Tuesday, April 12, 2016

The Punjab Health system is a joke. And it’s not funny.




Every summer the beloved Khadim-e-Ala makes Punjab dance the dance of dengue. It involves massive expenditure on spraying the city, creation of specialized units with ICU’s, surprise visits to buildings and of course, banners boasting the efforts with his portrait in that oh-so-smug smile.

If only people knew what a joke this actually is. The sprays are of very little benefit against the mosquitoes, the specialized units and ICU’s overburden the already full infrastructure but of course, you can’t doubt the effectiveness of those banners. But that’s not the problem. The dengue fiasco is given attention only because of the hype attached to it. If the government really wanted to do something about preventable deaths in Punjab, dengue would be much, much down the order.

For instance, the first infection they should be concerned about is Hepatitis C. It infects between 2.2 to 14% of Pakistan, depending upon different populations. 80% of these people develop chronic hepatitis and while about 15% remain asymptomatic, 65% develop chronic active hepatitis C. These patients are heading towards miserable life leading to a painful death. If you take a mean infection rate of 8.1, that makes the number of patients around 1,05,30,000. That’s more than 1 crore people who are going to die a miserable death from Hepatitis C in the next 20 years. Now compare that to the fuss created about dengue that has a mortality rate of less than 1%.

You must be thinking, “why don’t we hear about this?”. And that’s where the joke lies. You don’t see or hear about them because we, the doctors do. These people come to ER’s in scores and bleed out in our hands. You don’t hear about it because they die a slow miserable death, which even their relatives seem to expect with time. That makes it a bad story for the media and where’s there’s no media coverage, there’s no government action.

But that’s not all. The number of patients who die from other chronic diseases like heart disease, lung disease, kidney disease and strokes is unimaginable too. Among these, deaths from kidney disease are the most preventable ones. These patients require regular dialysis and since the poor population cannot afford it, they simply accept their fate and die. Now they don’t die of their kidney disease, they die of their poverty. If we were a poor country, one would accept it. But knowing that the Punjab government is willing to spend billions on roads but none on dialysis centers, you cannot use the “poor country” excuse. Again, these are the preventable deaths we deal with every day, knowing there is nothing we can do about them.

If you argue that well, chronic diseases kill people either way, there is more. There is such a massive shortage of supplies and machines in hospitals that people die of benign diseases everyday too. People from as far as Afghanistan come to Lahore expecting the best care for their loved ones. But only we know the sad state of affairs of public hospitals. The ER they present to has ONLY one ECG machine for about 100 patients who are already stuffed on each other usually two on a bed (if they’re lucky). That leads to very late diagnoses of heart attacks and poor management of patients requiring cardiopulmonary resuscitation. Moreover, there is immense lack of drugs. The poor people come to these “free” hospitals expecting that every treatment is free of cost. But the reality is that only the medical expertise they get from doctors is free. And by free I mean actually free as up to 30-40% residents in training hospitals work without salaries. But that doesn’t matter, since what we want best for the patients is never going to happen. All of the guidelines go down the drain when the only antibiotics available in the hospital are Augmentin and Flagyl. When we make the patients buy a few of the drugs privately, they tell us they have exhausted their resources and wish to go home, again accepting their fate. Along with that, average wait time for elective investigations like an ultrasonogram is one week, a CT scan two weeks and an MRI twenty days. Of course, usually these patients die well before they’ll ever get to their appointment.

Every now and then, young doctors go on protest for better facilities for the patients and better incentives for themselves. But the government doesn’t seem to care since good hospitals don’t get them votes, good roads do. But the faces don’t remain the same. Most of the people fighting this battle have disappeared to better worlds with a vast majority going to Ireland, UK and USA. There’s more respect, better infrastructure, higher pay and quite honestly, less depression.

As for me, I had always been a strong advocate of staying in Pakistan and serving the poor. But after training unpaid for a year and knowing I wasn’t respected either way, I realized I was fighting a lost battle. I had been a straight A’s student in O and A Levels, studied on self-finance in a public medical college, passed national and international postgraduate exams and got a year of disappointment for it all. On the other hand, many of my peers (and now me too) were offered attractive resident positions in the US. While saying goodbye, I just wanted everyone to bear witness that I tried my best to stay in this system and fight for it. But the cruel truth is that nobody cares, not even me now.

Friday, December 19, 2014

My USMLE Step 1 testimonial

I recently took the USMLE Step 1 and got a good score by the Grace of God. A lot of people have been asking me about my preparation so I thought I should write a blogpost about it to help others.

