The Dr Goodluck Jonathan led administration recently announced the decision to conduct an audit and review of postgraduate medical training, otherwise referred to as residency programs in the nation. The objective of this among other things is to examine the reasons for the unacceptable low throughput rates, low pass rates, examine existing regulatory framework and alternatives for funding etc.
So far, a one day stakeholders meetings to consider these have taken place.
This initiative, is highly welcomed, and comes at a time these programs have become largely 'spinal' in medical parlance; self serving and obfuscated.
Indeed, opportunities as these are rare.
The question is, what ails us so bad to warrant what we get?
The Medical field like other facets of the Nigerian life is a victim of the same general malaise, a so called Nigerian factor.This however does not preclude us from continuing to suggest sustainable solutions going forward.
A cursory look at the reasons for medical tourism are not too far fetched; A general loss of confidence in the capacity of our providers to qualitatively and quantitatively meet the healthcare needs of the population. This in itself is traceable to our organisation of the sector, and an ineffective human resource management approach.
Human resource issues which span planning, talent recruitment, training, motivations and rewards, promotions, discipline, attitudes and organizational culture and other labor issues are a recurring decimal.
On a personal note, these are sorely lacking, and represent the area of greatest need.
Other areas that need be looked at which form the fulcrum for human capital development in the health sector and that may help shape a new paradigm are the following:
1. Medicine as a second degree.
Current structures of medical education allow entry straight from the ordinary level or secondary school. This is at a time these candidates barely know themselves. Self identity is the psychological developmental task at this period and the individual lacks the capacity to fully and adequately understand the ramifications of the choice of medicine as a lifelong career path. He is unable to grasp or appraise the maturity, the demand, altruism and responsibilities inherent in this choice, which are its very defining characteristics.
Without these, the choice of medicine becomes an ego trip, a badge of honor, rather than what it is meant to be, a profession of care and compassion. It becomes an end to itself.
It is even more grevious considering the lack of appropriate guidance and counseling in our secondary schools.
The medical program is a rigorous one. The scope of it daunting. Inter semester breaks are non existent. Lecture and practical schedules span 8 -6 pm daily. Weekends often incorporated. There are no down times. It takes a genius to navigate with a semblance of normalcy.
Unless an individual is naturally inquisitive and curious, or comes in with a very robust intellectual background it is practically impossible to gain-in on other areas of intellectual endeavor. The problem therefore then is to produce a crop of persons without the necessary robustness or roundedness. It is a situation as dangerous as not being lettered at all.
I asked a friend to make a value call on whether to be attended by a wide starry eyed kid (literally) and a calm, level headed middle aged fellow. Her choice was unequivocal. The latter's maturity and probable experience inspired confidence.....
What do we have?
Arising from personal experience, it is a grave injustice to be sentenced to the 'life of misery' that medicine presents without the necessary passion and a clear, well informed opportunity for the choice which can only be garnered after a robust exposure to other facets of life, academia, people and choices. Things possible only through a first degree in other disciplines and a rounded university experience.
It is not for nothing that the United States requires a first degree as a minimum criteria for medicine. It is for nothing that they place premium on such criteria as extracurricular activities, leadership potentials, and general robustness of the individual to recruit to the medical discipline. Shouldn't we borrow a leaf?
2. Funding
The British UK makes use of discrete entities called deaneries or Local Training and Education Boards LTEB in medical manpower development. These are regional and geographic based administrative units. Lump sums of money are allocated and tied to deliverables on a yearly basis at each deanery. Further approval for funding depends on the outcomes from previous allocations.
Deliverables may include pass rates in the certification exams, satisfaction with content and quality of teaching materials, quality of services provided and available facilities.
3. Residency
Accreditation of a program presupposes the availability of physical infrastructure, equipment, and resource persons necessary for training. It is a seal or stamp of approval that what is produced meets a minimum standard qualitatively. Therefore, attention and emphasis must shift back to this area rather than the current short sight emphasis examinations.
