Madam, we have read "Poor patient counseling: How does it affect the prognosis of a disease?"¹ by Memon and Colleagues with interest. They have rightly pointed out a deficiency of our health care system which is neglected both at under and post graduate medical education as well as clinical practice. Patient counseling and doctor patient communication is a therapeutic intervention which has long lasting beneficial effects (e.g., reducing the patient\\\'s anxiety, providing comfort).² But the problem is not as simple as these young medical students have presented. There are few additional aspects which need to be considered.
Pakistan has a population of more than 187 million³ while the number of registered General and specialist doctors/ dentists with Pakistan Medical and Dental Council is 163206.⁴ Most of them are working in urban areas where only 36% of Pakistani population resides.³ In addition many of these registered doctors have moved abroad or are not practicing any more (the case with many female doctors who stop practicing after marriage).This leaves a relatively small number of qualified doctors to provide services to a very large population. We all have witnessed busy outpatient departments in the public hospitals where few house officers and residents along with a consultant or two are trying to attend hundreds of patients with different diseases, from a diverse backgrounds, cultures, languages and educational level. In these circumstances patient counseling thus becomes a victim of this abnormal doctor: patient ratio.
In the wards patient counseling and breaking the bad news is usually left to the most junior member of the team (House officer). This only results in further confusion and unanswered questions for the patients and their attendants.
In addition patient counseling is communication skill that needs to be taught both at the under graduate and post graduate medical training. Skills that medical students learn in their early years stay with them for life. To the best of our knowledge there is no specific training /teaching programme for under graduate medical students in Pakistan to prepare them for patient counseling. Patient counseling is only a small part of the three days communication skills workshop offered to post graduate trainees by College of Physicians and Surgeons of Pakistan (CPSP).
There is evidence that patients from low socioeconomic class and less privileged races are less likely to receive quality counseling as opposed to the patients with a better social class.^5,6 The patients from lower social classes receive less positive socio-emotional utterances and a more directive and less participatory consulting style, characterized by significantly less information giving, less directions and less socio-emotional and partnership building utterances from their doctor. This can also be a contributing factor towards poor patient counseling culture in Pakistan as majority of the Pakistani population is from low socioeconomic class.³
Poor patient counseling is only a part of the bigger problem that faces Pakistani health care system. There is a need to reform the medical education and health care system in Pakistan. Needless to say, that we have to increase the number of doctors and improve the doctor: patient ratio. Also medical students and post graduate trainees need to be trained in patient counseling skills through classes and workshops. The senior clinicians and faculty have to set personal examples where they should listen to their patient with patience, explore his/ her concerns, answer his/her questions and show empathy. All this should be done in the presence of young doctors so that they are also trained in the art of patient counseling which cannot be learned in class rooms and workshops alone.
 
Farooq Azam Rathore,1 Fareeha Farooq2
Department of Rehabilitation Medicine, Armed Forces Institute of Rehabilitation Medicine, Rawalpindi,1 Park View Town, Park Road, Islamabad.2
Corresponding Author: Farooq Azam Rathore.
Email: farooqrathore@gmail.com

1. Memon AA, Rehman A, Tahir F. Poor patient counseling: How does it affect the prognosis of a disease? J Pak Med Assoc 2012; 62: 56.
2. Street RL Jr, Makoul G, Arora NK, Epstein RM. How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient EducCouns 2009; 74: 295-301.
3. CIA World Fact Book Pakistan. (Online) (Cited 2012 Jan 17). Available from URL: https://www.cia.gov/library/publications/the-world-factbook/geos/pk.html.
4. Pakistan Medical and Dental Council.Statistics. (Online) (Cited 2012 Jan 17). Available from URL: http://www.pmdc.org.pk/Statistics/tabid/103/Default.aspx.
5. Willems S, De Maesschalck S, Deveugele M, Derese A, De Maeseneer J. Socio-economic status of the patient and doctor-patient communication: does it make a difference? Patient Educ Couns 2005; 56: 139-46.
6. Gordon HS, Street RL Jr, Sharf BF, Souchek J. Racial differences in doctors\\\' information-giving and patients\\\' participation. Cancer 2006; 107: 1313-20.