Intended for healthcare professionals


Subspecialty training opportunities in Pakistan for cleft lip and palate surgery

BMJ 2015; 351 doi: (Published 12 August 2015) Cite this as: BMJ 2015;351:h3516
  1. Kana Miyagi, plastic surgery registrar, Department of Plastic and Reconstructive Surgery, Addenbrooke’s Hospital, Cambridge, UK,
  2. Muhammad Riaz, consultant plastic and reconstructive surgeon, Department of Plastic and Reconstructive Surgery, Castle Hill Hospital, Cottingham, UK,
  3. Christopher Hill, consultant plastic and reconstructive surgeon, Department of Plastic and Reconstructive Surgery, Royal Victoria Hospital, Belfast, UK,
  4. Rashid Gatrad, professor in paediatric medicine, Walsall Hospitals NHS Trust, West Midlands, UK
  1. kana.miyagi{at}


Kana Miyagi and colleagues describe the opportunities available to gain surgical experience in cleft lip and palate surgery in Pakistan

Junior doctors often spend a period abroad to increase their exposure to areas of subspecialty interest and learn different approaches. Although the United States and Australia are popular choices for many juniors, one country that offers considerable potential is Pakistan. Many people in the United Kingdom harbour misconceptions about the country, gleaned from negative Western media coverage, viewing it as a place of political unrest and social inequality. However, the opportunities for gaining hands-on clinical experience are excellent.

One area where UK trainees can benefit from substantial clinical experience is in plastic surgery, particularly cleft lip and palate surgery, where superspecialisation has restricted attachments. Cleft lip and palate is a common condition in Pakistan, with an incidence of roughly one in 500.1 Poverty and lack of services, particularly in remote villages, leave children untreated. Concomitant impairments in feeding, speech, and schooling ultimately result in exclusion from society, and where services are available there is little multidisciplinary care.

Working with charities

Much of the need for cleft services in Pakistan is met by charities.2 In 1998 Pakistani doctors from the UK, with the support of a local charity, the Decent Welfare Society, established a cleft camp in a private hospital in Gujrat. They invited colleagues to attend, operate, and provide clinical support twice a year, for free.

The quality of surgery and training carried out by visiting surgeons was so high that the purpose built, state of the art Cleft Hospital was built, with funding from the Japanese government and the Midland International Aid Trust. The operating facilities and equipment in the hospital are comparable to those used in the UK. A doctor trained locally by international surgeons now works there regularly, supported by the SmileTrain charity and twice yearly visits from an international volunteer team. The service remains free at the point of care and is promoted using local media and by word of mouth.


Fig 1 Cleft Hospital in Gujrat. The modest exterior belies the well developed care environment inside


Fig 2 Clinical services are promoted to the public by word of mouth, mass media, and billboard advertising

Operating experience

We recently visited the Cleft Hospital in Gujrat to provide clinical care. On our arrival, there were already long queues of patients, some having travelled many hours to attend. The administration staff were remarkable in their organisation, enabling the high volume of patients to be guided efficiently through the system.

A comprehensive multidisciplinary cleft service is provided, including dentistry, speech therapy, and audiology. Many patients also sought care for conditions other than cleft lip and palate, and were treated as far as resources allowed.

The highly skilled local theatre nursing team quickly adapted to working with a new medical team and was able to anticipate surgical requirements. UK trained doctors may have to make some adjustments. For example, many equipment sets taken for granted in the UK were not stocked, although all necessary instruments were available and of high quality, and the theatre water supply was cold because of regular disruptions to the local power supply. Situational awareness is key and is an important skill to learn from the consultants.

We operated on 15 to 20 patients each day between two theatres, performing a mixture of cleft lip and palate repairs, cleft rhinoplasties, burns scar contracture releases, skin cancer excisions, and correction of other congenital malformations. The case volume was at least double that in the UK, resulting in operating days routinely lasting more than 10 hours.

Unmet need for perioperative care

Despite the good facilities, some obstacles to working with cleft patients in Pakistan remain. For example, the current lack of orthodontic intervention means that many palatal clefts are wide and consequently more challenging to correct.3 Because the centre is new, a number of core facilities are still being developed. These include specialist preoperative assessment for pre-existing medical conditions that may impact on fitness for general anaesthesia or the surgery itself and high dependency and intensive care units for aftercare of babies who are unstable postoperatively.

Dissemination of skills and education

A fundamental principle underlying the involvement of international doctors in the Cleft Hospital is the dissemination of knowledge and skills to the local community. Many of the Pakistani doctors who attend to operate have been trained by UK or US clinicians and are now in turn training new surgeons at local medical schools.


Fig 3 The collaborative intraoperative environment, where international consultant expertise is disseminated to local staff and visiting trainees

There is also a considerable drive to improve public health and provide education to the resident population. During our recent visit we were interviewed on television and shadowed throughout by a documentary film crew.

In addition, the Pakistan Association of Plastic Surgeons organises a variety of educational events and conferences, attracting a diverse array of international expert speakers. Presentations are delivered in English and cases presented by local doctors are of high educational value to UK trainees, particularly regarding management of large tumours that would have presented much earlier in resource rich settings and trauma and burns cases from conflict areas.

Engaging in clinical practice as a foreign trainee

Trainees who want to pursue a clinical attachment in Pakistan should liaise with UK consultants already involved in such initiatives. They should also contact charities and hospitals with links abroad. The Pakistan Medical and Dental Council is the national licensing body for medical practitioners. In general, local hospitals will be able to get permission for a foreign trainee to work under their supervision. UK medical qualifications are widely accepted. Unlike working for the NHS, there is no national medical indemnity scheme in Pakistan, and trainees should therefore discuss work plans with their own indemnity provider.

Junior doctors resident in the UK will be required to arrange a visiting visa (if attending for a short, unpaid attachment) or work visa (if planning a paid fellowship). At the time of writing, these cost £104 and £332, respectively, plus a £2 processing fee. Visa applications can be made in person (allow five working days) or by post (allow three weeks) through the High Commission of Pakistan in London.

In addition to the visa form, the application must include an original passport (valid for at least six months) and photocopy, two recent passport sized photographs, a letter of invitation or employment offer from the sponsor in Pakistan, the address of residence in Pakistan and itinerary, bank statements for the preceding three months, proof of residence in the UK, and a letter of reference from the current workplace. No additional vaccinations are required, although health and travel insurance are recommended.


  • Competing interests: We have read and understood BMJ’s policy on declaration of interests and declare the following interests: MR is a trustee of the Cleft Hospital and the Overseas Plastic Surgery Appeal, was the principal doctor involved in the development and provision of the cleft service in Gujrat, and attends the Cleft Hospital twice a year to provide clinical care. RG is a patron of the Midland International Aid Trust, which has provided financial support to the Cleft Hospital, Gujrat, and is involved in the development of the paediatric and obstetric services.


View Abstract