A day in the life of a medical student from Pakistan

A “house job” means long hours

Azeem started her “house job” (internship) in September2019 and worked up to 120 hours a week. “No one talks about it”, she says. “You’re on call for 31 hours, work the next day, and will probably have a night shift in the ER (Emergency) the day after. You might expect to get seven hours of sleep during a 31 hour shift, but it’s difficult to find time to sleep if you have sick patients.”

Many Pakistani students aren’t as concerned about their long hours as Azeem. She thinks that some interns rationalise the amount of work because they’re getting paid for it, unlike at medical school, and they get to use the title of doctor for the first time. Azeem says “interns accept that our working hours are inherent to our profession, but I think it’s dangerous and wrong.”

Azeem still wants to work in Pakistan. She explains: “You can have an important impact as a doctor, especially because of the high level of health illiteracy in Pakistan. This gives me a sense of purpose and makes the results of the hard work rewarding.”

Although passing the final examination of the Bachelor of Medicine and Surgery programme makes you a doctor, you need to complete the year in a house job to get a licence to practise in Pakistan. Azeem mentions three types of students who do not continue the course to the house job: foreigners who want to go back home, those who want to go abroad and become licensed there, and those who don’t want to practise medicine, who are mostly women “Women in our society are less likely to take up a full time working career compared with men, partially because they marry younger and are expected to lead lives that are less centred around their careers.”

More women than men are medical students

In Pakistan women outnumber men as medical students. “It’s not just that more women take the medical college admission test, it’s also because women score higher.” Azeem continues, “Only students with the highest marks can get into government medical schools. The Higher Education Commission and Pakistan Medical and Dental Council even considered putting up a ratio of 50% men: 50% women, because we were ‘wasting seats’ on women less likely to continue in a clinical career. Are you crazy? It [the ratio quota] wasn’t implemented.”

Students who don’t get top marks and aren’t accepted into government schools can apply to private medical schools, but the fees are higher than the $300 (£230; €255) Azeem pays annually.

Azeem lives at home, about 40 minutes from her university, but most of her classmates do not come from Lahore. “More than 65% of our students live in hostels affiliated with the universities,” she says. “There are dorms with up to three beds. They’re not that crowded, although the bathrooms aren’t as clean as you’d like them to be. Most of the hostel students miss home, and they tell me how lucky I am to live at home where I get homemade meals.”

Life as a student in a government medical school

At a government medical school, students work six days a week, from 8:00 to 14:00. “Many of my friends from other countries use their weekends to go hiking or visit other cities, but that’s much less common here,” Azeem says. “We mostly use our days off to hang out with friends or family. We don’t have a lot of clubs or nightlife; instead, we usually enjoy going out for lunch together.”

Azeem’s working days consist of two hours each of lectures, tutorials, or dissection and laboratory work. In their final three years students spend one to two hours on the wards each day. Azeem says, “Biochemistry is interesting because we experiment on blood, urine, and solutions of proteins and carbohydrates. I also enjoy physiology because we do experiments on frog hearts and on drugs, and in histology we look at slides of human tissue, draw what we see, and label them.”

“We are good at science, but I think we miss out on being taught about emotional aspects of healthcare, or about the health system itself,” Azeem says. “I hope that other medical schools around the world at least use some books written by authors from their own country and relevant to the needs and reality of that country. Our university doesn’t. I was taught public health and community medicine from a book written by a foreign author. The author stated that culture is important, but the book didn’t say anything about the situation in Pakistan. Only some of our most passionate teachers tell us about local context and social drivers [in Pakistan].”

Another example is a book of medicine we used, which stated that in hypertension management a Caucasian under 55 years should be started on ACE inhibitors as first line treatment, whereas people of African origin or Caucasians older than 55 years should be given calcium channel blockers as a first line in management, but Pakistan's majority population consists of neither and we never studied guidelines specific to us.”

Azeem has many Pakistani role models, such as Sania Nishtar, who was nominated for the position of director general of the World Health Organization in 2016.1 She is also inspired by some of the doctors at her local hospital. “They work their butts off.” she says, “They see 60 patients a day, realise they come from far and near, and make the time they need to see each patient. They know a lot, and rather than assuming diagnoses on the basis of a patient’s age, they consider the full range of diagnoses. They’ll also follow protocol, which is more difficult than it sounds—it’s common here [in Pakistan] to overprescribe antibiotics to be on the safe side, but these doctors won’t. The doctors I look up to are kind and sensitive to their patients, no matter who they are or where they come from.”

Azeem (fig 1) wants to pursue a career in public health, to work on making the Pakistani health system better. She explains: “I think a lot of medical students are trying to change the system for the better, and there is a lot that can be done. I hope that the current generation of medical students will take on some of these challenges and strive for a better health system.”

Fig 1

Nishwa Azeem

• Download figure
• Open in new tab
• Download powerpoint