Factors behind rising cases of wrong diagnosis
Toyosi Y. Raheem is the National President, Association of Medical Laboratory Scientists of Nigeria (AMLSN). In an exclusive interview with Assistant Editor, Chukwuma Muanya, he explained why most medical diagnosis conducted in government-owned hospitals are unreliable. He also spoke on the preponderance of fake and substandard medical laboratories nationwide and rising cases of deaths associated with wrong diagnosis by physicians.
It is believed that the battle between pathologists and lab scientists is the reason for the rising cases of misdiagnosis, over-diagnosis and under diagnosis in the country, which has led to the death of so many people, brain drain and medical tourism. What is your take on this?
What is happening between pathologists and medical laboratory scientists was not ‘a battle’ but a misunderstanding of roles and responsibilities on the part of the pathologists. The medical laboratory scientists have kept to their roles and responsibilities as enshrined in the extant schemes and laws governing the practice of medical laboratory science. This is unlike the pathologists who instead of consulting with patients in special clinics using the results generated by medical laboratory scientists, abandoned their responsibilities and are struggling with medical laboratory scientists in the running of the laboratory. In doing that, wrong or inappropriate laboratory equipment, reagents and policies and put in place for the laboratory, inappropriate decisions are taken on laboratory matters and all these weaken the laboratory systems and by extension, the health system leading to misdiagnosis and wrong treatment. That is why medical laboratory scientists insisted that enough is enough in the bastardisation of laboratory services in Nigeria and wastage of the scarce national resources!
What is the solution? What measures are you recommending to bring lasting solutions?
The directive to the Hon Minister of Health by Hon Justice M. N. Esowe of the National Industrial court on February 17, 2017, compelling the Hon Minister of Health to issue a circular to all Chief Medical Directors (CMDs) and Medical Directors (MDs) of tertiary health institutions in Nigeria, is the way out of the current messy condition if the Minister of health (Prof Isaac F Adewole) is to demonstrate his concern for the rule of law in Nigeria. It will be recalled that a similar circular ref C.5516/I/T3/152 dated 21st October 2014 was released in honour of a directive by National Industrial Court of Nigeria (NICN) in 2014. The circular was signed by the then Permanent Secretary of the Federal Ministry of Health (FMoH) –Mr. Linus Awute following compliance to a NICN court judgment of July 22nd, 2013- on appointment of non-medical doctor as consultants/payment of specialists allowance by the FMoH. The current leadership of the FMoH should not blackmail President Muhammadu Buhari led Federal Government of Nigeria (FGN) by creating an impression that the current government had no respect for the rule of law!
Since 1999 that I started reporting health, lab scientists and pathologists have been at loggerheads. Why?
Your observation is right. The truth is that as far back as 1972, the Federal Government of Nigeria approved a scheme of service for the then Medical Laboratory Technologists (now Medical Laboratory Scientists). The said scheme of service confers duties of managing medical laboratories on the then Medical Laboratory Scientists. Medical laboratory technologists performed those duties with little or no inputs from the pathologists. It would be recalled that medical Laboratory scientists were training the trainee pathologists on practical laboratory procedures and processes. This was aimed at enabling the young and fresh medical doctor/ resident doctors in pathology to know a little about laboratory practical to enable them appreciate the inputs needed for generating laboratory test results. Sadly, however, as soon as the military government and the headship of teaching hospital promulgated decree 10, of 1985 was taking over by the medical doctors from the former Hospital administrators who were non-medical doctors, things started falling apart in the health sector. The medical doctors stated insisting that they must head all service departments such laboratory and the pharmacy even where they have little or no inputs. This made pharmacists, nurses, medical laboratory scientists to insist on their professional autonomy and authority, which they were not ready to compromise.
