Shaista Khan
Shifa International, Islamabad, Pakistan

The GMC document “Tomorrow’s Doctors” states that: “…doctors must be…able to provide advice and explanations that are comprehensible to patients…” On countless occasions in England I had acted as a translator for an Asian patient who could not speak English. Although I could “get by,” I wanted to converse with such patients as fluently in Urdu as I did in English, and not hesitate when I couldn’t remember the word for “liver” for example. Since Urdu is similar to Hindi and Punjabi, I would be able to converse with a diverse number of people, a skill that would be invaluable when studying/working in the UK.

I also wanted to compare the health status of the Pakistani population with that of the UK, and to gain a better understanding of the health problems in a developing nation. Finally, I wanted to experience the rich culture of Pakistan, enjoy the sunshine and visit the beautiful sites.

Pakistan celebrated its Golden Jubilee in 1997, fifty years after the parting of the British Raj. The inhabitants of this historic land, the cradle of the Indus Valley civilisation, range from the blonde-haired blue-eyed tribes in the North, to the dark- skinned dark-eyed populations near the Arabian Sea, reflecting the diversity of the different invaders that passed through the region over many centuries. From the Arabian Sea port of Karachi in the South, Pakistan stretches to the Himalayas and three other mountain ranges in the North, separating it from Afghanistan, China and India. India forms the Eastern boundary, and Iran lies to the West.

Pakistan has one of the most rapidly growing populations in the world (currently at a rate of approximately 2.9%). The population was 31 million at its first census in 1951 and is now estimated at 145 million, although the recent flux of immigrants from Afghanistan makes an accurate count impossible. It currently has the seventh largest population in the world and is projected to be the third largest by 2050.

I was to stay with my family in Islamabad, the country’s capital, which nestles against the Margala Hills, the foothills of the Himalayas in northern Punjab. Technically it is not part of Punjab, but forms its own Capital Authority.

Islamabad is a city of wide, tree-lined streets, large houses, elegant public buildings and hustling bazaars. Houses are shaded by rows of flame trees, jacaranda and hibiscus, whilst roses, jasmine and bougainvillaea fill the parks.

The first week of my elective was in the General Medical ward at the Rawalpindi General Hospital (RGH), which was a government hospital in Rawalpindi.

To fully appreciate the patients that I was seeing on the wards I had to gain an understanding of the complexity of the health care system and the beliefs of the Pakistani people. Pakistan’s overall literacy rate is approximately 20%. That means a staggering 80% are illiterate. There is no established primary health care system; people do not have their own GP with whom they can discuss their everyday health concerns.

Unlike the modern allopathic practitioners, the traditional herbalists (Hakim) dispense pleasant tasting herbs and tonics, with a reputation for curing and rejuvenating the body.

In the Hakim system, history taking is brief and examination of the tongue, sclera and pulse is very important. Examination of the urine is sometimes performed. Hakims only have office practices, with no laboratory, radiography or other equipment. Faith healers are even more popular.

Those rural people who emerged from following homeopathic, advaric and faith medicine to consult an allopathic doctor have usually exhausted all other possibilities and are in the final thralls of disease. Conversely, the upper classes tended to consult allopathic doctors first, and only if these doctors could offer no hope did they turn to the Hakim.

Concepts such as Garmi-Sardi (hot-cold), a symptom complex similar to yin and yang, are deeply ingrained in the medical thinking of the people and patients like to know of special precautions regarding diet and liquids and when and with what to take their medicine.

At RGH a typical encounter with a new patient lasted around five minutes. The only record is that of prescriptions and laboratory tests ordered on letter-headed stationary. Physician-patient relationships are casual, and there is no loyalty to a specific physician. Obtaining several opinions in the same day from different practitioners is common (given ten minutes to think about having an elective or semi- urgent procedure, most patients will go home).

I walked past the beautiful water feature in the luxurious grounds of Shifa International Hospital and entered the air-conditioned building. This place was so serene and only thirty minutes from where I had just been. I was to spend five weeks in the famous cardiology department there.

Shifa International Hospital was conceived and incorporated in 1985-1987 by a small group of Pakistani doctors and other health care professionals who were working in the USA. Since then it has grown from over 450 contributing members to being a public limited company listed on the stock exchange.