The National Universities Commission must have an imput in the curriculum development, staffing, quality assurance and accreditation of residency programs.
There must be clearly delineated landmarks or milestones and specific deliverables to ensure a steady and progressive climb through the ranks of all candidates.
Premium must once again be placed on the 'taught' element in mentorship, didactic lectures delivered by the experts.
There must be opportunities for mutual teacher-students rating or assessment. And to achieve desirable results, teacher promotions and ratings must be tied to student achievements in specific and measurable ways.
What is good for the geese is equally good for the gander.
Part of the contribution of the National Universities Commission is to ensure that would-be trainers obtain minimum qualifications in educational methods and processes.
Residency as constituted in Nigeria now is synonymous with oppression, and servitude of the resident doctors. It is a tool of control and manipulation by those in charge for sundry benefits.
Small wonder, their products become equally egotistic, narcissistic, devoid of milk of human kindness and assume a godlike complex who needs to be appeased to attend to his responsibilities and patients.
It need not be so!
4. Assessments
These must be backed by validity and reliability studies and standardized. International best practice are another yardstick for assessments.
Besides the other assessment approaches of resident doctors, a credit or competency based model of assessment should be looked into. The beauty of this lies in its ability to identify areas of strengths, or weaknesses, and provides a framework for improvement and measuring improvements.
Credit needs to be accorded in areas of competence, whilst encouraging a strengthening of weaker areas. A wholesale or the 'all or none' discredit of individuals is unconscionable.
Membership, engagement and participation in relevant professional aassociations local and international should form one of the yardsticks for ratings.
5. Certification
Most advanced countries have a one off certification examination at the end of the specialist residential training. It is usually voluntary and its purpose is to ensure a minimum standard of practice regardless of the centre of training. It also serves to assure the public of conformity with best practices. Thus cliches like "board certified" are heard.
Not being board certified does not preclude practice and the earning of a living. What it does is to limit the opportunities for practice or the individual's earning potential as some employers and patients will require this.
There ought to be the availability of choice for all and sundry, patient and providers alike.
Certification in nigeria are currently staggered into two stages and highly punitive. Navigating them is like "salvation through fire"and have become a thing of competition rather than facilitation.
Teachers have abandoned their duty posts of facilitation for the "Examinations". These are the happiest days for these people, as they get to affirm and assert themselves.
It will be a good idea for the conduct of these examinations be supretended by independent observers.
Globally acknowledged standards of assessments equally need to be adopted.
Conflict of interest by the examiners is another problem that need be confronted. It is pertinent to note that many of the resource persons at individual centers double up as examiners centrally, and are beneficiaries of repeated examination registration by candidates. Refering to an earlier article of mine on this same subject, a professor of one of the specialities said to me "you claimed in your writeup that candidates often sit a single examination up to 8 or 9 times. If you bring your money to us 100 times, we will collect it". Need I say more?
6. Anti trust
A deliberate policy of healthy competition must be fostered and promoted by the federal government of Nigeria in and through all her rival agencies.
A policy of 'membership of only one postgraduate medical college' should be propagated, to promote healthy rivalry in practices between the two recognized Medical colleges.
Currently, most examiners of one college, say the West Africa College of Physicians double up as faculty and examiners of the National postgraduate Medical College of Nigeria. This leaves a 'monopoly' of sorts as the peoples, systems and processes between the two colleges are virtually identical.
Candidates usually have to register with both colleges in a game of lots.... If I don't scale one, I might the other.
In order to promote this healthy competition, examiners must be made to make a choice of which college to belong, the one which adequately reflects his values. The same should apply to the resident doctors.
The consequence of this will be that candidates will naturally gravitate towards that college which offers her better growth opportunities, at a reasonable costs, while the converse will be true for the other.
The colleges will thus compete for the candidate's money, and again "the customer will be king!"
The failings of monopolistic systems are well cataloged.
