Postgraduate Medical Education in Nigeria: Past, present and future
I am extremely delighted to be invited by the Sponsors of the Frontiers on Medical Education (FME) to deliver this maiden lecture in honour of our revered icon, Professor Linus Nwachukwu Ajabor JP, FRCOG, OON, Hon DSc on this special occasion of the 50th Anniversary Celebration of the Society of Gynaecology and Obstetrics of Nigeria (SOGON). Being asked to deliver this lecture by this noble group is not only an honour but a rare privilege as I am aware that there are many qualified professors among its rank who can equally deliver the lecture. Indeed, when Professor FME Diejomoah first called me on phone and started a long conversation on the lecture, I wanted to stop him at some point to ask why I was not being invited, being an academic son of Professor Ajabor, to be a sponsor and member of the FME. However, I stopped when he rapidly moved on to invite me to be the first guest speaker – as I immediately reasoned that this is an all-time privilege which could be jettisoned if I was to be a foundation member of the group. So, I decided to seize this opportunity and wait for another day to join this well intentioned group, whose members are all protégés of our highly respected Professor LN Ajabor.
I am indeed, very grateful to Professor FME Diejomoah and Professor M Ezimokhai, the prime movers of the FME for inviting me to deliver this epoch-making and foundational lecture.
Professor Linus Nwachukwu Ajabor is today one of Africa’s most highly respected living legends in obstetrics and gynaecology; a role model and mentor extra-ordinary of several generations of Nigerian teachers, professors and practitioners; a disciplinarian with a kind heart, who continues to promote and champion the ethical practice of obstetrics and gynaecology; a medical visionary who is forcefully passionate about his beliefs; and a leading disciple and guardian of post-graduate medical education in Nigeria. I would say without any fear of contradiction that Professor LN Ajabor is one of the very best that the profession of obstetrics and gynaecology has offered to the Nigerian people in efforts to promote women’s health and social well-being. In a career spanning over 54 years of medical practice in Nigeria, United Kingdom, USA, and Saudi Arabia, he distinguished himself as a trainer and teacher, a tutor and adviser of professors, and a high profile researcher whose research findings first provided insights into the peculiar nature of obstetrics and gynaecological practice in Nigeria.
Professor LN Ajabor was President of SOGON from 1999 to 2002. As President, he provided a new direction for SOGON, and strongly positioned our society to become a major player in social philanthropy at both the national and international levels. Today, SOGON has continued to enjoy the benefits and legacies so elegantly left behind during the Presidency of Professor Linus Ajabor.
Of all his many accolades, it is in medical education and mentorship that Professor Ajabor excelled and is leaving an indelible mark. At this point, I must reveal that my choice of obstetrics and gynaecology as a post-graduate discipline was largely influenced by Professor LN Ajabor. I served as his House Officer at the University of Benin Teaching Hospital (UBTH) between 1978 and 1979. At that point, I was torn in my career choice between my experiences with different mentors in different disciplines. These included Professor Sheila Kenny (Professor of Anaesthesia in Dublin), who had offered me a place in Scotland to study anaesthesia; Professor Jackson Omene (who was vehement that I should specialise in paediatrics); Professor Uchenna Nwosu (an erudite professor of obstetrics and gynaecology who taught me the scientific principles of the discipline as an undergraduate student in Ife); Professor Anah (a physician who impressed me greatly when I worked under him as a House Officer at the UBTH); and Professor JJ Andy, who till this day is still stupefied that I failed to study internal medicine despite his proclamation when I was a student under him that I was naturally a physician. My final choice of obstetrics and gynaecology rested principally on the influence of two persons – Professor Uchenna Nwosu and Professor Linus Ajabor: Professor Uchenna Nwosu for his focus on teaching obstetrics and gynaecology from primary scientific principles that widely opened my vistas to the discipline, and Professor Linus Ajabor for his didactic clinical teaching and focus on skills acquisition, professional discipline and ethical practice.
Clearly, Professor LN Ajabor is best described as the doyen of medical practice, whose several achievements and influences on professional practice cannot be summarised in a short lecture of this nature. The choice of Frontiers on Medical Education as theme of this lecture series and of Professor Linus Ajabor as the focus of the first lecture is therefore most appropriate and timely.
