By Mohsen Allam “This is where the problem begins,” says Dr. Mohamed Shaalan. “If you are among the top 100 students in your class, then you are selected to be a tutor within your school. This is something reserved for the precious few. As for the rest of the students, they have a huge personal burden they have to carry.” By Mohsen Allam “During our internships, we are broken into groups and are supposed to shadow doctors, but because the number of students in the groups is usually very high, often many students don’t show up and the doctors don’t care,” explains Dr. Adham Aboul Fotouh. “This means that you can graduate but you haven’t fulfilled the practical part.”

By Réhab El-Bakry

Doctors are among the most revered and respected professionals in most societies. Egypt is no exception; its every parents desire to see their child grow up to be a doctor. One of the results of this deeply held belief is that today there are too many medical school students, too few resources and far too few jobs.

The problem was recently brought to the fore by the Doctors Syndicate, which published a public plea to the Ministry of Higher Education in local newspapers requesting that the ministry reduce the number of students being accepted into medical schools around the country. According to statistics from the syndicate, there are already more than 160,000 doctors registered, with at least another 6000 expected to join the ranks during the 2004-05 academic year. Despite the syndicates plea, the Ministry of Higher Education already announced that there will be 7500 new students accepted into medical schools around the country for the coming school year.

Its all in books

Theres a catastrophic problem that is brewing in Egyptian medical schools and the medical profession as a whole that needs to be addressed or else we will have unqualified people playing doctor with other peoples lives, explains Dr. Mohamed Nawwar, a graduate of Cairo University medical school, who is currently completing his masters degree in Germany.

The quality of the training that most of these doctors get is terrible, to put it mildly. There is no system in place to ensure that we are in the process of learning new procedures, new techniques, or the uses of new medication while we are completing our internship or our residency. So people graduate and begin to practice medicine with questionable training if any at all. If I were a patient, I wouldnt want one of those fresh graduates for a doctor.

You get fewer students in these [Ministry of Interior] hospitals, especially in civilian posts, explains Dr. Sherif Arafa. But you also get some of the countrys best specialists working as consultants for these hospitals. So you get the opportunity to learn from the best.

The problem of a lack of good training is rooted in the countrys education system, according to industry observers. To get into medical school in the first place, students need to achieve extremely high scores in high school. At least in theory, this means that the number of students who get accepted into medical school is based on merit, but it also means that a lot of students get in without really having the desire and the commitment to continue in this extremely exhausting profession, says Nawwar. Half the people in medical school really wanted to become doctors while the other half just had the grades for it and thought it would be such a waste [if they didnt go], he adds.

While in medical school, students learn the theoretical part of medicine, but its the practical training that allows doctors-to-be to observe other professionals and pick up the habits that truly separate a good doctor from a bad one. Dr. Mohamed Shaalan, oncologist and owner of Shaalan Medical Center, explains that the technical training is what really makes a doctor stand out. Theories are one thing, but thats all they really are, theories. Its the practical experience that you are supposed to have during your internship and residency that really gives you the experience and the comfort to make decisions that can affect the lives of people, he says. The problem is that the system here doesnt really give doctors the training they need to do that.

Shaalan says that while an internship the year-long training that all medical students are required to complete before receiving their licenses and membership into the syndicate is mandatory, a residency is not. And it is the residency where future doctors are weeded out from those who are either uncommitted or ill-prepared to handle such a stressful career. During a residency, medical students are meant to be constantly observed and assessed during every procedure by more experienced doctors and professors. This is where the problem begins, says Shaalan. If you are among the top 100 students in your class, then you are selected to be a tutor within your school. This allows you to learn directly from doctors, but also gives you access to the latest academic information and techniques. Plus, you also get to do your internship in the university hospitals which often have the best doctors monitoring your progress. This is something reserved for the precious few. As for the rest of the students, they have a huge personal burden they have to carry.

Students who cannot complete their residency in the university hospitals are actually not required to complete one. This means, as private practitioner Dr. Adham Aboul Fotouh puts it, that doctors with minimal training can legally practice.

During our internships, we are broken into groups and are supposed to shadow doctors, but because the number of students in the groups is usually very high, often many students dont show up and the doctors dont care, explains Aboul Fotouh. This means that you can graduate but you havent fulfilled the practical part. Since we dont have to complete a residency like in most other countries where you are supervised for a period of two to five years then its simply not safe for patients.

Students who are not among the top 100 have the option of taking a takleef or an exemption from the Ministry of Health. Students get assigned to any of the government-funded hospitals or clinics located throughout the country. Where you get assigned is determined by your average the lower your grade, the farther you are from the major cities and the smaller the facility you are assigned to.

In theory, the system might make sense, but in practice, young doctors dont get good enough training because they dont have adequate opportunities to learn from doctors. And because the farther you go from Cairo, the fewer resources you have to teach doctors techniques, explains Shaalan. So the onus is on them to keep up with the latest information and new techniques that are out there.

For those medical students who are a better connected, they can usually get their assignment transferred from the Ministry of Health to one of the other ministerial hospitals. The most coveted transfers are to the decently equipped military, police or Ministry of Interior hospitals. A handful of students every year succeed at getting this transfer which allows them to train in better hospitals. Dr. Sherif Arafa was among the lucky few appointed to a Ministry of Interior hospital, which was one of the best publicly funded, although not fully public, hospitals. You get fewer students in these hospitals, especially in civilian posts, explains Arafa. But you also get some of the countrys best specialists working as consultants for these hospitals. So you get the opportunity to learn from the best. How much you actually learn is actually up to you as the individual doctor to take the initiative. But at least you have the chance to learn.