What I used (I'll explain the brackets later):
1. UWORLD
2. First Aid
3. Pathoma (redundant)
4. Kaplan review books (redundant)

Total time: 7 months (effectively 5 months)

Kaplan period: (~2 months)
I started off in April with a late November plan to take the exam. Initially I sat down with the Kaplan review books for Step 1 because that's what everybody tells you to do. I completed Biochemistry and Anatomy in about a month each. Halfway through Physiology, I realized I was chewing more than I could swallow. I made the decision to abandon Kaplans altogether. These 2 months I regretted.

UWORLD: (~3 months)
I then started solving UWORLD questions for the sole purpose of learning. It was really tough for me since I usually got 40-50% right per block. But I didn't fret. I spent a lot of time on the explanations and studied UWORLD as my primary knowledge base. Once completed, I revised them completely a second time briefly (and a third time after my first FA read). Here I would like to mention that while UWORLD is a very good learning tool, I would not recommend it as an assessment tool. It is much harder than the actual exam and tends to ask questions in a very different way.

First Aid: (2 months till exam)
First Aid is the best prep you can get. Almost all of the exam is from First Aid. At first it may look like a strange jumbled up piece of crap but with repetition, you come to realize its greatness. It tells you everything you should know for the exam.The biochemistry part might be a little hard to fathom if your old knowledge is dusty. That's the only part where studying the biochem Kaplan felt relevant: to ease the transition to First Aid. I studied Pathoma for the system part of FA too but felt it was redundant and left it as well. The first read of First Aid is very important. You need to make sure you understand each and everything written there, even if you don't remember it later. I spent an average of one day per chapter for my first read, just making sure I understood everything. The second read should be to identify your weak points and stuff you tend to forget. With each subsequent read, you'd realize the problematic stuff gets smaller and smaller and you feel more comfortable with the book.

NBME:
NBME's are the best representatives of the actual exam. I took my first NBME 35 days out (NBME 11) after feeling a little confident with FA and got a 234. It was okay but I believed I could score higher. Still, I booked 27th November for the exam, being confident that I'd make it better in that time. 5 days out, I took NBME 16 and got 237. I was devastated. I felt like running around circles. I really thought I was going to improve but a score of 237 felt like I wasn't doing enough. My performance charts for both NBME's are shown. Then I had a Eurika moment when I was going through the explanations of questions. I realized that the exam is only as difficult as you make it to be. There was a question in NBME 16 that sounded like one of those that you feel like you have no idea about. And when I found the right answer, I realized that it demanded the simplest possible explanation for it. Bearing this in mind (and the thought that 240ish wasn't a bad score either), I gathered my confidence and went for the exam.

Exam day:
Naturally, I was extremely anxious but confident too. I took a lot of chocolates with me and some Panadol Extra tablets. I did the first two blocks in one go because I was feeling very confident. I did each question as quickly as possible while marking the doubtful/ difficult ones. Almost everybody I knew had problems with their timing and this is the best strategy to deal with it. With this strategy I always had 6-10 minutes surplus after the first go in each block. NEVER spend any time trying to confirm the answer in the first go, do it in the surplus time. My first block was really tough but the second one was okay. I took a 5-7 minutes break and did two more blocks. Then two more and then the final one. Briefly, blocks 1, 6 and 7 felt really tough and I had to mark 13-16 questions per block. Blocks 2, 3, 4 and 5 felt very easy and I marked 6-7 questions per block. After the exam I wasn't sure how I performed but I was confident I wouldn't get a bad score.

General advice:
1. Confidence is key. You should be confident that you know everything and are ready for the exam. Keep a date in your mind and stick with it. I had planned for the last week of November from Day 1. I got the triad of October-November-December but never once thought of delaying the exam.
2. Don't listen to people too much, believe in yourself. When I decided to go ahead with my last score of 237, a lot of people tried to convince me to delay my exam. Some even joked that I should leave the exam half-completed if it felt too difficult so I could reappear.
3. Never be afraid of a question. Always tell yourself that you know the idea behind the question and it's only a matter of getting there. You should never feel like "Oh my God, I never studied this/ forgot this". Most of the times, you can easily get the right answer in such questions just by simplifying it.
4. Try reading the last line of each question before reading the full question. It tells you what to look for before reading the question. This is very very helpful.
5. Keep yourself positive no matter what i.e. don't think you can't do anything but study. In the last month leading to the exam, I took a week off to study for FCPS Part I and went out with friends on several occasions including going to the cinema once.
6. People had scared me that anatomy is really tough on the exam and I should have studied a separate book for that. I did not feel so. While there were really tough scenarios, the questions were really simple. Most of it I knew from my knowledge of first year anatomy. You may study a separate book for it if you like but I wouldn't recommend it.

