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Medicine: Tough road to certification and specialisation

By Chukwuma Muanya and Adaku Onyenucheya
09 December 2018   |   4:25 am
For medical doctors, the journey to becoming certified to practice, like other professionals, begins with the acquisition of the basic medical degree.

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For medical doctors, the journey to becoming certified to practice, like other professionals, begins with the acquisition of the basic medical degree. Two of the major hurdles that they have to cross en route to becoming specialists are the housemanship and residency training programmes (RTP).

Interestingly, undergoing the housemanship and RTP are becoming Herculean feats, especially for the poor and the not-so-well-connected.

While the former is a year-long compulsory training that all fresh medical doctors must undergo in accredited institutions, the latter, a three to seven-year training programme is an integral part of career progression towards becoming specialists.

The RTP is a structured, institutional based competency-training programme for persons, who possess the Bachelor of Medicine and Bachelor of Surgery (MB.BSc, MB. CH, B, BDS), or its equivalent; have gone through the National Youth Service Corps (NYSC) programme with discharge or exemption certificate, and possess professional indemnity certificate from a reputable insurance company, among others.

On completion of training as fellows of Postgraduate Medical College, they are appointed consultants.

However, The Guardian’s investigation revealed that graduates of medical schools now struggle to get placements for their housemanship, while becoming a resident doctor is now harder than ever because of the inability of the 52 teaching hospitals, and federal health institutions in the country to accommodate over 2, 000 fresh doctors churned out yearly.

First year resident doctors are called “interns,” while senior residents in their final year of residency are called “chief residents.” A resident physician is referred to as a resident doctor, or a senior house officer.

Graduates from medical schools can apply for residency by looking out for openings in teaching hospitals that offer the specialised course that they want.

The National Postgraduate Medical College of Nigeria (NPMCN) conducts an examination called “primary,” which holds twice a year, and it is from here that successful graduate doctors proceed to undergo their residency.

The NPMCN charges N40, 000 for the examination, while the alternative, the West African Postgraduate Medical College (of Physicians or Surgeons), charges N148, 000.

Most medical doctors are increasingly shying away from “general practice” because of the prestige that comes with being a specialist doctor, in addition to the fact that specialist doctors are well paid.

As a result of the thinning spaces for residency training, some medical graduates now have to cough out as much as N500, 000 before they are allowed to undergo the residency training.

Upon the completion of residency training, resident doctors are awarded the Fellowship of NPMCN and/or West African Postgraduate Medical College.

However, parents, guardians and stakeholders are worried that a lot of graduate doctors are finding it difficult to get placements for their residency training, a development that has forced a lot of brilliant graduate doctors to travel out just because they could not secure spots for residency locally. Those without the wherewithal to undergo residency end up in general practice even after successfully passing the primary examination.

As part of efforts to address the many challenges facing the RTP, and in an effort to reduce brain drain, President Muhammadu Buhari, in June 2018, signed into law the Medical Residency Training Act 2018.

This law regulates the RTP for the training of medical practitioners and dental surgeons. It is also aimed at assuring the quality and competence of medical practice and practitioners in the country through statutory medical training programmes to encourage medical tourism from other countries to Nigeria, and build further confidence in the country’s medical system.

Only recently, when the outcry over the pathetic state of the residency programme and housemanship for graduate doctors became loud, Health Minister, Prof. Isaac Adewole, when accosted remarked cynically that it is not compulsory for all graduating medical students to follow through the programme and be certified to practice.

He shocked many when he stressed that the programme cannot accommodate every candidate, and that is the reason why some medical school graduates eventually go into other vocations, such as fashion designing, farming and other such endeavours.

When contacted by The Guardian to shed light on his claim that some graduates of medical schools would end up veering into other areas, including fashion designing, Adewole alleged that he was quoted out of context.

“What I said is that there is nowhere in the world that all graduate doctors end up becoming specialists. Some will obviously specialise; others would become general practitioners, and others may go into other things,” Adewole told The Guardian.

Adewole said the Federal Government was equally concerned about the problems facing the health sector and has set up a special committee to work on all the issues.

