An estimated ten to sixteen percent of
the general population suffers from mild to moderate psychiatric illnesses.
One percent of the population suffers from severe mental illnesses. The
rates of depression in Pakistan are very high, estimating between 30 to
50%. Nearly 16 per 1000 of the children between three to nine years of
age suffer from severe mental retardation.2
There are many possible causes which contribute
to high rates of mental health problems in Pakistan, including; interfamily
marriages, high rates of birth injuries, economic decline and high rates
of unemployment, rapidly changing social and cultural values, fragmentation
of the family system, and loss of religious values. Prejudices based on
race, culture, sects and language have resulted in conflicts among people
and have caused a sense of insecurity. The last two decades have seen
mass migration of people from rural to the urban areas. This has inevitably
led to a number of people living without social support. During the same
period Pakistan has experienced non-stop terrorism.
Psychological and emotional help to the
general public is provided by faith healers, spiritual leaders, homeopathic
doctors, magicians, Hakims (those who claim to practice Greek medicine
or Indian medicine), palmists and other fortune tellers, who regularly
advertise in the newspapers as well as in the form of graffiti. They offer
help for sexual, psychological and relationship problems. The irony of
the situation is that, the limited number of mental health professionals
wouldn’t be able to cope, if these people stop working!
There are currently four mental hospitals
in the country, while another 20 units are attached to the medical colleges
in the government sector. Medical colleges in the private sector offer
nearly the same number of psychiatric units. The standard of care varies
among different government sector medical colleges. This gap widens among
the private sector medical colleges. Most of the medical colleges in the
country, including those in the public sector, have psychiatry departments.
Currently there are 131 districts in Pakistan. Each district has a hospital
attached which also have mental health units. However, basic health units,
which provide primary care to rural population, do not have mental health
professionals attached to them. Patients with psychiatric problems can
directly present themselves to the out patient departments of district
and teaching hospitals. Gadit and Khalid2 estimated there are nearly 2,070
psychiatric inpatient beds in different mental hospitals throughout the
country, and another 870 in different teaching hospitals. Public sector
contributes another 600 beds. According to a WHO estimate, in 2001, there
were 320 psychiatrists based in major urban centers.3 Most
of these are trained in the west.
Psychiatric Training
Undergraduate training - After ten years of school and further two years of college education,
those with nearly eighty percent marks can apply for a place in a medical
college. Those who pass an entrance test get admitted. The medical course
lasts for nearly 5 years in Pakistan. In the first two years
(pre clinical years) students are taught the subjects of anatomy, physiology
and biochemistry. During the remaining three years (clinical years) they
are taught Pharmacology and therapeutics, forensic medicine and toxicology,
surgery, medicine, pathology, community medicine, obstetrics & gynecology,
otolaryngology and pediatrics. Students also train on hospital wards.
In addition to the above mentioned disciplines, students also train in
related medical and surgical specialties. The students are examined through
four professional examinations. One conducted after every year, except
the first one which is conducted after the year one and two. During their
final professional examination, students are assessed through an essay
paper and a clinical examination in the following subjects; medicine,
surgery, obstetrics & gynecology, otolaryngology and Pediatrics.
Psychiatry is recognized as an important
part of the curriculum by the Pakistan Medical and Dental Council (PMDC).
However, there is a lack of uniformity over psychiatric curriculum in
different medical schools.
In the absence of a prescribed curriculum by the PMDC, teaching of behavioral
s ciences varies widely among different medical
schools. In the final year, students spend six to eight weeks on psychiatric
wards. Students also receive a few theoretical lectures in their fifth
year of the medical college. They are examined in their final exams, in
the subject of psychiatry through one optional question, which is part
of an essay paper in medicine. Most of the junior doctors decide to work
as general practitioners or family physicians after their training. There
is no structure to general practitioner training. Most junior doctors
devise their own training, and work in two or three specialties they think
are important for their future work. psychiatry rarely catches their interest,
as they do not realize its need at this stage. Niaz, et al,4 in a survey of medical students in Karachi, concluded that, nearly 32%
students believed psychiatrists are not respected and 42% believed that
they earn less money than other specialists. More than half (54%) of the
students were reluctant to choose psychiatry as a career. Clinical students
held positive views about psychiatry than pre-clinical students.
Postgraduate Training - To be a practicing psychiatrist one needs to have a degree recognized
by the Pakistan Medical & Dental Council (PMDC). The postgraduate
degrees and diplomas can be roughly divided into major diplomas and minor
diplomas. Those with major diplomas only, can work in teaching hospitals
as psychiatrists. Others can practice psychiatry privately or even in
the district general hospitals.
Postgraduate medical training in Pakistan
is regulated by the College of Physicians and Surgeons of Pakistan (CPSP).
The college offered membership (MCPS) and fellowship (FCPS) exams in psychiatry.
The MCPS exam was stopped a few years ago. This probably means an even
smaller number of psychiatrists in Pakistan in the future. The college
looks at FCPS as an exit examination and doctors can practice psychiatry
after that.
The College of Physicians and Surgeons
of Pakistan is also responsible for accreditation of training institutes,
and of setting curricula for different specialties. Out of all the registered
health care specialists, nearly eighty percent are trained by the college
of physicians and surgeons of Pakistan. By March 2001 the college had
awarded 179 FCPS diplomas and 47 MCPS diplomas to psychiatrists.
Some universities offer postgraduate qualifications
as well. The Punjab University offers Diploma in Psychological Medicine
(DPM). Another diploma, Diploma in Psychiatric Practice (DPP) was a joint
initiative between Egypt and London. This diploma was however, stopped
the last year. A research degree, Doctor of Medicine (MD) is being offered
by some Universities. However, there is currently no university degree
which is considered equivalent to a CPSP degree.