This lecture titled “Postgraduate Medical Education in Nigeria: Past, Present and Future” is organised in four main sections. In the first section, the history, origin and intentions of postgraduate medical training will be described from the international perspective. In the second section of the paper, I will discuss the history of postgraduate medical education in Nigeria and how this has developed over time. The third section of the paper will focus on elucidating the challenges facing post-graduate medical education in Nigeria. In this section, I will do a comparative analysis with postgraduate education in other parts of the world. In the final section, we will conclude by making substantive recommendations on ways to improve post-graduate medical training in Nigeria.
Meaning and Scope of Postgraduate Medical Education
By postgraduate medical education, we mean the constellation of learning activities carried out to enable doctors develop relevant competencies and deeper knowledge in specific subject areas after completion of basic medical education. Postgraduate Medical Education (PME) as described in this paper includes pre-registration training, vocational/professional training, specialist and sub-specialist training as well as other forms of training obtained after the initial undergraduate medical education.
The purpose of medical education is to improve the health of all people and to develop new knowledge and innovations for high-level medical practice. Therefore, our definition also includes Masters and PhD training undertaken by medically qualified doctors in fields such as the basic medical sciences, public health, health economics and other disciplines. Indeed, the new mantra in PME is for medical graduates to obtain skills for high quality multi-disciplinary research and experimentation needed to make ground-breaking discoveries in various specialist and sub-specialist areas. The importance of mainstream postgraduate training for the medically trained professional in the new millennium can therefore not be over- emphasized.
PME includes both further theoretical education and intense clinical and practical training. Additionally, the ability to conceptualise and implement research and to report relevant research findings in a concise, evidence-based and acceptable manner so that such research can be reproduced elsewhere is an important goal of postgraduate medical education. PME is a life-long continuum of training which includes supervised Residency Training (RT), Continuing Medical Education (CME) or Continuing Professional Development (CPD).
History of Postgraduate Medical Education
The history of PME as first conceived internationally has been well described. The development of PME started rather erratically at the beginning of the 20th century. Professor W. Osler first recognised the need for continuing education in medicine at a lecture he delivered to graduating students at McGill University in 1905 when he said: “the hardest conviction to get into the mind of a beginner is that the education upon which he is engaged is not a College Course, not a Medical Couse, but a Life Course, for which the work of a few years under teachers is but a preparation2”. Osler later became the Chairman of the Postgraduate Medical Association, an association set up in 1911 to promote postgraduate medical education in the UK. Before then a series of Acts had suggested the need for continuing medical education, in particular the General Council of Medical Education (GCME), which was passed in 1858. In 1886, the GCME promulgated an act stipulating that applicants to it must have “passed a qualifying examination sufficiently to guarantee the possession of the knowledge and skills required for the efficient practice of medicine, surgery and midwifery”.
In 1921, the report of a committee (the Althone Committee) 3 recommended that a University Medical School devoted to post-graduate medical education should be established. This report gave birth to the Hammersmith Postgraduate Medical School established in 1935, and the British Postgraduate Medical Federation in 1945. The Christ Church Conference held in 1961 under the chairmanship of Sir Richard Pickering, Regius Professor of Medicine at Oxford University gave rise to multiple academic activities and the building of partnerships that eventually led to the establishment of clinical postgraduate training in various UK hospitals, the development of residency training programs and the founding of the Royal Postgraduate Colleges.
The UK Medical Act of 1956 began the mandatory one year training for House officers. The progression to Senior House Officers, Registrar and then Senior Registrar started many years later. Since then, many reforms have taken place in postgraduate clinical training in various disciplines. After 2005, the Modernising Medical Careers (MMC) Reform program came into effect in the specialty of obstetrics and gynaecology. The House Officer and first year Senior House Officer Posts were replaced with a compulsory two-year foundational learning. This is now followed by a competitive entry into a formal specialty-based training. The Registrar and Senior Registrar posts were merged in 1995 as Specialist Registrar grade often entered after a longer period as Senior House Officer. Following the MMC, the Specialist Registrar has been replaced with Specialist Training Registrars who may be in the position for periods of up to 8 years.
Thus, under MMC, the career path in obstetrics and gynaecology in the UK now includes a lengthy period of 9 years divided into three stages. Stage 1 consists of Foundational training of 2 years, which often includes a training module on women’s health. Stage 2 comprises the core training, divided into 1) Basic training of 2 years, 2) intermediate training of 3 years and 3) advanced training of 2 years. MRCOG Part2 is now taken at the end of the intermediate training while the advanced training period largely consists post-MRCOG advanced training in skills development and sub-specialty training.
Features of UK Postgraduate Medical Education
From the above, it is evident that the UK training in obstetrics and gynaecology and perhaps in other clinical disciplines are intensely structured and formalised. They are academically oriented and are often affiliated to supporting Universities, which make their research training more intense. More and more, the number of years in formal training has increased while emphasis is placed on skills acquisition, mentorship, sub-specialty training and research.
However, there is still a tendency to separate clinical postgraduate training from postgraduate training in the basic sciences or public health. Often, doctors wishing to undertake these forms of training have to seek admissions into structured Masters and PhD programs administered by Academic Departments in Universities. The lack of integration of PME in Teaching Hospitals and those in Universities is still a challenge even in developed countries.
History of Postgraduate Medical Education in Nigeria
Medical education began in Nigeria between 1947 and 1952 when the University of Ibadan started training doctors under a special relationship with the University of London. The University College Hospital Ibadan opened its doors to teaching staff and students in 1957, while the relationship between the University of Ibadan and the University of London was terminated in 1962. It is therefore not surprising that PME started rather late in Nigeria in 1973, with the formation of the West African College of Surgeons in 1973. Before then, Nigerian doctors seeking postgraduate medical education either went to the USA, UK or other European countries. Some returned home when the exchange rates between the naira and international currencies were still in favour of Nigeria at the time. But a large number remained in those countries and never returned home. It was an attempt to reverse this inordinate brain drain of high profile medical personnel that led patriotic Nigerians to begin the establishment of PME in Nigeria. Mention must be made of such Nigerians that founded and grounded PME in Nigeria during the formative years. These include our honouree today, Professor Linus Ajabor and others such as Professor E. Latunde Odeku, Professor TA Lambo, Professor WV Fowler, Dr DJO Foulkes-Crabbe, Professor FO Dosekun, Dr TE Dada, Dr Bayo Banjo, Dr O Olowu, Dr TO Bada, Dr BS Afenifuja, Professor J Olu Mabayoje, Professor BK Adadevoh, Professor MA Bankole, Dr EO Odunjo, Prof TAI Grillo, Professor GO Onuaguluchi, Professor EA Elebute, Professor A Akinkugbe, Professor V Aimakhu, Professor OA Ladipo, Professor Wole Akande, and Professor Adeleye among several others.
It is therefore not surprising that PME in Nigeria was started by Nigerians who studied abroad and returned home with a passion to replicate what they saw in the individual countries where they studied. Thus, PME was fashioned after the UK model where most returning Nigerian specialists had studied, but with a slashes of American and Canadian models as well. Thus, PME can be described as an amalgam of UK, American and Canadian postgraduate training models characterised in ways to suit our prevailing medical situation.
Two postgraduate Medical Training programmes present exist in Nigeria – the West African Postgraduate Medical College and the Nigerian Postgraduate Medical College. The need for postgraduate medical education programme in Nigeria was first recognised when the Medical and Dental Practitioners Act was passed and the Nigeria Medical Council was established in 1963. Examining boards were immediately established for the specialities of Medicine, Surgery, Obstetrics and Gynaecology, Paediatrics and Public Health by the NMC to draw up curricular and postgraduate training and examinations in the relevant disciplines. A delegation led by Professor J. Olu Mabayoje, then Registrar of the NMC visited several European countries and hospitals to fine-tune their recommendations on ways to establish a viable post-graduate training programme in Nigeria.
The proposals of Examining Boards in various specialties were approved by the NMC and given legal backing by Decree No. 44 of 1969. In 1970, the NMC (postgraduate examinations) published its syllabuses and regulations in various disciplines. In February 1970, the NMC informed all States’ Ministries of Health in the country about these postgraduate training programmes and advocated for their uptake throughout the country. Some of the advantages of the training program advanced by the NMC at the time included: 1) reduction in cost of training; 2) training in local environment would enable trainees provided much needed clinical services at the same time; and 3) reduction in level of brain drain of essential professionals. The template for the training then consisted of Primary Examinations, Part 1 Examination and the Part II Final Examinations. The first Primary Examination (then called Basic Science Examination) took place in May 1972. Of the 29 candidates presented, 15 passed; while in in November 1973, of the 12 candidates who attended, 3 passed. External examiners were invited from Oxford, Dundee and Makerere to take part in these examinations at the time.
As for the Part 1 examination, the first examination in internal medicine was held in November 1973, with one candidate being successful out of five. One external examiner came from the Royal College of Physicians (UK), while another was invited from the University of Ghana Medical School. The external examiners reported that the standards were fair and that the successful candidate would most likely have passed the UK MRCP examination. In the first Part I FMCOG examination, one candidate was successful out of four, and the external examiners also wrote favourable reports about the high standards of the examination.
Later, Part I examinations followed in Surgery and Paediatrics in January 1974. Of three candidates that took the examination in Surgery, two passed, while the only candidate in Paediatrics was successful.
Transition to the National Post-graduate Medical College (NPMC): Thus, it can be said that PME in Nigeria started under the tutelage of the NMC, but a more formal setting was needed to firmly entrench its practice. At its Annual General Meeting of the Nigerian Medical Association in 1971, a motion to set up a separate body to conduct postgraduate training and examinations in Nigeria was moved by Professor Adeyemo Elebute. This led to the formation of the National Medical College as the first medical postgraduate education nomenclature in Nigeria. The first office of the National Medical College was within the office of the Nigerian Medical Council in Alaka, Lagos, but this was later moved to the College of Medicine of the University of Lagos in Idi-Araba, Lagos. The Registrar of the Nigerian Medical Council continued to be the Secretary and Chief Administrative Officer of the National Medical College. The first person to hold the position of Secretary of the National Medical College after its separation from the Nigerian Medical Council was Professor NE Henshaw.
The Decree establishing the National Postgraduate Medical College was signed into law by General Olusegun Obasanjo on September 24, 1979. The Decree provided for the establishment of 1) 13 Faculties, each with a Faculty Board and Faculty Board of Examiners; 20 A Senate that supervises academic programmes; and 3) a Governing Board that oversees the financial, administrative and management policies of the College. President Shehu Shagari formally inaugurated the College on February 19, 1984.
The mandate of the NPMC is “to plan, implement, monitor and evaluate postgraduate programmes required to produce medical and dental specialists of the highest quality, competence and dedication, who will provide teaching and optimal health care for the people. Lifelong learning is expected to be maintained by continuing professional development programmes of the College”.
The vision of the College is “to produce medical and dental specialists of the highest standards who will provide world class services in teaching, research and healthcare”.
The West African Postgraduate Medical College
The Association of Surgeons of West Africa was formed in 1960, with the objective to promote postgraduate education and research in surgery and related disciplines throughout West Africa. The Association of Physicians of West Africa comprising Gambia, Sierra Leone, Ghana and Nigeria was formed in 1963 with similar objectives to promote learning and research among physicians in the specialties of internal medicine, paediatrics, psychiatry, pathology and community health. A Committee was later constituted under the aegis of the Commonwealth Secretariat to harmonize the two Associations, a move that later gave birth to the West African Postgraduate Medical College (WAPMC) in 1976. Till date, the WAPMC comprises two composite Colleges – the West African College of Surgeons and the West African College of Physicians. The WAPMC has designed its academic and examination programs based largely on the programme of the Nigerian Postgraduate Medical College, but influenced heavily by the UK programmes in related disciplines. The Colleges commenced their examinations in 1979, with the specific objectives “to: 1) advance professional education and training in all medical, pharmaceutical and Nursing disciplines; and 2) promote and achieve a high standard of professional practice and competence among practitioners”.
However, most of the infrastructure, including trainees and training Faculties of the WAPMC have resided and have emanated from Nigeria. This has from time to time led to the argument that this is a duplication of effort to have two medical post-graduate training institutions running parallel programs in the country. However, the regional focus of the WAPMC has tended to give it more international recognition and acceptability, especially as it allows for cross-country exchange of medical specialists across West Africa.
Status of Residency Training in Nigeria
The pattern of residency training in Nigeria has not changed since it first debuted in the late 1970s and early 1980s. Both Programs – the NPMC and WAPMC – adopt the same methodology, consisting of hospital-based residency followed by examinations at periodic intervals.
• Professor Okonofua, the vice-chancellor, University of Medical Sciences, Ondo, Ondo State, delivered this lecture in honour of Professor L.N Ajabor, under the Series on Frontiers In Medical Education at the International Conference of the Society of Gynaecology and Obstetrics (SOGON) in November 2015.