Interestingly, it was not the first time that the minister was criticising the RTP. In May 2016, Adewole who spoke while inaugurating a Ministerial Committee on the Restructuring of the Residency Programme described it as a disaster, and currently bastardised.

He highlighted the importance of the programme to the medical profession saying, “for some of us who went through this programme, we can confirm that what we have now is a disaster. It has been bastardised. This is an important programme that should not be allowed to die.”

He, however, ruled out reviving the overseas residency programme, stressing rather that some kind of exchange with leading specialist institutions abroad would be more tolerable, considering the nation’s financial situation.

“I am not sure we can have one year abroad as we used to have, but we can do short time exchange programmes,” he explained, just as he regretted that previous efforts to restructure the programme failed because they were commissioned at the height of industrial disharmony in the sector.
“To stem this tide and in a bid to holistically address the attendant problems, this administration has decided to appraise the existing programme in all its ramifications with a view to institutionalising an effective, efficient and sustainable residency training programme for the country.”

He charged the committee to appraise the report of the previous committee on residency programme submitted to the Minister of Health in April 2014, as it affects recruitment and career progression of resident doctors, including the existing structure.”

The Guardian investigation further revealed that the major problem faced by the RTP was poor funding, as most of the teaching hospitals do not have adequate funding, accommodation and infrastructure to take in applicants for residency training.

It was also gathered that most times, resident doctors’ salaries are slashed, and in some cases, they are owed for months.

Investigation further revealed that even though the National Postgraduate Medical College, and the West African Postgraduate Medical College are parastatals of government, there is almost no dedicated budget for actual postgraduate training. Budgets provided are normally inclusive of salaries and overheads, but not much is dedicated to the actual programme implementation; teaching and research related to medical postgraduate training.

Unfortunately, the Tertiary Education Trust Fund (TETFund) that provides funding for tertiary education in the country does not include medical postgraduate training in its resource allocation, citing the non-inclusion of medical education in the law that established it as the reason for the exclusion.

Compounding the situation is the fact that federal and state ministries of health or private proprietors are supposed to fund the teaching and tertiary hospitals under which postgraduate medical education is accommodated.

Unfortunately, more often than not, these institutions do not receive dedicated funding for postgraduate training. Consequently, postgraduate training in the country is almost left as an afterthought without the needed financial support to enable it gain the required momentum.

Very reliable sources confirm that it costs between N30m to N50m to train one specialist. This explains why some stakeholders are calling for the privatisation of teaching and tertiary hospitals, a development they say would provide the needed funds to boost postgraduate medical education, and by extension the MRTP.

Critics also argue that it was high time the country started bonding the beneficiaries of this project as a return for investments.

This, they say is done in Ghana and a number of other countries, where doctors, after their residency training are assigned to areas of need in the country for a period, in return for the cost of training borne by government. What presently obtains in the country is that specialist doctors are free to go anywhere they like once their training is completed.

President of Nigeria Medical Association (NMA), Dr. Francis Faduyile, agrees with Adewole that because of constraints in the system, some medical doctors drift into other professions and trades.

The NMA boss, who admitted that the residency training was in shamble told The Guardian: “It is obvious that we have more doctors that are taking to other professions. I have some of them who are in the banking industry, and some are into politics. So, what the minster said is that certainly, not all of us can be resident doctors or specialists.”

However, “the stance of NMA has always been that the government should increase spaces available for these trainings for doctors in order for most of them to be able to have a shot at residency training.”

On whose responsibility is it to find a place for a medical graduate on internship, Faduyile said it was the government’s, just as he advised that it would make a lot of sense to “centralise the process so that postings can be done from the Federal Ministry of Health in order to ensure that every applicant is given a fair chance to secure a place.”

He continued: “What we see is that there may be over 200 people contesting for 50 spaces in the Lagos State University Teaching Hospital (LASUTH), meanwhile in Makurdi, there may be up to 20 spaces up for grabs. So, we want to see even distribution of house officers generally so that people will get even treatment anywhere that they are in the country.”