Eventual score and conclusion:

My actual score was 251 which I had a lot of trouble believing. It was definitely much higher than I expected. It shows that while NBME's are an essential tool, you should never let them keep you down. That being said, I would also like to emphasize that what's true for me, might not be true for you. Feel free to post any queries, I'd be happy to reply.

Best of luck!

Wednesday, July 4, 2012

A poem from a brilliant young doctor

The best graduate of Allama Iqbal Medical College for the session 2002 to 2007, Muhammad Zaman Khan expresses his feelings in a poem.

It is a great honor for me to introduce Dr Muhammad Zaman Khan, one of the most idealized personalities of Jinnah Hospital. Here is a glimpse of his excellence.


He expresses his feelings about the current situation in these words:

Aey Khadim-e-aala rehney de, is khidmat se bezaar hain hum
Gar jeena marna aik sa he, merney k lia tayyar hain hum
Ho malik arbon kharbon ke, aur 'Khadim' bhookhey nangoun ke?
Ye shaubada bazi rehney de, be-haal sahi, baidaar hain hum
Auroun ki to wa’da shikni par, cheekhay bhi bohat, chillaey bohat
Kuch yaad dilaya ham ne agar, to keh daala “ghaddaar hain hum”

Hum tairey a’qoubat khanoon main, goonjey hain hila kar bunyaadain
Hum cheekh nahi majbooron ki, Aa ghour se sun lalkaar hain hum

Ye ehl-e-sitam ham se larr kar, khud haamptay kaamptay phirtey hain
Lapkey to jala kar rakh dain gey, ae barq! Subak raftaar hain hum

Haan tuj se shikayat na-haq he, han tuj se taqaaza khoob nahi
Hum ne hi diye they vote tujhe, is zulm k bhi haq-daar hain hum
Wake up, Pakistan.

Tuesday, July 3, 2012

Salute to the Punjab Government

When doctors are emotionally blackmailed to work and arrested for non-compliance, it's time for them to go.

I am a medical student of Final Year in a public medical college. I scored straight A's in both O and A Levels and have been passing my annual professional exams in first divisions. So you can safely presume that I'm not retarded.

Not long ago, I made the very tough decision to enter this profession. Now, I was facing the very tough decision whether to serve my country or go abroad and earn a worthwhile salary. But this decision has been made for me, thanks to the Punjab Government.

Lets take a quick round-up of the doctors' strike:

  • Doctors went on strike for a service structure last year but the government merely increased the existing pays to cool the doctors down and promised a proper service structure.
  • February 2012: Supreme Court orders Punjab Government to give the doctors a service structure.
  • May 2012: Doctors continue to pursue the government to give the doctors a service structures or they'll call a strike.
  • 15th June, 2012: Doctors call an OPD strike. This doubled their duty as instead of dealing OPD patients in office hours, they were dealing with them 24/7 in the emergencies. Wards and Operation Theaters were running as normal too.
  • Media gives the impression "Doctors are on strike and patients are dying". The public and the government are convinced.

  • 1st July, 2012: YDA calls a meeting of it's general body to discuss the future of the strike.
  • 11.30 PM: Police raids the Services Hospitals hostels and arrests all doctors in their sight. Remember, these were the doctors who were resting after their Emergency shift and were going to work the next shift.
  • After this treatment, all doctors from public hospitals flee. 

Now let's answer a few questions in the minds of the public.

Where is the injustice?
In Pakistan, doctors do not have a service structure. What this essentially means is that after 5 years of MBBS, about 50% of the doctors will get a paid house job of Rs 22,000 per month (Yes! In contrary to the blatant government lie that doctors earn at least 60,000!). The rest will work as honorary house officers, not earning a dime for their 36 hours shifts. After the house job, he'll have to pass FCPS Part-I to get employed as a trainee. If he is lucky enough to get a paid seat, he'll earn Rs 44,000 per month. Otherwise, he'll have to work honorary till a paid seat is vacated. Once he completes 4 years of his specialization, his contract ends and he is unemployed again. Again, he can start working on an honorary post as a Senior Registrar till a paid seat is available. Yes, 5 years of MBBS, 1 year of house job, 4 years of FCPS and there is still no guarantee of a paid job. I personally know a Senior Registrar working for free, tell me and I'll tell you the correspondence.
So who are the senior doctors? Out of about 34,000 young doctors in Punjab, only 200 will get from grade 17 to 20 via Public Service Commission. Wonderful prospects there, you see.
If there's one thing the doctors are fighting for, it's equality. Equality with other professions of this country, if not any special treatment.

