Healthcare is a multidimensional field, requiring several disciplines to synergize to provide holistic patient care. However, in Pakistan, the medical fraternity functions under a rigid hierarchy, with doctors, especially physicians, at the top. Such a dominant attitude springs from social mentality, professional education, and institutional practices that carefully drive a false sense of superiority among doctors. This hierarchy dies down collaboration, which takes away from the contribution of other professionals and, in the long run, affects patient care. Hence, this article examines the roots, the present-day manifestations, and the ramifications of such a medical hierarchy, proposing ways to reinstate balanced healthcare collaboration.
Historical Roots of the Medical Hierarchy
The genesis of the medical hierarchy in Pakistan stemmed from the colonial period when the British set up their healthcare structures specifically in support of Western-trained physicians. Colonial authorities viewed clinical medicine as superior to indigenous healing practices like Unani medicine and Ayurveda, which were prevalent across the Indian subcontinent. The spinoffs, however, were not just at the medical level; they operated on a well-structured strategy for consolidating colonial might. By opening hospitals, setting up medical colleges, and designing public health policies leading at times entirely to the dictates of Western medicine, the British were able to create a class of elite physicians trained to act as intermediaries between the colonial state and the local populace.
The emphasis on clinical medicine suppressed and marginalized any other medical discipline that did not complement clinical medicine. Nursing, midwifery, and pharmacy were, hence, perceived primarily as subservient, relegated in importance, or, at times, excluded entirely. They didn’t get the opportunity to dominate sectors as crucial contributors to a healthcare system but were seen more as purely technical vocations. This ground structure instilled a hierarchy in the professional ranks, with doctors being the unquestioned rulers and the rest appearing subservient.
After independence, Pakistan inherited this structure from colonialism, further increasing its dimensions. Healthcare policies continued to operate as per the doctor’s centralized position, and even the presence of allied healthcare professionals was often disregarded. Medical education institutions with Western-style training were enshrined as the gold standard for developing physicians, and their graduates were taken as embodiments of intellectual and professional prestige that fortified their dominance in the healthcare system.
Pakistani universities have traditionally underfunded pharmacy and physiotherapy education programs; these two branches of learning have never been subsumed into an existing healthcare system. Some allied health professionals have no defined jobs within the hospital setting, which maintains an ethos of undervaluing their input or ignoring it altogether compared to countries with a multidisciplinary healthcare model.
Colonial influences also coalesced to form a physician-centric public health policy. Preventive care, community health initiatives, and holistic patient management, in which allied healthcare professionals play a crucial role, are hastily dismissed or poorly catered to instead of clinical interventions controlled by physicians.
Grasping these historically rooted reasons is critical to locating the systemic issues that thwart interdisciplinary collaboration in Pakistan’s healthcare system.
The Superiority Complex Among Doctors
In Pakistan, medical doctors often have an erroneous perception of superiority over their colleagues, owing to society’s perception of the profession, its prestige, and its general nature. This is not so much a personal fault as a consequence of certain systemic factors creating an almost absolute doctor hierarchy.
Beginning early, medical students and junior doctors are crammed with clinical excellence and decision-making in their training, while interprofessional skills are sparsely taught. While this provides the students with skills to diagnose and treat health problems, it hardly gives room for collaboration with others involved in health care.
In Pakistan, the profession is of immense prestige, which gives a blanket impression associated with authority and, in some cases, infallibility. This immediacy puts fellow healthcare workers and patients in a submission mode regarding any judgment made by a doctor, thus reaffirming their supremacy and limiting the healthy communication so essential in a collaborative approach to healthcare.
Overstepping Boundaries: Case Studies
In Pakistan, the hierarchy has taken different shapes in overlapping professional boundaries. While this is occasionally unintentional, it stems from either a lack of education or ignorance of the expertise of other healthcare professionals. Such practices lead to less-than-optimal results, affecting patient care and undermining the work of allied healthcare experts. Below are a few examples of the ripple effects of this overreach.
Medication Mismanagement: Ignoring Pharmacist Expertise
Even though pharmacists are trained specialists in pharmacology and drug interactions, their say in the whole affair rarely counts in lieu of the current mode of pharmaceuticals practised in Pakistan. More often than not, doctors tend to prescribe medicines without consultation with a pharmacist who is wholly qualified to do assessments on patients on multiple medications due to chronic illnesses. An assessment is needed concerning drug interactions, contraindications, and patient-specific pharmacokinetics. In the absence of a pharmacist, these considerations may not be adequately addressed and may, therefore, lead to dangerous patient outcomes, such as adverse drug reactions, therapeutic failures, or overdoses.
For instance, concomitant use of certain painkillers with anticoagulants increases the risk of internal bleeding, which, under normal circumstances, a pharmacist will know yet may escape the radar of some prescribing doctors.