The attempt by pathologists to claim relationship with the regulatory activity similar to that of the former Institute of Medical Laboratory Technology of Nigeria (now Medical Laboratory Science Council of Nigeria) was in 1992 when Medical and Dental Council of Nigeria, MDCN (a regulatory Body for medical doctors introduced regulation of clinical laboratory ‘Practical’ to their Functions. This with time was erroneously translated by MDCN to mean regulation of clinical Laboratory ‘Practice’. One wonders how regulation of clinical laboratory practical for medical and dental students and trainee or resident doctors in area of pathology could be translated to mean day-to-day practice or duties by medical laboratory scientists (the then medical lab technologists). This was the first attempt by pathologists to turn medical laboratory scientists to their errand boys. That was resisted even at that time.
In year 2000, the FMoH, Establishment Office under the Head of Civil Service of the Federation, carried-out job evaluation for health professionals in Nigeria and medical laboratory scientists were rated as belonging to High-level professional group. So, in 2001, a new scheme of service was approved for medical Laboratory scientists which in addition to their earlier prescribed duties, added performance of other highly specialised tests on clinical samples from humans, among other functions. The scheme of service also enables medical laboratory scientists to have career progression up to Director Level. So today, we now have many Deputy Directors and Directors in Public medical laboratories in Nigeria. Obviously, the pathologists were envious of the growth and development within the medical laboratory science profession. They had wished the profession remained in its rudimentary form while only medicine and surgery would advance. This would have been at the expense of quality laboratory service to the patients and to the beneficiaries of the services of medical laboratory scientists. The climax of the situation was in 2003 when in an effort to secure total professional autonomy through self-governance, Act 11 of 2003 (Cap M25, LFN 2004) was signed into Law by the then President of the Country (his excellency Chief Olusegun Obasanjo (GCFR). The truth is that Healthcare is a teamwork involving different health professionals with diverse and relevant expertise and is regulated by their different enabling laws in such a way as to strengthen the health sector.
What is the situation now?
The situation today is that the medical laboratories continue to get less and less attention because the pathologists were heading the laboratories in public laboratories. As a result, inappropriate reagents and equipment are procured in most government laboratories, medical laboratory scientists who are the end-users of such equipment and reagent were not involved in the processes, and issues that bordered on the medical laboratories were given little or no attention, the pathologists are not committed to strengthening the laboratory workforce and systems. The outcome is that the health system that normally derives its strength on the quality of laboratory services becomes weakened.
Medical laboratory scientists, technicians and assistants usually take the blames for all these inadequacies and when anything goes wrong, it would be shifted to the “lab people” That was why the medical laboratory scientists clearly insisted on taking ‘the bull by the horn’ and demanded self-governance as stated in the extant scheme of service and the enabling law for our profession. There were agitations, dialogue, negotiations and discussions with FMoH, Ministry of Labour and Employment and other relevant authorities and stakeholders. When all these failed, the medical laboratory scientists approached courts of competent jurisdictions-the National Industrial Courts of Nigeria for adjudication in 2006 in the case of medical laboratory scientists and the pathologists in Obafemi Awolowo Teaching Hospital Ile –Ife, Federa Medical Centre (FMC), Asaba, Jos University Teaching Hospital (JUTH) Jos, University of Uyo Teaching Hospital, University of Nigeria Teaching Hospital (UNTH) Enugu, former Federal Medical Centre Abakaliki now Federal Teaching Hospital, Abakaliki (FETHA) etc in 2006, 2012, 2014, 2015, 2016 respectively.
What is the position of the FMoH and the minister?
