How A Pakistani Doctor Excelled In Academic Medicine In America
Dr. Abdul Nadir narrates the journey, tribulations and services of Dr. Arshad Jahangir, an eminent Pakistani American doctor who has become a formidable name in academic medicine
Who are these “academic doctors” and how are they different from other clinicians? I had this question on my mind when I approached Dr. Arshad Jahangir (AJ) for an interview. He emailed me his 68-page curriculum vitae which I found extremely impressive, particularly considering that he began his medical journey in Pakistan, where the perseverance and commitment required for doing original work and ultimately achieving academic excellence remains elusive for most.
Currently, AJ holds the appointments of Director of Center for Advanced Atrial Fibrillation Therapies at Aurora Health Systems in Wisconsin and Illinois and is a Clinical Professor at the University of Wisconsin, School of Medicine and Public Health. He is credited with publishing 154 original papers in cutting-edge, peer-reviewed journals, 34 book chapters, hundreds of abstracts and many grants including those he received from the National Institute of Health (NIH). He has also travelled the world presenting his original work to the medical community.
AJ grew up in Islamabad and completed his early pre-medical and medical education in Karachi. He matriculated from the Cantt Public School in 1977 and completed his pre-medical college education from the Adamjee Science College in 1979. Based on high merit scores, he was accepted into the premier medical institution of Pakistan, the Dow Medical College (DMC). AJ had an inquisitive mind, curious to learn the why and the how of any problem he encountered. This was despite the fact that, like everyone else getting an education in Pakistan more than three decades ago, he was also exposed to “traditional rote learning” prevalent in Pakistan. However, AJ was inclined to understand the “mechanisms and basics of science”, right from the beginning of his medical education.
Upon entry into the DMC, he was exposed to the vibrant student political unions and soon he joined the progressive, left-wing National Student Federation (NSF). Despite his education in Pakistan, where students gain entry into medical school without going through a four-year rigorous college education as is compulsory in US, AJ felt that he was adept in the subjects of humanities due to the “daily grind spent on the streets of Karachi”. He did this in the company of fellow DMC medical students who were active in politics. As activists, AJ and his colleagues learned “about the societal aspects of medicine, the inequalities and disparities prevalent in the society and how difficult it is to deliver even the primary care to non-affording patients for whom the students and physicians had to collect money to provide lifesaving medications.” The politics of AJ and his colleagues was based on bringing awareness to the public about the unfortunate disparities present in education and health which pervaded the Pakistani society. Further, they wanted to bring a change and provide justice for the Pakistani citizens through freedom of expression which unfortunately had been forbidden during the strict martial law of that era. Nonetheless, through involvement in politics, even during those times, AJ quickly learned that a change in society occurs only through the application of scientific methods to diagnose, analyze and solve the social problems. In his words, “Address the root cause of the problem and not just merely treat the symptoms.”
The journey in DMC was “based on self-study”. Many teachers were not updated with the ever-growing body of literature of medicine, and students had to prepare for essay-type exams and viva questions based on the books published by the DMC faculty and not from the latest international editions available. Nevertheless, AJ kept up his focus and did well in studies, graduating among the top students of his class in 1986. He had developed an interest in cardiology as a medical student, having regularly witnessed sudden cardiac deaths and heart attacks which were quite common in Karachi. In fact, one of his seniors dropped dead while participating in a sporting event which furthered his interest in causes of sudden deaths, especially in young people like his DMC senior. Thus, he further pursued his career in cardiology as a House Officer at the Civil Hospital Karachi (CHK) while training under Dr. Shareef. At that time, invasive cardiology was just being introduced at Civil Hospital Karachi and there was no specialized area to manage patients with sudden cardiac death or cardiac arrhythmia. AJ passed his US Foreign Medical Graduate Examination in Medical Sciences (FMGEMS), securing his place among the top 5 percent of all candidates and was soon preparing to fly to the US for further training in Internal Medicine. He started at Nassau County Medical Center in Long Island, New York in 1990.
The AIDS epidemic was taking its toll in the US when AJ began his career in Long Island. The emergency rooms were crowded with extremely sick AIDS patients requiring intensive monitoring, exposing AJ to basic investigative tools which were not available to the students in Karachi, such as performing a gram stain in the hospital wards to diagnose the bacteria responsible for causing pneumonia before starting appropriate antibiotics, or the instant ability to conduct arterial blood gases to figure out what exactly was the oxygenation and ventilation status of his patients. He had to learn these technological aspects of medicine, which were all new to him. He had to prepare cases daily to present to his seniors, a new exercise for him as well, forcing him to work 2-3 times harder than his peers who were already well-prepared due to their education in US.
“My theoretical knowledge was very good, but I lacked practical experience with the technology”, he said about himself. “Many students in DMC read textbooks from cover to cover giving them a deeper and stronger foundation in basic subjects like physiology, pathology and pharmacology, compared with US medical students who rush through these subjects in a limited period of time.” AJ’s self-study and strong conceptual background helped him to overcome the obstacles he faced in his first year which were due to his lack of exposure to technical tools in medicine. He said, “It takes a few months for a graduate from Pakistan to overcome these deficiencies and ultimately almost all of them excel as they keep working harder in their chosen medical fields.”