Another option is for young doctors to resign from the Ministry of Health and work full time in private hospitals. Aboul Fotouh says this is very similar to a residency but within the private sector. They are the only full-time doctors in hospitals, he says. They get to be in the hospital all day, they do some diagnostic work while the expert consultants are not in the hospital and they make more money than in the public sector. When you think about it, my graduating class included 1200 students. Only 100 of us got hired by the university, the rest of us had to do something. Thats why we each pursue different endeavors. But how much you accomplish depends on your personal initiative.

Systematically in flux

The issue of self motivation is probably one of the most essential when it comes to medical training. In a sector where scientific advances are developing every day, doctors worldwide have to take the initiative to read up on the latest techniques. However, in Egyptian medical schools self initiation is more important than in other countries, where there are better professor-to-student ratios. Arafa says that one of the chronic problems of Egypts medical education is the lack of a systematic curriculum that ensures that doctors are completely qualified to carry out procedures before advancing to more complicated ones. There is no clear curriculum outlined anywhere. So what I learned in my internship might be completely different from what another doctor learned at another hospital. Things get even worse during your residency because there are no guidelines as to what you are supposed to do. For example, there are no guidelines for what you can do with supervision or without supervision. Theres no uniform way to assess how much youve learned.

In most cases, its left up to the supervising doctor. But in terms of having a governmental body that assesses the progress of doctors or even a body loosely affiliated with medical schools to monitor the progress of doctors and assess them, Arafa says there is no such thing. This lack of monitoring has led and continues to lead to disasters. For example, a few years ago, local newspapers revealed that the vice president of one of the local hospitals had actually never completed medical school. He had worked as a surgeon for almost 10 years without a degree. This man had been practicing medicine for at least 15 years, 10 of which he was a surgeon and he didnt even finish school, exclaims Dalia Montasser, a doctor resident at one of the local government hospitals. And theres no way for us to actually find out how many people have managed to become doctors without having the required training to do so, says Montasser. I see it all the time. Some interns and residents just float through the hallways. They dont take the initiative to learn anything and no one forces them to. Then there are those who constantly ask questions, observe procedures performed by other doctors and keep trying to get as many supervised opportunities as they can.

Montasser says there are many who test out procedures on patients without being fully trained to perform them. But no one keeps track and no one follows up. So people have all kinds of procedures performed that they really dont need, and many times they dont even know about it.

As for doctors assigned in the remote areas for their residency, Aboul Fotouh says they end up being primary doctors responsible for a full medical unit. They also have very few resources, if any, to train and no one to learn from. In the rest of the world, the residency is considered the most important part of your training because you are fully licensed as a physician, youre hired by a hospital and youre making a decent income so you can concentrate on your work. But most importantly, your work is supervised and you get the chance to do research while working, which is very important. In most countries, the residency can be as short as two years or as long as five; the duration depends on the country and the specialization.

With such few options, many young doctors just move to western countries to complete their residency, their masters degrees or PhDs.

Surgical brain drain

For those with the financial resources, numerous young doctors who complete their internship in Egypt try to travel abroad to live up to their potential. Shaalan was among them. I finished my internship and relocated to the States where I completed my residency and my education. Then I came back, says Shaalan. A lot of young doctors are finding different ways to go abroad. Traditionally its been the United States and the United Kingdom. But now there are students going to Germany and Canada. Some people come back to Egypt while others just continue to live abroad.

Arafa has just completed his paperwork to continue his education in the UK, although he has already completed his residency and a masters degree. I cant see me living up to my full potential here because I have to choose do I want to make decent living or do I want to be a doctor? Here, these are two very separate things. As a resident and even as a young instructor in university, you make between LE 200 and LE 500 a month. And since you cant live on this salary, you have to supplement your income, so you work for a private clinic in the evenings. When you get a bit more experience, you can work as a consultant, which means youre contracted by several hospitals and then you go to your private clinic. All this gives you virtually no time to study, which is something that doctors have to do for the rest of their lives. He adds that in other countries you spend a lot of money for your education but once youre done, the chances of being hired as a resident and getting paid well are much better than in Egypt.

Shaalan agrees. Almost all physicians in Egypt consult in several places and have their own private clinics. As a well-established oncologist, he still works with the National Cancer Institute, consults and has his own clinic and day hospital. Thats the way its done, he says. You just run around all over the city, commuting from here to there because hospitals here do not hire doctors full time nor would most doctors feel comfortable working in one place full time because they dont always expect hospitals to uphold their end of the bargain. So everyone is a consultant.

While the situation may look extremely bleak, if the ministries of health and higher education would cap the numbers of students admitted and address the issue of low pay, most doctors believe that the situation would improve. But their proposed solutions could create new problems such as finding higher education institutions willing to absorb the number of university graduates who traditionally went to medical school.

The second problem would be in scrounging together the resources to pay all the interns, graduates and residents in government-owned hospitals decent wages. Then there is the issue of actually creating a system to monitor the progress of young doctors, which will require both financial and human resources.

So its more likely that the plea from the Doctors Syndicate will fall on deaf ears and the system will remain the same for some time. Unfortunately, that means the potential for disastrous mistakes will only grow. bt