The hospital is located on 11.2 acres in sector H-8/4 in Islamabad. It was established to become a centre of health care excellence in Pakistan and is well on the way to achieving this. A major feature of its healthcare delivery system is the level of medical technology that is used, especially in the field of diagnostic imaging. Radiographic and fluoroscopic imaging, C. T. scans, mammographies, mobile X-rays, ultrasonography and cardiac catheterisation are all offered. In addition Shifa is famous for its cardiothoracic surgical programme. The hospital currently provides 6 operating rooms, 170 inpatient beds including ICU, CCU and NICU, 32 specialist clinics, and a physiotherapy centre. Shifa also claims to have the largest group of US Board-certified specialists available at one institution in Pakistan.

My typical day began with a case presentation and discussion by a house officer, led by a consultant. A ward round was next, followed by Cath Lab to observe angiographies, angioplasties and pacemaker insertion. Next was cardiology outpatient’s clinic. Then another seminar, followed again by clinic where I could perform ECGs and exercise tolerance tests, as well as observing transoesophageal echo cardiography. The day ended with another ward round.

I did not have to stick to this schedule, and was free to spend time in theatre, wards, CCU and other clinics.

My consultant had been working in England for the past 10 years and had only returned to Pakistan two months earlier.

Emergency medicine is an essential component of the Pakistani health system. The practice of emergency medicine varies according to the size, location and affiliations of the hospital. In smaller hospitals and clinics most patients with serious or life- threatening emergencies are told to go promptly to a regional hospital. An anaesthetist handles intubations and as the law forbids alcohol, alcohol-related illnesses and injuries are rarely seen. Problems such as consent, custody (in the case of children) and worries about home circumstances in the elderly, are not encountered by staff because the joint family system provides a social safety net, and fears of malpractice claims are practically nonexistent.

There were 10.8 million hypertension cases in Pakistan according to the National Health Survey 1994. According to 1998 estimates there are now over 12 million cases. Nearly one-third of all deaths in the country are due to heart disease, and 1% of babies born here, 5% of school-age children, and 14% of the adult population suffer from some form of cardiac disorder.

In 1995, Pakistan was rated as having the 8th highest incidence of diabetes in the world (4 million). The World Health Organisation predicts that this will rise to a mighty 15 million by 2025.

Preventative measures for cardiac problems are to an extent dependent on change of lifestyle. The primary cause of the high incidence of heart disease in Pakistan is probably the fat-saturated, high-salt diet and lack of physical exercise. Smoking is another factor. Given the low public awareness of the cardiac diseases and their causes I was encouraged to see a lot of health ‘infomercials’ sponsored by the Health Department on television. Since even people in the remotest villages have televisions these days (even if they don’t have running water!), it means that this information is reaching all the comers of Pakistan. Health professionals are now speaking up and appealing to the people to pay heed to the need for a change in lifestyle.

As I reflect on my elective I realise that I have learnt so much in such a short space of time.

My knowledge of cardiovascular disease and general medicine has improved vastly and I have perfected my examination skills. I can even pick up diastolic murmurs now! I have learnt how to perform and interpret exercise tolerance tests, can interpret echocardiograms, my knowledge of drugs has gone from knowing the basics to knowing exactly which combination of drugs a patient with heart failure should be taking. The seminars and case presentations were invaluable. The ward rounds and clinics gave me the opportunity to see physical signs that I had only ever read about. I saw rare and tropical diseases, and diseases at such advanced stages that it was shocking. I had improved my Urdu, and the importance of good doctor-patient communication was reinforced. I had enhanced my ability to insert cannulas, N G tubes, catheters, and apply dressings.

But perhaps more importantly than this I have seen how a simple gesture, a kind word, or just asking patients about their concerns can make the difference to a patient.

“Tomorrow’s Doctors” states the attitudes that are needed to be a good doctor. These include the ability to cope with uncertainty, a respect for patients that encompasses the diversity of background and opportunity, language, culture and way of life, and the ability to adapt to change. Although I had these skills to some extent before undertaking my elective, my experiences in Pakistan have improved them and made me more aware of their importance.

My elective was nothing like I expected it to be, yet everything I hoped it would be: stimulating, informative, enjoyable and thought-provoking. If I ever had any doubt as to whether I wanted to be a doctor it was all gone … did I really want to be a doctor? Yes. In fact I can’t wait.

REFERENCES
Pappas G. Akhtar T. Gergen PJ. Hadden WG. Khan AQ. Health status of the Pakistani population: a health profile and comparison with the United States. American Journal of Public Health. 91 (1 ):93-8, 2001 Jan.
World Health Organisation website: www.who.int

Shaista Khan 2003