A little anecdote

The year was 2022, and it marked the first month of my initial rotation at one of the largest tertiary care hospitals in Punjab, Pakistan. After having assisted with several procedures in the ENT operating room one morning, I found myself on call for the next 18 hours in the emergency department as the new intern.

As soon as the shift changed, a young boy landed in the ED with his father clutching his nose with a large piece of white linen spattered entirely with blood. After the initial resuscitation, the patient was stable enough to be admitted for inpatient management. The case we were dealing with was a nasopharyngeal angiofibroma, which demanded a comprehensive investigation.

This was perhaps the first time the inadequacies of our health care system would become so apparent to me. The patient needed a CT angiography, for which he had to be taken to another tertiary care center located on the outer rim of the city for his CT. Moreover, many of his medications were not in stock at the hospital and had to be requested privately. Seeing all this and more during my intern year proved a petrifying realization for me, having to work in a system that was not even remotely patient-friendly. Even more shocking was the fact that it was just “the usual” for most providers who had been in the system a couple of years longer than me.

The challenges

While medical students are supposed to rotate through almost all the various specialties their teaching hospital offers, especially so during the final year of medical school (often referred to as the sub-internship), the experience of working as an actual doctor is rarely emulated during medical school. That was certainly my experience, whether due to the old-school curriculum at my institute that restricted this or the USMLEs and the boards (which generally keep the students preoccupied). I am sure many of you can relate.

The seemingly small things—the things that might appear either too distant to us as medical students—or simply too inconsiderable become little speed-breakers that you have to encounter every day as an intern or a resident. Navigating clerical barriers, financial challenges that the families face, and communication gaps widened by low health literacy (especially prevalent in the underrepresented groups)—all of these that we were never prepared for, were now real challenges.

Why does it continue to work?

As I rotated from one specialty to another, I gained insight into how this system continued to operate, apparently in perpetuity, rather than collapsing, which seemed to be the only possibility for a system so hollow that served neither the patient nor the health care professionals. What sustained it? The answer lay in the doctors and nurses working in the system who had evolved so well as to continue to work without feeling handicapped by the established setup. Handicapped, they were, yes. But did that mean they could simply give up on patients? That makes me proud, being a witness to their determination.

In emergency departments where heparin is scarcely found, where the patients are requested to arrange potassium chloride for themselves, where point-of-care ultrasound is a novel concept, and where defibrillators rarely function—you would be astonished at how well the doctors learned to make do with whatever little is available. Yes, there are major lapses, and the level of care provided is far below the standards. But if we focus solely on the “standard protocols,” “level of care,” and “evidence-based practice” without discussing the grossly under-equipped health care establishments in developing countries, we are missing a crucial part of the picture.

Help needed

Talking about evidence-based practice is essential to advancing medicine. The newer, safer regimens for conditions ranging from autoimmune diseases to metabolic syndromes should absolutely be promoted, so as to keep the medical community informed and aligned. But this goes only so far in the landscape I have described.

When in place of modern disease modifying drugs, the best we can offer our patients are corticosteroids, there emerges a galactic void in the academic support by the scientific community in establishing guidelines and standards of care for resource-limited health care systems.

Muhammad Usama is an occupational health physician in Pakistan.