What about the taxes spent on doctors?
Hardly any money is spent on doctors in reality. The medical teachers don't earn much, and facilities are in alarming state. Regardless, first the 90% female doctors who don't even practice after graduating should be held accountable instead of the ones working tirelessly in the wards. So please, think before you speak

Isn't this country too poor to afford this service structure?
No. Healthcare is a top priority in all developed countries. But we are an unfortunate lot where the state has failed to give the doctors a service structure for the past 65 years. Here, Rs 2 billion are spent on laptops to support political campaigns but we are too poor for an efficient healthcare system.

What do doctors earn in other countries?
Doctors mostly go to the gulf, US, UK or Australia.
KSA- 4,000 riyals onwards.
USA- $10,000 onwards.
UK- 2,000 pounds onwards.
Australia- $7,000 onwards.
And just for interest, Indian doctors earn 1,70,000 Indian rupees. That's more than PKR 2 lacs.

Why don't they leave then?
This, just like our Ex-Prime Minister, is the million dollar question. The doctors are putting their patients- the poor Pakistanis ahead of their prospects to earn abroad. But they are frustrated now. They want a better future in Pakistan, or else other countries will sweep this country of it's finest minds.

As for me, I don't see how things are going to get any better for doctors in this country. Naturally, I have planned to apply abroad. And I'd like to salute the Punjab Government for helping me and many others like me to make this decision.

Thursday, May 5, 2011

Shh... Don't tell the Taliban


While contradicting statements keep coming, it's not that difficult to make out the actual story behind Osama's death.

Let's analyze the story at hand. The following are a few key points we're told:

1. Osama lived nearby the Pakistan Military Academy for years where every nook and cranny is cleared.

2. ISI, rated among the top intelligence agencies in the world didn't have any clue of his presence in such an area.

3. Four combat helicopters entered the Pakistan airspace up till the PMA (about 300 km assuming they came from the Afghan border) and Pakistan didn't have any idea.

4. There was a 40 minutes' operation near the PMA and still, Pakistan didn't have any idea until after they left.

5. All this happened while PAF didn't have any idea, though with all their state-of-the-art technological equipment, their response time to an airspace violation is 5 minutes.

6. The government, army and ISI, all made public statements/ apologies about their ignorance.

The response in Pakistan:
  1. Confusion and insult for the majority.
  2. Protests, funerals and tears by some religious parties.
  3. Terrible threats by the Taliban to attack Pakistan in every way.

Now, I'd like to bring to your attention a tweet of a journalist in the Guardian.
"Pak diplomat just told me: we have to play to our people's sensitivities. of course we were involved but we can't admit it"

Add that to the possibility that we were told about our involvement and imagine what the response would have been. I rest my case.

Sunday, April 10, 2011

The Accursed Child

In this modern era where cell phones and Botox change our lifestyles, our thinking is still not much different from the dark ages.

If you browse through any Urdu newspaper to the classified section, you might come across an ad that says "بیٹا" (son) in a big font. If you read, it says "Insha-Allah beta ho ga" (God-willing, it'll be a son). Not just in the newspaper, these people have started sending spam text messages like "Boy or girl, choice is yours". Staring us in the face, this is a gruesome reality that tells us our thinking has not evolved at all.

The stigma attached to the birth of a female child is undeniable in our society. No matter which class you belong to, every family (with both father and mother) wants their next child to be a son. Men go as far as marrying multiple wives just because they believe a particular woman is "meant" only to bear girls. So much so, that I once heard a woman respond to the news of a female birth as "Oho! Kuch nahi hota" (Oho! It's okay). For all those protesting against the honor killings of women in the rural areas, I ask the question, why do you ignore those lamenting the birth of girls in the first place in the urban areas?

One of the major reasons for this stigma, which again no one talks about, is the tradition of dowry. This tradition is in direct contrast to the teachings of Islam which in fact make it obligatory for the groom to pay the bride upon marriage in the form of Mahr. The moment a girl is born, the first thought in her father's mind is about her dowry, not her name. I have seen well-educated and noble families sending lists of articles they wanted as dowry with a bride. A family, on average, spends more than one million rupees ($11,700) to marry their daughter off. This is in sharp contrast to the generally accepted limit of Mahr, which is one month's salary of the husband. And even that is spared "willfully" by the bride. Furthermore, Mahr is often mistaken as an amount that is to be given upon dissolution of marriage. Ergo, the following consequences.