He said medical graduates are paid equivalent of what Level 10.4 officers in the Civil Service (which is equivalent of Consolidated Medical Salary Scale (COMESS) 1), of the employing state or federal government.

A consultant paediatric surgeon and Chief Medical Director (CMD) of the Lagos University Teaching Hospital (LUTH) Idi-Araba, Prof. Chris Bode said: Non-specialists and specialists, as well, should continue to undergo periodic re-training to keep them up-to-date in their lines of engagement. The residency training programme is one of the few solid legacies of a selfless generation that set out to replicate in our sub-region, their experiences passing through the residency structures overseas, starting from the 1960s,” Bode said.

Commenting on the year-long compulsory housemanship training, which all fresh medical doctors must undergo in accredited institutions, he said the rising number of medical schools in the country has resulted in more doctors being churned out, thus outstripping the number of available training facilities for housemanship.

“In times past, housemanship training took place not only in teaching hospitals, but also in general hospitals, state hospitals, private hospitals and mission hospitals. But in the past three decades, only federal tertiary institutions have consistently maintained their facilities at accreditation-worthy levels for training these doctors. State governments that are responsible for general hospitals (meant for secondary-level care) are not funding these critical institutions, thus general hospitals have largely collapsed except in only one or two states of the federation.

“Mission hospitals suffered from policy inconsistency, disruptive and ill-advised take-overs by past administrations with resultant withdrawal of another training avenue. Private hospitals have undeniably experienced shrunken revenue base in recent years, with many erstwhile employers of house officers reducing their quota to remain solvent. So, in reality, only Federal Government tertiary institutions are admitting, training and paying the largest number of house officers in the country.

Worried by the situation, which he admitted was in shamble, the health minister has been campaigning for an all-inclusive solution, where newly-graduated medical doctors would have the opportunity to undergo their housemanship training immediately after graduating from medical school.

The Federal Executive Council (FEC) approved this proposal last year, and the Medical and Dental Council of Nigeria (MDCN) was mandated to centrally coordinate the exercise that would be hopefully funded beginning from next year.

Stakeholders are of the view that state governments should be encouraged to reactivate state general hospitals as most states with grandiose physical facilities lack the human compliment to man them. There is also need for states to employ consultants and other staff to maximally use these facilities, and this also calls for the provision of optimal ambience of security and comfort for those expected to take up residence and work in the rural areas.

States should consider incentivising rural posting for consultants willing to man outposts in the hinterland and supervise the new doctors. Mission hospitals and credible private hospitals should also be encouraged to upgrade their facilities to benefit from this Federal Government initiative, and admit new doctors for training.

THE RTP is a rigorous training programme for doctors desiring to become specialists since it is not everyone that can become one. The training is a three-stage process.

The Primary Examination (stage) is conducted to select those eligible for training, and those qualified (junior residents), undergo a two-three year intensive tutelage under specialists in their chosen fields, and on passing the Part I examination, they become senior residents (SR) or members of the training college. This level qualifies trainees as middle-level manpower and in countries like Ghana, they are posted to rural areas compulsorily to man distant outposts before coming back for further training.

Another two to four years of training at a higher level qualifies a senior resident to write a final (Part II) examination. If successful, he/she becomes a consultant and fellow of his training college.

The investment is enormous, which includes salary for five to seven years, other entitlements, cost of trainers, cost of running training facilities and other hidden costs.

The country’s three postgraduate colleges are the National Postgraduate College of Nigeria, the West African College of Surgeons, and the West African College of Physicians.

But it is important to point out that not everyone passes every stage of the examinations listed above. In fact, the pass rate at the primary examination at one of the colleges was a mere 7.4-29.4 per cent, with an average pass rate of 18.6 per cent over a 19-year period. Such a stringent examination has ensured that only the best candidates and the most prepared of these doctors are eligible for selection.

The RTP produced enough manpower to man healthcare posts during the brain-drain era of the late 1980s and early 1990s when top specialists emigrated to the Gulf states in search of greener pastures.