The crisis of engagement: A major challenge in medical education in Pakistan

Although medical education is considered to be academic training but it sets the core values for medical practitioners and is a foundational process for producing knowledgeable, ethical, and clinically capable healthcare professionals. Medical education in Pakistan has drastically improved over the past few years. Despite the reforms, there are a number of challenges that still need to be overcome. Among the most pressing problems are low classroom attendance and a stern attitude of medical students toward clinical subjects throughout the MBBS program. Consistent attendance and regular student engagement in the academic activities are a critical component of the MBBS training program. Studies have reported a positive correlation between attendance and academic performance in medical students1, 2. Better attendance is also linked with a better understanding of clinical reasoning and patient management1. Various studies have highlighted low attendance among the medical students in Pakistan. Khan et al reported that average class attendance in pre-clinical years ranges from 50% to 65% in many institutions3. Another recent study reported that attendance even drops down to 40-50% in clinical years4. Students have been reported to attend the classes to meet the bare minimum set by the regulatory authority, usually to avoid being barred from the exams rather than attending the classes for academic interest3, 5. Digging into the cause of such decline in attendance across the medical years shows that multiple factors are involved in declining attendance among medical students. Around 70% of medical students preferred self or group study over attending lectures6. A recent study reported that students focus more on high-stakes exams, and there is a decreasing trend in attending the clinical rotations that don’t directly impact grades5. Students also reported outdated teaching methods with passive teaching and unstructured ward interactions as a cause of low interest7. Stress and burnout from continuous academic pressure and competition is yet another reason for poor student engagement8. Medical students are not provided with adequate breaks after their professional examinations to recapitulate their energies for the next sessions. A study also related poor teacher’s attitude with low engagement of medical students9. To tackle this issue, multiple reforms can be done at various levels. Starting from the implementation of regulatory policies. Attendance should not be merely for the presence of students and record keeping, but rather to increase student’s interests and motivation. Reforms such as the usage of biometric systems, digital log-books, and learning analytics can support this3. Along with these, surprise audits can yet improve attendance. Restructuring of the teaching methodologies used in clinical teaching is also expected to improve the student’s engagement. Ward rounds should be more interactive, patient- centred and competency-based to improve student’s motivation. For clinical teaching, frequent use of Mini clinical evaluation exercises (Mini-CEX), ObjectiveStructured Clinical Examinations (OSCEs), and simulation labs should be routinely used10. Along with curricular reforms and administrative changes, the human behavior aspect also needs to be addressed. Institutions need to work on the motivation of students as well as the faculty. Faculty development programs must train teachers to become mentors to inspire the students rather than being instructors. Rewarding the faculty contributing in high-quality clinical teaching will also increase the motivation of faculty, which will directly influence the motivation of students9. Better student support programs, improved counselling and wellness plans should also be integrated in medical institutions to reduce burnout and foster motivation among medical students8. Failure to complete essential teaching and training in Medicine, Surgery, Gynecology, and Pediatrics can leave significant gaps in student’s education and preparation for medical practice11. Without this training, such a person will lack the necessary clinical skills, experience, and competence to diagnose and treat patients independently. Moreover, they cannot meet the standards expected from a qualified doctor, which jeopardizes patient safety and well-being. Poor attendance and apathetic attitude towards clinical subjects are symptoms of a larger crisis in medical education in Pakistan, and this aspect needs to be addressed appropriately. Policies alone cannot handle this situation. Constructive reforms addressing the curriculum, faculty, and students are required. With such reforms, we can hope to train doctors who are not only knowledgeable but also clinically competent and compassionate.