Luckily, AJ got a call from the prestigious Mayo clinic of Rochester, Minnesota, to join them as a second-year internal medicine resident.
“Actually, I had applied to Mayo Clinic for a first-year internship position; however, because of the requirement for a year of prior training in the US for international graduates, they had kept my application on hold and offered an interview for the position of a second-year medical resident. I seized the opportunity to enter this world-class medical institute that is a dream for any medical graduate,” he recalls. “I had no background in research, but my desire for research and academics and the top grades in FMGEMS helped me to get the coveted position in one of the best medical institutions in the world.
Soon AJ was learning the basics of research from clinical observation, scientific methodology, data analysis and putting it all together as scientific studies to obtain insight into disease mechanism and treatment. During the nineties, limited tools were available to understand the basic cellular and molecular basis of disease. Cardiac electrophysiology practice was still based on a trial and error approach, including selection of an appropriate anti-arrhythmic for the treatment of life-threatening cardiac arrhythmia. As someone who was interested in understanding basic mechanisms, AJ said, “Scientific breakthroughs come from learning the fundamental processes at the cellular and molecular level. It’s not just about observing patients’ symptoms and their clinical presentations, but practically applying these principles.”
He undoubtedly loved the experience at this major academic center and opportunities to grow his academic career abounded. He said, “Getting a spot in cardiology at Mayo Clinic wasn’t easy; it was highly competitive; however, Mayo Clinic is a fair system and their mission is to advance the application of science in medicine, to transfer knowledge and to provide equal opportunity to any capable physician. All these attributes have made this institute great, serving the society spanning over a century.” He was in the next phase of his training after completing internal medicine residency at Mayo Clinic where he matched in the Clinician-Investigator track of cardiology fellowship with two years entirely devoted to research. “The lessons that I learned at DMC, that scientific methods are important to bring change in a society or a field, were operative in our day-to-day work here. While clinicians make a big difference in the lives of their patients, it is academic doctors who play a major role in order to go to the next level of preventing disease in the community. As clinicians, we can reach thousands, but as academicians and investigators we can reach millions through our research, presentations, and publications.” After completing his four-year training in cardiology, he spent another year as a cardiac electrophysiology fellow and finally joined Mayo Clinic as a faculty member in 1997.
As faculty, AJ was using all he had learned as a trainee – from basics of ion-channel electrophysiology to clinical medicine – to decipher the mechanism and management of patients with complex cardiac arrhythmia. He was fortunate to find the right mentors who guided him through his journey. He worked hard, “I was there first and left last; it is your family and personal time, nobody gives you extra time so I was working over the weekend and late into the evening.” He was presenting his work on the national and international stage; and he was elated when he received his first five-year NIH grant to pursue his interest in defining mechanisms underlying aging-associated susceptibility to cardiac injury and arrhythmogenesis. He felt that this accomplishment, the fruit of long hours of labor especially for a clinician, with little prior research background and who had to compete with successful PhD scientists at the national level, was not possible without the environment provided by the colleagues at Mayo.
While working in research, he was equally excited about his clinical practice, managing patients with complex arrhythmia using state-of-the-art cardiac electrical mapping and catheter-based ablation procedures. “If you work hard, organize yourself, and plan ahead, no one can stop you from accomplishing your dreams and goals,” he said. AJ got more interested in the role that ion channels play in cardiac cell regulation, molecular basis of arrhythmia, cardiac aging and how mitochondrial dysfunction’ role in aging and scar formation in the heart promoting arrhythmogenesis.
Burning the mid-night oil continued to bear fruit. He made himself capable to read and critique grants for NIH and became successful in obtaining other multimillion-dollar grants to advance understanding of the basis of the heart’s susceptibility to injury and arrhythmogenesis. He was invited by the NIH on a regular basis to critically review grants submitted by the top scientists in the country for funding and became a permanent member of the NIH scientific study section for grant review. He believes that “the next breakthrough in medicine will come by advancing translational research, bringing knowledge from the molecular level to the clinics by physician-researchers”. Physicians like him, with understanding at both bench and clinical level, play an important role and work as an essential bridge between the scientists in the laboratory who have little understanding of disease management to those physicians in the front line practicing in clinics and hospitals typically, [while] unaware of the latest bench research. Unfortunately, there has been a decline in the interest of clinicians to engage in research, because of the hardships, lack of appreciation by hospital administrators and overall culture based on clinician’s financial productivity and ultimately the focus on revenue generation in hospitals. Says AJ, “Currently there is a big gap between scientists and clinicians that is growing with an immense need for doctors who can tie basic science to clinical medicine not only to improve care of sick patients but also to promote wellness in the healthy.”
He adds, “It is the best time for young physicians and investigators to do research. We will not only be treating people who have a disease, but will also be able to detect and find out in advance the possibility of the origination of a disease. We have the tools that can help us identify risks through genetics and biomarkers that need refinement for early diagnosis, prognosis and identification of those who will have a positive therapeutic response to various interventions, to fulfill the promise of personalised medicine. You can now engineer genes to alter the expression of diseases which were previously incurable. While these tools are in an investigative stage, within a few years the new knowledge will change the practice of medicine.” He advises young clinicians, “Academic medicine is a hard journey, but the reward of changing the field of medicine, alleviating suffering and changing our society is bigger than any financial incentive, he added, “Life as an investigator is becoming difficult as funding is shrinking, hospitals are not helping academics, there is more pressure to generate revenue and research is expensive with intense competition and constant pressure to publish or perish. However, without the contribution of young physicians, the scientific progress cannot move as fast as it is needed.”
He also says, “Young clinicians should identify knowledge gaps and review literature in depth to come up with the right questions to generate sound hypotheses and work with their mentors to advance science and clinical practice. Don’t accept any dogmas unless it is scientifically proven; however, you will also learn to realize your limitations and it [is what which] makes you humble. Humility is an essential trait that you learn as a physician and as an investigator and be aware of the fact that little knowledge is dangerous.
He defined any physician as an academic who is driven by evidence to translate science into medical practice, or help generate or disseminate knowledge. Those who generate new knowledge and those who translate that knowledge into clinical practice are all part of academics. AJ believes that research will keep advancing and physicians who care about their patients are becoming better at using evidence and turning basic discoveries into clinical tools.
After staying at Mayo Clinic, Rochester, for about two decades and rising above the academic ladder to become a Professor of Medicine, AJ was invited to lead the area of cardio-gerontology research at the Mayo Clinic, Arizona in 2010. He started the research program in Scottsdale/Phoenix and a couple of years later, he was invited by Dr. Jamil Tajik. He was one of his mentors and pioneer in cardiac imaging at Mayo Clinic who had moved to Milwaukee to start a translational research program on cardiovascular aging and arrhythmia in Wisconsin. He felt privileged to work with the two giants of cardiology there, Dr. Tajik himself and Dr. Masood Akhter, two pioneers and stalwarts of clinical electrophysiology.
AJ continues to practice academic medicine in Wisconsin, combining research with patient care and interacts with trainees and young faculty in various phases of their career, not only at his own institution but throughout USA and in Pakistan to guide them in research and cardiac electrophysiology practice.
AJ was all praise for US society which welcomed him with open arms, helped him to become what he wanted and continues to welcome international graduates with opportunities to excel. Nonetheless, he follows his roots and loves his native language and literature. He has tried to inculcate good attributes of Pakistani culture in his three children that are going to college, while embracing the freedom of choice available in US culture. He has remained connected to Pakistan and routinely goes to academic conferences held under the auspices of Pakistan Heart Rhythm Society and academic medical centers. AJ’s biggest joy is working with young physicians who want to learn the basis of disease. He wants to guide them and provide them the opportunities he lacked when he was pursuing medical education in Pakistan. He said, “Young Pakistani students are full of potential, they are respectful and look up to many US-trained physicians as role models. They have the talent and the will to work hard and by proper guidance, the sky is the limit for them.”
Most recently, he has come to realize that young Pakistani physicians have become very resourceful using online tools for learning and really knowing their stuff. “Raw talent in Pakistan is exceptional; and medicine ultimately is self-study but requires proper mentorship and role models to follow for the young doctors in Pakistan to accomplish their full potential and advance their career, whether staying in Pakistan or training abroad.” He pointed out that Agha Khan University, Dow Medical University and King Edwards Medical University are excellent institutions and provide direction for other aspiring institutions in Pakistan. He felt that some institutions in Pakistan that are commercially oriented need to improve focus on academics. The freedom of speech in the US allows US students to have free and open discussion with their teachers, while in Pakistan some educationists still lord over their students. He said, “I would like my students to be able to speak to me without fear and should know I am not the last authority or the last word, but a student of science like them.” AJ believes in equal opportunities for all. He points out that contrary to the popular belief that everything is hunky-dory in US, even in US many people live worse than in Pakistan and the disparities in healthcare is something we all need to fight to alleviate human suffering.
“Health care is a basic right and it should be the responsibility of the state to provide medical care to its citizens; medicine should not be commercialized and diseases need to be diagnosed earlier than at a [later] stage where these become difficult and expensive to manage [and treat].”
Personally, AJ spends time with his family, loves art and travelling, which takes him around the world and allows him to interact with physicians and students. He used to paint and write as a medical student and is planning to write and publish English poetry when he has more time available. As a leaving question, I asked him, “How were you able to live in the blustery and cold mid-west weather for so many decades?” His answer was crisp: “It is the warmth of people that matters, otherwise weather doesn’t bother me.”
I found AJ to be a down-to-earth gentleman and a cutting-edge academician who embodies excellence in medicine. He made a difference for his patients in the mid-west and made an impact in the field of medicine through his research and publications while continuing to inspire and interact with his peers and juniors in Pakistan to help advance their careers. Our prayers are for his success in any goals he sets for himself in the future.
Dr. Abdul Nadir M.D. is an Assistant Professor at University of Arizona, U.S. He is the head of Gastroenterology and Hepatology at Maroof International Hospital, Islamabad.