Percieved Need Of Emergency Medicine Training In Paksitan

doi: 10.1111/j.1742-6723.2008.01139.x

Emergency Medicine Australasia (2009) 21, 143–146

EDUCATION AND TRAINING

Perceived need for emergency medicine training in Pakistan: A survey of medical education leadership Junaid A Razzak, Adnan Ahmed, Ali Faisal Saleem and Muazzam Nasrullah Department of Emergency Medicine, Aga Khan University, Karachi, Pakistan

Abstract Objective:

To assess the perception of leaders of the academic medical institutions regarding the need for specialty training in emergency medicine.

Methods:

A cross-sectional survey was conducted in all medical colleges of Pakistan in September 2005. Our sample included all academic leaders of recognized medical colleges in Pakistan. A questionnaire was designed and sent (mailed and faxed) to vice chancellors, deans, principals or medical directors of the institutions. Reminders were sent through faxes and emails wherever available, followed by phone calls if responses were not available after several attempts.

Results:

At the time of study, there were 39 medical colleges recognized by Pakistan Medical and Dental Council. Of these, responses were received from 26 teaching institutions in the country. A majority of the respondents (85%) were not satisfied with the care provided in the ED of their primary teaching hospital, and three-fourth (74%) thought that doctors specialized in other disciplines, like internal medicine and family medicine, cannot adequately manage all emergencies. When asked if Pakistan should have a separate residency training programme in emergency medicine, 96% responded in affirmative, and many (85%) thought that they will start a residency programme in emergency medicine if it was approved as a separate specialty.

Conclusion:

This survey shows significant support for a separate local training programme for emergency medicine in the country.

Key words:

emergency medicine, Pakistan, residency, training.

Introduction Emergency medicine (EM) is a medical specialty with the principal mission of evaluating, managing, Correspondence:

treating and preventing unexpected illness and injury.1 It is a relatively new specialty even in more developed countries. In USA, the first residency programme started about 35 years ago, followed by its recognition

Dr Junaid A Razzak, Department of Emergency Medicine, Aga Khan University, Stadium Road, PO Box 3500, Karachi 74800, Pakistan. Email: [email protected]

Junaid A Razzak, MD, PhD, FACEP, Associate Professor; Adnan Ahmed, MB BS, Research Officer; Ali Faisal Saleem, MB BS, Pediatric Resident; Muazzam Nasrullah, MB BS, Masters in Safety Promotion, Research Coordinator.

© 2009 The Authors Journal compilation © 2009 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

JA Razzak et al.

by the American Board of Medical Specialties in 1979. Currently, around 40 countries have specialty societies in EM, and more than 20 countries have postgraduate training programmes. Many of these countries are low- and middle-income countries, like Turkey, Bosnia, Jordan, Nicaragua etc.2 The most important step in the development of EM in other countries is the recognition that EM incorporates a unique body of knowledge requiring specialized practitioners or emergency physicians.3 In Pakistan, EM is still in its infancy.4,5 There is no academic department of EM currently. There is only one postgraduate residency training programme in the country, but there is no exit examination for the trainees yet. The objective of our study was to assess the perception of leaders of academic medical institutions regarding the need for specialty training in this area.

Methods Pakistan is a low-income country with a per capita income of less than US$ 7206 and a population of 165 million.7 About 0.8% of gross domestic product is spent on health care.8 While suffering from classic diseases of poverty, like infections, complications of pregnancy, Pakistan is also suffering from a large burden of noncommunicable diseases, like cardiovascular diseases and injuries.9,10 Postgraduate medical education and certification are available in over 50 specialties and subspecialties in Pakistan overseen by the College of Physicians and Surgeons Pakistan.11 This cross-sectional survey was conducted in August to September of 2005 and was based on a structured questionnaire in English. The questionnaire was focused on assessment of the current situation of ED in their institutions, the degree of specialization of the staff, the satisfaction of the interviewee with the care provided, the degree of emphasis placed on EM rotations at the undergraduate and postgraduate trainees and support for a separate residency programme in this field. An attached letter describing the purpose of the study and a request for a response from vice chancellors, deans, principals or medical directors of medical universities/colleges were sent. The survey form was sent to all medical colleges (public and private) registered with Pakistan Medical and Dental Council.12 At the time of survey, there were 39 registered medical colleges. Thirty-four colleges confirmed receipt of the survey form. Where no response 144

was available, reminders were sent either by repeated faxes and mails, followed by phone calls. Up to five calls were attempted. Data were entered into SPSS (version 13, SPSS, Chicago, IL, USA) and simple univariate analysis was performed.