The FCPS exam has two parts (FCPS). The
eligibility criteria for the part one exam include; MBBS or equivalent
qualification registered with the PMDC and one year house job (internship
in the USA) in an institution recognized by the CPSP or PMDC. The house
job does not need to be in Psychiatry. The exam is held three times a
year. Theory examinations are held in nearly ten different cities. There
are three overseas centers. Exams are conducted in English language. The
examination consists of two theory papers, each consisting of one hundred
Multiple Choice Questions (MCQs). These papers test candidates on, general
anatomy, histology, human development, neuroanatomy, nNeurophysiology,
neuropathology, psychopharmacology, psychology, genetics as well as statistics
and epidemiology.
The candidates have to undertake four
years training in a recognized institute before they can take the part
two of the FCPS examinations. The candidates have to register for training
with a tutor approved by the college in an accredited department of psychiatry.
The tutors have the responsibility to supervise training in accordance
with the college standards. Tutors are psychiatrists with a higher degree
and at least five years of experience as a teacher and a consultant in
a medical college. There is prescribed training for tutors in teaching
and research methods before they are registered as tutors. The training
is arranged by the College of Physicians and Surgeons of Pakistan, in
collaboration with WH0.
The candidates need to submit a logbook,
proof of attendance of workshops and proof of acceptance of research dissertation
or alternatively two publications in national journals in order to be
able to sit for the exams. The candidates should have attended workshops
in information technology, research methodology and dissertation writing
and communication skills. Candidates are expected to have seen patients
from the following disciplines, apart from general adult psychiatry (100
outpatients and 100 inpatients), psychotherapy (20), child psychiatry
and learning disability (50), substance abuse (25), geriatric psychiatry
(15), organic psychiatry (15), forensic psychiatry (10), liaison psychiatry
(15) neurology (20) and psychometry (20). psychiatric rehabilitation and
community psychiatry cases are optional.
The examination consists of two theory
papers. The first paper consists of problem solving MCQs, while the second
includes short essay questions. The clinical examination consists of one
long case, two short cases and a viva voce to examine candidate’s
theoretical knowledge.
Funding for training is a major issue
in Pakistani health system. There have been major changes in the health
service in Pakistan over the last few years. The emphasis has shifted
from tertiary care to primary and secondary care. However, due to lack
of careful planning and financial restraints, funding for the teaching
hospitals has reduced. The teaching hospitals are less willing to pay
the salaries of the trainees. This is particularly true for new trainees
who do not have longstanding posts as medical officers (equivalent to
Senior House Officers in the UK). Most of the trainees therefore fund
themselves. Recently the College of Physicians and Surgeons have put a
ban on having unpaid trainees in the training centers. This may result
in further reduction of training posts.
Once a doctor has been awarded with the
Fellowship of The College of Physicians and Surgeons, he can apply for
the post of a senior rRegistrar or even an assistant professor in a medical
college. They can also work as consultants in district general hospitals.
An assistant professor is also consultant psychiatrist in the attached
university hospital. The consultant posts have three tiers in Pakistan.
Assistant professors and associate professors can receive supervision
and support by the professors. In the absence of a proper system of support
and supervision for the junior consultants, this is the only possible
support that can be offered.
Summary
Psychiatric training in Pakistan is at
the very early stages, at both undergraduate and the postgraduate level.
The health system is not well established with significant resources.
Farooq6 has rightly pointed out a major change in psychiatric
training in Pakistan is needed; so that the training is broad-based and
equips the psychiatrist to work effectively with other disciplines, particularly
primary care.
Including psychiatry as a separate subject
in the medical curriculum can help future doctors to recognize and to
some extent treat mental health problems. It is also important that more
family physicians and general practitioners are trained in recognizing
mental health problems. In the UK for example the medical students have
to orientate themselves to the psychiatric services during the third,
fourth and the final year of the training. They also have to appear in
a clinical exam in addition to a written paper. According to Davies et
al.7 this approach to “curriculum places students in
contact with psychiatric patients at a much earlier stage of their training
than was previously the case. This permits psychiatric knowledge and skills
to be inculcated while students are more receptive to new ideas, with
the potential to inform their later practice. Many students form their
ultimate career choices during their undergraduate course”.
It is not possible to arrange training
in the fields of forensic psychiatry, psychotherapy, geriatric psychiatry,
drug and alcohol abuse, child psychiatry and learning disability, due
to a lack of training consultants. Arranging the training around cases
from subspecialties certainly can help in recognizing these problems.
However, lack of supervision in these fields compromises training. Collaboration
with Pakistani mental health professionals abroad who are experts in these
fields can be helpful in arranging short courses, as well as in arranging
limited support through email, video conferencing etc.
Although the curriculum is clearer for
the part one of the exams, part two curriculum is rather vague. In terms
of the part one exam, it is not clear how general anatomy can help the
future psychiatrists. Compulsory training in research is a positive feature
of the FCPS examination. However, this can be compromised if the supervisors
are not well trained in research methodology.
Community education in the form of news
paper articles, radio talks etc. and liaison with non medical persons
like faith healers can not only help patients, but also help the professionals
in identifying and developing locally developed psychological treatments.
The patients are mostly looked after by
their families in Pakistan. It is therefore important that training is
focused on community based psychiatry. Drug abuse problem in Pakistan
is on a rise and most patients are treated by non psychiatric doctors.
It will make some sense to include more cases of drug abuse as a vital
part of the training system. Psychological therapies are not readily available
in Pakistan. Psychologists mostly provide counseling using an eclectic
approach. There is currently no psychotherapist working in national health
system in Pakistan. Placing more emphasis on training in psychotherapy
will certainly improve psychiatric care. Family is an important resource,
and therapies in this area can be used to improve patient care.
References