In the major cities, among the 1210 infants found dead in 2010 by Edhi Foundation, 9 out of 10 were female.

Even though the ratio of male: female is 1 male/ female upon birth, it rises to 1.06 males/ female for the ages 0-14 years.

Along with this, we hear stories of both blatant murders and increasing burning "accidents" right after marriage.

All said and done, the future is still a big question mark. Such thinking and associated traditions are engraved deeply in our minds generation after generation. As long as the stigma attached to the female child is there, it'll show our immaturity as humans, let alone as a nation.

Sunday, April 3, 2011

Are we human, or are we doctors?


A recent study has shown that doctors have stomachs, reproductive organs and families. This is an outrage and will not be tolerated by the government.

I am a medical student in a government hospital. I am witness to the doctor-government saga and would like to share the facts which lie behind the propagandas of both the doctors and the government.

Firstly, this is not a protest. This is a breaking point. The doctors have been protesting for many many years and the government paid little, if any, attention. The facts underlying this event are actually beyond the comprehension of anybody who has not been to the wards of the hospital but I will try my best to explain them.

The wards:
The patients outnumber the beds in such a way that there are upto 3 patients on one bed at times. The paramedics and nurses are understaffed. But there is an ample number of doctors which I'll explain why.

The dysfunctional system:
The first question in a medical student's life is where he'd work after MBBS. This is not a joke. An estimated 1500 doctors leave Pakistan every year to work abroad. This year, 5000 post-graduate trainees are estimated to leave. This is not a small number. These are the cream of the doctors attracted by different countries including the Gulf, US, UK and Australia. These doctors do not return. The few who do, are appointed professors, who then start private practice for the elite. They are mere parasites with no intentions of "helping humanity". The doctors who work hard for decades in government hospitals hardly get any professors' posts and hence, not that good private practice either.
The junior doctors suffer the most. There are about 30-40 house officers in every ward among which only 8 are paid and the rest are unpaid. These are doctors who have studied for five years without any social life and now getting Rs 18,000 as house officers, ie if they're lucky enough to get the paid job. After a year of house job, they start their fellowship for which they have to appear in the FCPS part I (Fellowship of the College of Physicians and Surgeons). About 12,000 graduates appear in all disciplines in FCPS-I and 250 are declared successful. These 250 then apply to the hospitals for fellowships. At a given time, 10 or more post-graduate trainees are to be present in a ward. Among these only 8 are paid at Rs 16-22,000. After 4 years of training, they are supposed to leave the hospital and appear in FCPS part II which is the toughest exam in the medical field. The few who manage to pass it and have a strong backing from someone of power, are hired as Registrars in government hospitals at a pay of Rs 30,000. Here on, their pay increases on yearly increments and their seniority increases on political backing.
Now, a doctor of the age of 35 (if he aced every exam in first attempt), is earning Rs 30,000. With that money, he has to run a family. During the past 15 years, he has spent his days and nights in hospitals and served patients for 10 years. As a house officers he has worked non-stop shifts of 36 hours. Side-by-side, a matric-pass driver is earning 35,000 in a government office. The bank the doctor goes to to collect his pay has a security guard earning more than the doctor. If he goes to get a car on lease, the bank tells him his monthly salary needs to be at least 40,000. If you do not understand the injustice here, there is no point of carrying on.

The conflict:
Towards the later part of the strike, the government agreed to increase the salaries of the young doctors (house officers and trainees) to Rs 28,000 and Rs 44,000. This was injustice to the senior doctors who in this scenario would be earning about as much as house officers and lesser than the trainees. This was unacceptable to the doctors and hence they refused.
Currently, the Professors, Associate Professors and Assistant Professors are running the hospitals. Out of respect, the Senior Registrars are visiting to help their seniors and the patients from time to time but not on a regular basis.

The future:
The doctors have handed over their resignations. There is no point in a compromise on their side because they have better options elsewhere (even as a driver or a police constable). They would now be looking for alternative jobs eg private hospitals which pay enough money for a doctor to make ends meet. Others would apply abroad where their talent is appreciated (in the US, a trainee earns about Rs 300,000). The government is running out of options to run the hospitals. They are hiring house officers as medical officers (equivalent of trainee without FCPS-I).

While people play the blame-game, the general public is suffering. It is easy to blame the doctors but for that you'd be denying them basic human rights. They have the right to work or resign. If the government is not able to give attractive packages to the doctors while they enjoy in mansions, the doctors cannot be blamed for looking for a way to make ends meet for their families. They have compromised for years, blackmailed emotionally not to do anything lest patients will suffer. But now they have reached a breaking point and given up.