Results Of the 39 medical colleges, 34 (87%) received the survey form and 26 (67%) responded. Thirteen (50%) of the responses were from the public sector and the other 13 (50%) from the private sector. Among the respondents were 1 (4%) vice chancellor, 4 (15%) deans, 18 (67%) principals, 2 (8%) vice principals and 1 (4%) medical director. The provincial distribution of the institutions is: Punjab (n = 17, 70%), Sindh (n = 14, 64%), Frontier (n = 7, 57%) and Baluchistan (n = 1, 100%) (Fig. 1). A majority of the respondents (n = 23, 85%) were not satisfied with the care provided in their ED, one (3%) respondent was unsure and the rest (n = 3, 11%) were satisfied, a finding similar in both the private and public sector institutions. Only three (11.5%) institutions had any specialized staff for their ED. Eight institutions (30%) had residents/trainees managing the ED. Fifteen institutions (56%) had both dedicated ED staff and residents/trainees. In one case, general practitioners were appointed by district government in the ED. Three-fourth of the respondents (74%) thought that the doctors specialized in other disciplines, like internal medicine and family medicine, cannot adequately manage all emergencies. When asked if the country should develop a separate residency programme in emergency medicine, 96% responded in affirmative, and 85% thought that they will start a residency programme in EM if it was approved as a separate specialty. Institutions offering a separate rotation for medical students were evenly divided, that is, 50% each, which excluded students rotating in other specialties who would come to the emergency room to admit patients. Seventeen (65%) institutions had internees and residents from other specialties rotating through their emergency room during their training period (Table 1).

Discussion The majority of our respondents in the survey thought that the country needs postgraduate training in EM and that current quality of care in their ED is not satisfactory. Three-fourth of the respondents were in the opinion that doctors from other specialties cannot

© 2009 The Authors Journal compilation © 2009 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Perceived need for emergency medicine training

TOTAL NUMBER OF MEDICAL COLLEGES IN PAKISTAN 34 TOTAL NUMBER OF MEDICAL COLLEGES CONTACTED 31 TOTAL RESPONSES RECEIVED 27

Figure 1.

UNABLE TO CONTACT 3 NO RESPONSE RECEIVED 4

RESPONSES FROM KARACHI 7

RESPONSES FROM PUBLIC SECTOR 13

RESPONSES FROM REST OF PAKISTAN 20

RESPONSES FROM PRIVATE SECTOR 14

Response and Distribution of Medical Colleges.

Table 1. Questionnaire response on assessment of ED in institutions of Pakistan Parameter Currently satisfied with patient care in their ER Presence of EM rotation for medical students Agree with the separate residency in EM in Pakistan Once established would offer residency in EM at their institution Doctors from other disciplines currently manage acute emergencies

Yes

No

3 (11%)

23 (85%)

13 (48%)

14 (52%)

26 (96%)

1 (4%)

23 (85%)

4 (15%)

7 (26%)

12 (74%)

ER, emergency room; EM, emergency medicine.

adequately manage all emergencies. Trained emergency physicians are needed to manage acute illnesses and injuries before patients are either discharged home or are admitted to inpatient services. The ED are the primary source for medical care for a large number of patients. In Karachi, for example, three large government hospitals (Jinnah Postgraduate Medical College, Civil Hospital Karachi, Abbasi Shaheed Hospital) and two large private hospitals (Aga Khan Hospital and Liaqat National Hospital) provide care to approximately half a million patients every year. The study found that there is currently no formal training in EM at the undergraduate level in Pakistan. Instead, students are exposed to ‘emergencies’ as part of their inpatient ward rotations. This used to be the case

in other countries as well. More recently, more and more medical colleges in the USA and UK are offering either elective or mandatory rotation in EM.13 One of the reasons for lack of training opportunities for medical students is perhaps the lack of teaching faculty based in the ED. Supporting EM as a formal specialty would have other benefits, including development of the area of clinical toxicology and improvement and ownership of the area of emergency medical services providing care in the prehospital arena. Pakistan is a developing country that can benefit from improved emergency care. According to a study on the burden of disease in Pakistan diarrhoea, lower respiratory infections, ischaemic heart disease, septicemia and injuries are among the top 15 causes of premature deaths.14 Data from Karachi, the biggest city of Pakistan, show that the main causes of death in adults included circulatory disorders, injuries (road traffic crashes, burns) and complications of pregnancy.15 Pakistan is also extremely vulnerable to natural and man-made disasters. In 2005, the earthquake resulted in loss of over 70 000 lives in Northern Pakistan.16 In the past 5 years, there have been 58 bomb blasts alone in Karachi city of Pakistan, leading to 689 injuries and 164 deaths.17 Quality of emergency care, despite a high demand, remains poor. Data from two districts of Pakistan showed that 98% of community leaders expressed poor satisfaction with the emergency care provided. The same study showed that 98% of health-care providers thought that their facilities were inadequately equipped to treat emergencies. A review of medications and