It is really unfortunate that the FMoH has refused to be an unbiased umpire in the matter between medical laboratory scientists and the pathologists. There is always a seeming support for pathologists by the leadership of the FMoH despite the clear statutes that confer the powers and prescribed duties on medical laboratory scientists. The FMoH is always unwilling to direct the pathologists to adhere to their primary duties of using completed laboratory results generated by medical laboratory scientists to consult patients in special clinics run for relevant patients as originally envisaged for pathologists. A doctor that worth his/her salts including pathologists should attend to patients and not to struggle for day-to-day running of medical laboratory services in the laboratory which is the professional core area of medical laboratory scientists. Pathologists may also offer to consult with doctors on the interpretation of the laboratory results, if the doctors find the result too difficult for them to understand. This is similar to a builder using the drawing of an architect in the built environment. This is quite different from bricklayer-engineer relationship used by the writer of the article under reference. This illustration by the writer is one of the many derogatory relationships often used by the pathologists when describing the professional relationship between them and medical laboratory scientists- two distinct and separate professionals in the health sector.
I know there are so many lingering court cases. How far?
After painstakingly pursuing our cases at the National Industrial Court of Nigeria (NICN), the Courts ruled in these matters in 2013 -against FMC Asaba; 2014 -against JUTH; 2015 -against JUTH; 2016- against Obafemi Awolowo University Teaching Hospital (OAUTH) Ife and University of Uyo Teaching Hospital; and in 2017- against the Minister of Health, JUTH, FETHA, UNTH, National Orthopaedic Hospital Enugu, and others).
On the AMLSN versus FMC Asaba case:
After a detailed consideration of the MLSCN Act No II, 2003 & others plus the Scheme of Service, the Court, held thus: –
1. Medical Laboratory scientists are distinct professionals … & consequently entitled to be accorded due recognition…
2. Medical Lab Scientists are entitled to operate/work in a separate laboratory services dept.
3. Laboratory department is not in conflict with others in the areas of compositions, responsibilities and schedule of duties….
4. Medical Laboratory Scientists can relate and will relate with other health professionals for the effective and efficient care of the patients.
5. Directed immediate recognition of the existing MLS Dept. & Scheme of Service.
On the AMLSN versus JUTH Jos case:
1. Declared rights pronounced in favour of the Medical Laboratory Scientists (claimants) via Asaba judgment is a notice to all medical laboratory scientists where we practice and to respect our status of the (claimants).
2. The above judgment is now a permanent identity of all medical laboratory scientists in Nigeria (the claimants) wherever they are employed to work in the public health sector of the Federation.
3. Once the above is brought to the notice of the employer of all medical laboratory scientists (the Claimants) in the Public Health Sector, we have a legal duty to adjust our administrative structure to reflect the legal status attached to us.
On the AMLSN/National Union of Medical Technologists and Associations Allied to Medicine (NUMPTAM) versus OAUTH-Ife case:
1. Provision of MLSCN Act No II of 2003 (Cap M25 LFN, 2004)
2. Scheme of Service
3. Entitled to autonomy of practice
4. Bound by the Scheme of Service
(b) Reliefs: –
1. Declaration … only qualified and registered persons can practice the profession…
2. Responsibility for the day to day running of laboratory service/ department is placed on Director, Medical Laboratory Services.
3. Medical Laboratory Scientists are entitled to autonomy of practice within their field of competence.
4. Pathologists and other defendants are bound by the Scheme of Service for medical Laboratory scientists… as it affects the running and administration of the Medical Laboratory Science Departments.
5. Pathologists … are not entitled to practice medical laboratory science profession and medical laboratory scientists cannot practice medicine and surgery
6. Pathologists wish to head the labs were contrary to the Act & Scheme of Service for medical lab scientists.
7. Injunction restraining Chief Executive Officers (CEOs) of health Institutions eroding or undermining autonomy of practice by Medical Laboratory Scientists by imposing Supervisory control of non – Scientists on medical laboratory scientists
8. The Judge clearly stated that an employer couldn’t deploy her staffers to erode the autonomy granted to a particular profession by deploying people who are not members of that profession to head or supervise such profession and its members. This was clearly stated by the presiding judge on P 26 (last paragraph) of the judgment.
On the AMLSN versus FETHA, UNTH, National Orthopaedic Hospital Enugu, the Minister of Health & others; University of Uyo Teaching Hospital cases and other similar cases sought identical reliefs as those of the above cases.