Exercise Prescriptions: Overlooking Physiotherapy Expertise
Physiotherapy is now an advanced science that entails and represents an integration of deeper and basic knowledge of anatomy, biomechanics, and rehabilitation methods; however, they are often not asked by doctors to suggest treatment methods to their patients recovering from injury, surgery, or chronic illness.
Orthopedic surgeries, such as knee replacements, require specific regimens to help patients regain joint mobility and strength due to the danger of stiffness or malfunction of the bone without proper rehabilitation input. Simply telling a patient to “walk more” isn’t the solution.
Such practices also demean the physiotherapist as a profession, depriving the patients of a facility that could help them improve their quality of life or rehabilitation trajectory.
Dietary Missteps: Marginalizing Nutritionists
Nutrition is a pillar upon which chronic disease management, recovery from illness, and health rest can be achieved. A nutritionist is well-trained to structure individualized meal plans according to the patient’s dietary needs, existing health conditions, and cultural preferences. Meanwhile, most doctors only recommend general guidelines for nutrition, which may end up being impractical or ineffective.
A common example would be diabetic patients who are told to “avoid sugar”; this kind of vague advice neglects the nuanced approach to treating blood glucose levels. A nutritionist would build around the principles of carbohydrate counting, portion sizes, and the glycemic index of foods to provide a complete dietary guide to promote steady blood sugar levels and health.
Leaving this knowledge out of any intervention does not just reduce the possibility of beneficial outcomes but also makes one forget the important elements in the holistic nature of health care.
Breaking Down the Hierarchy: Toward Collaborative Healthcare
A significant move is required to shift away from the hierarchy and toward more collaborative strategies in the delivery of healthcare. Communication and collaboration will improve patient outcomes and optimize the use of available resources. Below are major steps to provoke the turnaround; details will follow.
Integrating Interprofessional Education (IPE)
Interprofessional Education (IPE) has created collaboration among healthcare professionals. Medical, pharmacy, physiotherapy, and nutrition students must work together for training in workshops, simulations, and actual case scenarios. This will go a long way towards building respect and understanding of each profession’s contribution to patient care.
For instance, a medical student doing a case study on polypharmacy could learn from a pharmacy student about the interplay of various drug interactions and patient-specific pharmacology unique to that case. Just as valid would be a physiotherapy and nutrition student learning to work hand in hand in rehabilitation planning, learning how exercise and diet play off each other and complement medical interventions. Curricula in Pakistan’s medical schools must begin to reevaluate and evolve to implement such inter-professional modules.
Public Awareness Campaigns
Public education on the roles and values of allied health professionals can go a long way toward decreasing the undue reverence with which doctors are treated as sole authorities in healthcare. Awareness campaigns through social media, television, and community programs can help pharmacists, physiotherapists, and nutritionists improve patient care.
For example, these public service messages can state how pharmacists avoid drug errors through joint drug therapies, physiotherapists accelerate healing by applying for specialized rehabilitation programs, and nutritionists assist in putting together a dietary program. This could be made even better by testimonials of patients who have benefitted from those professionals.
Through community workshops, allied professionals will have opportunities to educate communities about their roles.
Policy Reforms
Regulatory bodies like the Pakistan Medical Commission and the Pharmacy Council of Pakistan are called upon to provide policies to empower multiple allied healthcare professionals. For example:
Pharmacists should employ the use of their power to review and alter prescriptions whenever possibilities for drug interactions or contraindications arise.
Physiotherapists should be permitted independent management of their rehabilitation programs without the permission of a doctor.
Nutritionists should have a formal role in hospitals and clinics, making the dietary intervention part of the whole patient care.
Further, accreditation standards for the hospital could include the practices of multidisciplinary professionals, thus motivating the hospital to include the allied professionals in their team.
Learning from International Models
Pakistan can incorporate interdisciplinary healthcare models from the UK, Canada, and Australia, and collaboration among practitioners has significantly improved outcomes. Such models can be initiated in teaching hospitals and, over time, expanded throughout the country. Training for healthcare leaders on how best to implement these approaches can further help hasten the adoption of collaboration.
The medical hierarchy in Pakistan, deeply grounded in historical discrimination, weakens the vital role of other healthcare professionals. However, this hampers patient care and entrenches redundancies in the already flawed healthcare system.
A paradigm shift from hierarchical to collaborative will resolve this issue, rooted in education, policy reforms, and cultural change. Recognizing the importance of pharmacists, physiotherapists, nutritionists, and many more is not just a matter of professional equity; it is a social necessity for a competent patient care system. The road ahead calls for concerted action to bring about the fall of the old hierarchies and reap the benefits of teamwork in healthcare.
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Momina Areej is currently pursuing an MPhil in Clinical Pharmacy Practice. With a passion for writing, she covers diverse topics including world issues, literature reviews, and poetry, bringing insightful perspectives to each subject. Her writing blends critical analysis with creative expression, reflecting her broad interests and academic background.