© 2009 The Authors Journal compilation © 2009 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

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equipment available showed that many critical supplies needed in an emergency were not found in emergency care facilities.18 Besides human resources, emergency medical care in a country like Pakistan would be challenged by the lack of financial resources and absence of insurance systems. Although government has an extensive health-care system, the quality of care, and thus use of these services, is limited. Health-care expenditure constitutes only 0.75% of total national budget.19 Poorly funded government health-care facilities have led to a greater role for the private sector. Almost 80% households consult the private sector against only 23% to the public sector.20 Proportion of private sector contribution to the emergency care in Pakistan is not known. In the context of high demand, poor government spending and large proportion of private sector, out of pocket expenses, the emergency care in Pakistan is likely to evolve, at least initially, in areas with high private paying capacity. The future emergency physicians in Pakistan will have to evolve a system of fee for service payment, which is not only sustainable and attractive for new generations of emergency physicians, but also ethical. From the policy perspective, the challenge of developing emergency medicine in a country like Pakistan is to ensure an improvement of emergency care access to all, instead of an increasing gap between the rich and poor.

This survey shows an overwhelming support for training programmes in the field of EM in Pakistan. This will have potential benefits for the patients, medical trainees and might help in the development of areas of medicine, like clinical toxicology and prehospital care, which remain underdeveloped so far.

3.

Arnold JL. International emergency medicine and the recent development of emergency medicine worldwide. Ann. Emerg. Med. 1999; 33: 97–103.

4.

Raftery KA. Emergency medicine in southern Pakistan. Ann. Emerg. Med. 1996; 27: 79–83.

5.

Mehdi IJ. Emergency medicine in Pakistan. Ann. Emerg. Med. 1996; 27: 84–8.

6.

The World Bank Group. Pakistan Country Overview 2006. Washington DC. The World Bank Group, 2007.

7.

Central Intelligence Agency (CIA). The World Fact Book. 2007. Available from URL: http://www.cia.gov/library/publications/ the-world-factbook/geos/pk.html [Accessed 18 September 2007].

8.

World Bank. Knowledge for Development. Washington DC: World Bank Group, 1998/1999.

9.

Nishtar S, Bile KM, Ahmed A, Amjad S, Iqbal A. Integrated population-based surveillance of noncommunicable diseases: the Pakistan model. Am. J. Prev. Med. 2005; 29 (Suppl 1): 102–6.

10. Nishtar S, Mohamud KB, Razzak J et al. Injury prevention and control: national action plan for NCD prevention, control and health promotion in Pakistan. J. Pak. Med. Assoc. 2004; 54 (Suppl 3): S57–68. 11. College of Physicians and Surgeons Pakistan (CPSP). CPSP Training Programs. 2007. Available from URL: http://www. cpsp.edu.pk/ [Accessed 31 October 2007]. 12. Pakistan Medical and Dental Council. Recognized Medical and Dental Colleges in Pakistan. Available from URL: http:// www.pmdc.org.pk/list_colleges.htm [Accessed 3 October 2007.]

14. Hyder AA, Morrow RH. Applying burden of disease methods in developing countries: a case study from Pakistan. Am. J. Public Health 2000; 90: 1235–40. 15. Marsh DR, Kadir MM, Husein K, Luby SP, Siddiqui R, Khalid SB. Adult mortality in slums of Karachi, Pakistan. J. Pak. Med. Assoc 2000; 50: 300–06. 16. Irish Red Cross. Pakistan Earthquake Appeal. Available from URL: http://www.redcross.ie/services_overseas/pakistan [Accessed 31 October 2007]. 17. Mehmood A, Razzak J, Khan SJ. Blast injuries in Karachi. Paper presented at: Health Sciences Research Assembly October 2007, Karachi, Pakistan.

Competing interests None declared. Accepted 22 September 2008

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Conclusion

1.

2.

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18. Razzak JA, Hyder AA, Akhtar T, Khan M, Khan UR. Assessing emergency medical care in low income countries: a pilot study from Pakistan. BMC Emerg. Med. 2008; 8: 8. 19. Government of Pakistan. Economic Survey of Pakistan (2005– 06). Islamabad: Finance Division, Economic Adviser’s Wing, 2007. 20. Government of Pakistan. Pakistan Social and Living Standards Measurement Survey (Round-1), 2004–05. Islamabad: Federal Bureau of Statistics, 2005.

© 2009 The Authors Journal compilation © 2009 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine