How to boost gastroenterology training in Nigeria, by Ajayi
Medical experts have made recommendations on how to boost gastroenterology training in Nigeria.
Gastroenterology is the medical specialty that deals specifically with investigation, diagnosis, and management of disorders of the digestive system, including the pancreas and liver.
The experts at the 60th birthday anniversary of the Chief Medical Director (CMD), University College Hospital (UCH) Ibadan, Oyo State, Prof. Jesse Abiodun Otegbayo, said to make trainees better for the future, the country needs to: encourage the pursuit of new knowledge; return to clinical problem solving; customise evidence-based medicine (EBM); and close the gap between what society expects and what it is getting.
Professor of Medicine and Gastroenterology and Chief Medical Director of Ekiti State University Teaching Hospital, Oladimeji Ajayi, in a lecture delivered at Otegbayo’s 60th birthday anniversary, called for establishment of repair and maintenance centres and inauguration of Nigerian or National College of Gastroenterology to further compliment training.
Ajayi also called for establishment of National Digestive Disease Centres in both Lagos and Abuja, fully equipped with state-of-art facilities to serve as the apex referral centre for gastrointestinal tract (GIT) diseases, as well as a central training hub for gastroenterology in Nigeria.
Ajayi said stimulation based training should be encouraged. He said as supposedly rare GI diseases are now frequently diagnosed, there is urgent need to step up training in various subspecialties of gastroenterology to meet future demand and subspecialty curriculum in all areas of gastroenterology subspecialties to be put in place.
The professor of medicine said gastroenterology training programmes must provide an intellectual environment for acquiring knowledge, skills, clinical judgment, attitudes, and values of professionalism that are essential to the practice of gastroenterology
He said while it is recognised that trainees provide substantial service to their teaching hospitals, service commitments should never compromise the achievement of educational goals and objectives.
Ajayi said every aspect of training should include cultivation of an attitude of skepticism and inquiry and a dedication to continuing education that will remain with the trainees throughout their professional careers.
He said a major contributor to the enhancement of a scholarly attitude is active participation in one or more research projects, ideally followed by presentation of the work at a national meeting and publication of a paper in a peer-reviewed journal.
“In keeping with the trend in medical training across all specialties, sub-specialisation of gastroenterology training must be our focus. To start with, we can have five subspecialties: nutrition, hepatology, endoscopy, oncology and inflammatory bowel disease (IBD). Curricula should be developed to meet the expected competencies and training needs,” he said.
Everyone to be trained first as a general gastroenterologist or hepatologist. Additional one year post part II to be spent in any areas of gastroenterology subspecialties abroad for those that desire to become super specialists,” he said.
Ajayi, however, said there are challenges to future training, which include impoverished state of the nation’s economy leading to: inadequate funding of the health sector; poor remunerations and working environment; high cost of endoscopy equipment and accessories; brain drain; and insecurity.
He also decried insincerity on the part of government and her agencies coupled with unstable policies, corruption and poor infrastructural development.
He said, in the past, training in gastroenterology was unstructured with no clear-cut curriculum. Ajayi said most gastroenterologists were trained in general medicine and only showed special interest in gastroenterology. He said early trainers were those that trained abroad, duration of training was two years post Part I and opportunity for one year abroad post Part I.
Ajayi said these few trainers were concentrated in the 1st generation teaching hospitals. He said trainees were equally little in number as they had the perception that gastroenterology was a specialty with a high morbidity and mortality rates.
The gastroenterologist said few training centres had flexible fibereoptic endoscopes and procedures performed were essentially diagnostics (late 70s and early 80s). He said available diagnostic procedures include barium studies and liver biopsy but frequent equipment breakdown leading to prolong endoscopy holidays and no technicians or biomedical engineers to fix damaged endoscopes.
Ajayi said training suffered a set back during the period of the brain drain with the introduction of Structural Adjustment Programme (SAP) in the late 80s by the then Federal Military Government and trainers left the country in droves for greener pastures leaving the trainees to sort out themselves.
Ajayi, however, said structured training in gastroenterology started in the early 2000s with the development of a curriculum coupled with the competencies trainees must have spanning a period of three years post Part I. He said this structured training was designed to make trainees “competent undifferentiated gastroenterologists.”
Ajayi said training in gastroenterology received a boost with the birth of Society for Gastroenterology and Hepatology in Nigeria (SOGHIN) in 2007 in Port Harcourt and later with the inauguration of World Gastroenterology Organisation (WGO) training centre in Lagos on April 18, 2015.
He said more drug companies suddenly became interested in gastroenterology and actually got involved in training by sponsoring symposia in local conferences and also sponsoring trainers and trainees to both local and international conferences.
Ajayi said gastrointestinal diseases that were earlier thought to be rare are now increasingly diagnosed as a result of new diagnostic skills and knowledge available from the structured training and that more resident doctors are now showing interest in gastroenterology no thanks to the availability of endoscopy in more training centres in the country.
On current challenges to training, the gastroenterologist enumerated: Few trainers available; Poor funding of residency training/healthcare financing; Non recruitment of new resident doctors with over use of the currently available ones thereby compromising training; Lack of equipment or facilities even at top training institutions; Frequent breakdown of equipment with no backup or replacement; Non availability of maintenance and repair units or centres nationwide; Unstandardised procedures; Non regulation of practice; Poor utilisation of WGO Training Centre in Lagos; Second wave of brain drain; Lack off or poor collaboration with other international Gastrointestinal (GI) societies and training institutions – exchange programme.
On the way forward, Ajayi said while diagnostic opportunities in gastroenterology have increased considerably over the last decades, their availability is still not homogeneous nationwide. He said training curriculum needed to be restructured in such as way to make the up coming trainees become differentiated or highly differentiated gastroenterologists as the case may be.
The gastroenterologist said while consolidating on the gains of diagnostic endoscopy procedures, efforts must be geared up towards competence and mastery of therapeutic Endoscopic retrograde cholangiopancreatography (ERCP) or interventional endoscopists.
ERCP is a procedure that combines upper GI endoscopy and x-rays to treat problems of the bile and pancreatic ducts.
To achieve this objective, Ajayi said there should be adequate funding by government, private sector and Non Governmental Organisations (NGOs). He called for incorporation of e-learning including simulation-based, multimedia, videos and live demonstrations/procedures to compliment training needs.
Ajayi said SOGHIN must play a major role in the training by setting the standard thereby regulating the practice and its website must be active and highly interactive coupled with an e-learning platform.
He said standardisation of endoscopy practice across board is sacrosanct and equally the Postgraduate colleges must have an e-learning educational platform on their websites to meet the ordinary and extraordinary needs
The gastroenterologist said local manuals and guidelines must be developed and updated regularly and international guidelines to be harmonized and adapted to our local training needs.
Ajayi called for collaboration and linkages with international gastroenterological and training societies with possibility of exchange programmes to be established as a matter of urgency and that re-introduction of one year exchange training abroad to be vigorously pursued by SOGHIN.