The management of these hospitals was hiding under the fact that the Minister of Health had not given them a circular to affect the court judgments. Surprisingly and unfortunately, those charged with ensuring that the statutes of government and laws of the land are obeyed are the same elements doing everything to frustrate these judgments and preventing our members from enjoying the fruits of government’s good intentions. They are daily manifestly trying to enthrone the law of the jungle by disrespecting the pronouncements of the National Industrial Court of Nigeria (NICN). They have used the machinery and instruments, power and authority of government vested in them to wittingly suppress, subjugate and ensure that government provision for other health professionals especially that of Medical Laboratory Scientists is denied them. This has become an overarching trend by successive leadership at the FMOH and heads of its health facilities and institutions. This trend has resulted in further fuelling the rancor and disharmony in workplaces that is prevailing currently in most of the health institutions in Nigeria.
We are glad that Hon. Justice M. N. Esowe at the NICN, Abuja in her judgment on Friday February 17, 2017 expressly directed the CMD and the DA of JUTH- Prof. Edmund Bangwas and Ali Bitrus respectively to within 30 days, remove all Pathologists and all persons not allowed by the LFN Cap M25, LFN, 2004 (MLSCN Act) to be in the Medical Laboratory Services department from the Laboratory failing which they shall be committed straight to the prison.
The Judgment also applied to FETHA, UNTH, NAUTH, and National Orthopaedic Hospital (NOH) Enugu. The Hon Minister of Health Prof Isaac Adewole was also directed in the judgment to issue appropriate circular directing all CMDs/MDs of Federal tertiary health Institutions to comply with the court orders.
Are there other things you will like me to know?
The story of Baby Oyinkansola Eniola at the Lagos State University Teaching Hospital (LUTH) Idi Araba in 2006 referred to by the writer of the article was turned upside down! The truth of the matter was that our members –Mrs. Kazeem, Mr. Adeniyi, Mr. Soji Aiyelari were all retired compulsorily from service of Lagos University Teaching Hospital (LUTH) as a result of the case (for not asserting their professional authority and for not keeping to their professional responsibilities as medical laboratory scientists) in the haematology department and Blood Bank of LUTH where the tests were performed on the transfused blood and on baby Eniola’s blood. It was embarrassing and surprising too, that Mr. E. Onifade (another medical laboratory scientist) who was then Assistant Director of Laboratory Services who was not even allowed by pathologists in connivance with the LUTH Management, to perform his duties as Assistant Director Laboratory Services was demoted by the panel.
All efforts made to convince the panel that the refusal of pathologists and LUTH management to allow Mr. Onifade perform his duties as Assistant Director Laboratory Services had restricted him (Mr. Onifade) to Microbiology laboratory, were not accepted by the panel. The panel claimed that Mr. Onifade as the most senior medical laboratory scientist in LUTH Laboratory at that time should have extended his supervisory duties to haematology and blood bank. Hence he was unjustifiably demoted for that. Even Prof Okannny who was briefly removed as HOD of the Haematology laboratory was reinstated back by LUTH management while our colleagues mentioned above, were retired compulsorily! Prof. Tolu Odukoya was never sacked as a result of the case. He actually completed his full term as CMD of LUTH. One wonders why the writer of the article was telling lies and turning everything upside down on matters that medical laboratory scientists suffered greatest injuries. The lesson learnt from the injuries to our members in Baby Eniola’s case is that medical laboratory scientists should have defended their territory (the laboratory) very well.
We are anxiously monitoring and watching the body language and actions of the Minister of Health, Minister of State for Health (both of whom are medical doctors) and his team. One thing we are sure of is that nobody is above the law and nobody should be above the law in Nigeria, no matter how highly placed! These judgments will not be allowed by us to be swept under the carpet as done for those judgments given to the Nurses in the past.
When rule of law fail, anarchy is promoted. Enough is enough!!