Is Psychiatry in Pakistan left out in the cold?

My first encounter with psychiatry was in the final year of medical school. After all, it was a Psychiatry lecture on ‘Mood Disorders’ which did not need my selective attention. I was more interested in preparing for my semester exam and making sure to not miss the pulse on the simulated patient this time (no I wasn’t a horrible student; exam station was on a pulseless disease called Takayasu’s arteritis). My point being, knowing how a Mood Disorder can actually have deleterious effects on one’s life, was not my priority — NO EXAM!! This is how I was introduced to Psychiatry.

My second encounter with psychiatry was during my house job (internship) when on one busy day, a former Medicine resident officer came to the ward to get her certificate signed by the registrar. As we both were waiting in the staff’s room for the registrar, we casually started talking, and she mentioned her rotation in psychiatry for 3 months. Believe it or not, this was news for me. And no, it was not 1800s — it was 2010 — this very same century. Moreover, I engaged more in the conversation and developed a curiosity that was more than a passing interest.

During my medicine rotation when patients, especially females, presenting with complaints of generalized body ache, headache, difficulty breathing or vague symptoms, I heard clinicians say, ‘oh she’s OPD XX case.’ Code for Psychiatry referral. Once this verdict was announced, the patient immediately became untouchable. That’s all I knew about this mysterious sub-specialty of Medicine.

However, after a very thoughtful chai break, I decided to take this rotation as a house officer. When I discussed with a senior, I was asked ‘isn’t it too early to prepare for your FCPS part 1?’ and I wasn’t sure what that person meant. I later figured out that post-graduate trainees opt for Psychiatry rotation to buy time for exam preparation since there was minimal-or no- clinical work in Psychiatry. Not encouraging. Finally, I managed to get a rotation in one of the oldest Psychiatry facilities in Pakistan. I finally saw what and where OPD XX was.

I knew where I was headed. Osler said that it’s a “calling.” Many are called to heal, some to teach, others to preach and ascertain justice. I realized that this is where I am needed. During my training, there were times when I was called to see a patient and my mere presence, i.e., a resident from psychiatry would change the air. Not just clinical team buy families and patients as well. But what hurt me most was this encounter when one novice intern was very apologetic and terrified to show their enthusiasm towards my assessment.

After all, you do not want to be someone who is interested in Psych. Imagine becoming a Psychiatrist, a pseudo doctor!!

This is my 8th year in Psychiatry. I received my postgraduate qualification in adult psychiatry, worked as a student psychiatrist and a faculty member for more than 2 years in a very reputable institute, and today I am one of the 2 child and Adolescent psychiatry fellows in the country. Telling my story was an attempt to lay a background for the field of Psychiatry in Pakistan. Having a keen interest in scholarship, I will focus on pitfalls in Academic Psychiatry.

There is increased international attention to mental health because of the appreciation of the vast suffering it causes to affected persons and their families. Furthermore, WHO statistics indicate that 1 in every 4 persons will suffer from a mental health problem at some point in their lifetime. What that translates into, for us in Pakistan, is that around 50 million Pakistanis at some point in their lifetime will suffer from a mental health problem.

In the face of this high burden of mental health problems, there are only around 500 Psychiatrists are practicing in Pakistan catering to a population of approximately 207 million. This creates an alarming ratio of one psychiatrist to about half a million people (Khan, 2016).

Why are the numbers not increasing? Do we not have enough doctors, medical schools, or it is more than that? One might wonder, why is Psychiatry treated as Cinderella of Medical family.

With almost 110 medical schools, the country graduates around 15–20,000 medical doctors every year. The majority of these schools do not have a mandatory undergraduate psychiatry curriculum and therefore, do not have a professional examination. Although Psychiatry is recognized as an essential part of the curriculum by the Pakistan Medical and Dental Council (PMDC), there is no consensus of experts, leaving a room for ambiguity among medical educators.

Psychiatry needs deep intuitive insight into complex matters and etiological factors leading to a clinical presentation of a disorder. Checklist and mechanical teaching taikes away the essence of it. The organic, dynamic discussion among medical students may help them question their pre conceived notion. The less than passionate nature of teaching the subject does not enthuse these students. When students see their role models exhibiting therapeutic pessimism and stigmatizing attitudes & behaviors towards patients with mental illnesses, the disdain is further strengthened. E.g., patients with psychiatric conditions are often rejected by healthcare providers and are often felt to be manipulative, and less deserving of care.

Considering our cultural context, there is immense pressure from families for students when they are choosing their subspecialties, and Psychiatry is seen as the least prestigious specialty. Only 17% of medical students and graduates report interest in choosing Psychiatry as a career.

The decision for choosing a sub-specialty is not always based on the values and moral responsibility. Money is a crucial motive. Psychiatry is the least paying specialty. This is linked to the emigration of psychiatrists from Pakistan to higher-income countries. Common reasons for moving abroad are lucrative salary, improved quality of training, job satisfaction, the geopolitical situation in Pakistan, better management and systems, and peer pressure.

Unfortunately. Psychiatry has become a blind spot of Pakistan’s medical academia. This is crucial and concerning as this group will continue to influence stakeholders well into the future. As long as such decision-makers fail to see the urgency for placing Psychiatry high on the medical school curriculum agenda, then the motivation to pursue psychiatry and follow the ‘calling’ remain low. The result will be a continuing the cadre of healthcare providers with minimal Mental Health literacy.

To continue with the current status quo in Pakistan will mean hindering individuals from developing their human potential. This will be especially unfortunate given the current global evidence and its implications for Pakistan. A harmonized minimum curriculum should be drawn up and implemented, and awareness and advocacy to change perceptions about Psychiatry as a specialty is required. There should be no more shame or stigma associated with mental illness (or the doctors who look after them) than there is for physical ailments. If the country does not plan effectively now, to respond to the needs of implementing the SDGs as well as addressing the potentially substantial mental health needs of the populace, it will be a great disservice.

The best time to have started was yesterday. The next best time is NOW.

Originally published at http://childpsychling.wordpress.com on December 6, 2018.