annum fee is way out of hand. Accounting for inflation, it’s as high as 24 lacs. Most private colleges charge between 16-17 lacs.”

Long story short, if you’re a student at a private medical college, you’re paying 16-17 lacs per annum, almost 85 lacs in total for education that’s practically useless. What’s the point of paying 85 lacs for a 5-years MBBS program when most of your learning will happen on the field? And if you are the kind of student that has made it to a government med school against the odds and without familial wealth of any significance, then the road ahead will be arduous. That is why the best course of action would be to take your skills and go somewhere they are appreciated. n