7. Continuing Medical Education
One of the excuses for the insensitivity of the exams is the lack of framework for continuing medical education. The reasoning is that once you escape the gulag, further control over the specialist is lost. In other words, he is no longer subject to specialized CME activities to keep track of his progress in the given field. Medicine being what it is require continual updates and review of learned information to keep abreast of current developments.
Present attempts at CMEs are at best jejune, tepid and disjointed.
Specialist CME providers, organizations that provide educational materials on various specialist subjects are practically non existent in Nigeria. Ditto the use of online platforms for delivery and tracking of CME credits.
These present an economic opportunity for our specialists if the appropriate framework is institutionalized.
In concluding, these are mere suggestions from an active participant in the medical milieu. They are by no means exhaustive, and may be a template for a global review of our system
So far, a one day stakeholders meetings to consider these have taken place.
This initiative, is highly welcomed, and comes at a time these programs have become largely 'spinal' in medical parlance; self serving and obfuscated.
Indeed, opportunities as these are rare.
The question is, what ails us so bad to warrant what we get?
The Medical field like other facets of the Nigerian life is a victim of the same general malaise, a so called Nigerian factor.This however does not preclude us from continuing to suggest sustainable solutions going forward.
A cursory look at the reasons for medical tourism are not too far fetched; A general loss of confidence in the capacity of our providers to qualitatively and quantitatively meet the healthcare needs of the population. This in itself is traceable to our organisation of the sector, and an ineffective human resource management approach.
Human resource issues which span planning, talent recruitment, training, motivations and rewards, promotions, discipline, attitudes and organizational culture and other labor issues are a recurring decimal.
On a personal note, these are sorely lacking, and represent the area of greatest need.
Other areas that need be looked at which form the fulcrum for human capital development in the health sector and that may help shape a new paradigm are the following:
1. Medicine as a second degree.
Current structures of medical education allow entry straight from the ordinary level or secondary school. This is at a time these candidates barely know themselves. Self identity is the psychological developmental task at this period and the individual lacks the capacity to fully and adequately understand the ramifications of the choice of medicine as a lifelong career path. He is unable to grasp or appraise the maturity, the demand, altruism and responsibilities inherent in this choice, which are its very defining characteristics.
Without these, the choice of medicine becomes an ego trip, a badge of honor, rather than what it is meant to be, a profession of care and compassion. It becomes an end to itself.
It is even more grevious considering the lack of appropriate guidance and counseling in our secondary schools.
The medical program is a rigorous one. The scope of it daunting. Inter semester breaks are non existent. Lecture and practical schedules span 8 -6 pm daily. Weekends often incorporated. There are no down times. It takes a genius to navigate with a semblance of normalcy.
Unless an individual is naturally inquisitive and curious, or comes in with a very robust intellectual background it is practically impossible to gain-in on other areas of intellectual endeavor. The problem therefore then is to produce a crop of persons without the necessary robustness or roundedness. It is a situation as dangerous as not being lettered at all.
I asked a friend to make a value call on whether to be attended by a wide starry eyed kid (literally) and a calm, level headed middle aged fellow. Her choice was unequivocal. The latter's maturity and probable experience inspired confidence.....
What do we have?
Arising from personal experience, it is a grave injustice to be sentenced to the 'life of misery' that medicine presents without the necessary passion and a clear, well informed opportunity for the choice which can only be garnered after a robust exposure to other facets of life, academia, people and choices. Things possible only through a first degree in other disciplines and a rounded university experience.
It is not for nothing that the United States requires a first degree as a minimum criteria for medicine. It is for nothing that they place premium on such criteria as extracurricular activities, leadership potentials, and general robustness of the individual to recruit to the medical discipline. Shouldn't we borrow a leaf?
2. Funding
The British UK makes use of discrete entities called deaneries or Local Training and Education Boards LTEB in medical manpower development. These are regional and geographic based administrative units. Lump sums of money are allocated and tied to deliverables on a yearly basis at each deanery. Further approval for funding depends on the outcomes from previous allocations.
Deliverables may include pass rates in the certification exams, satisfaction with content and quality of teaching materials, quality of services provided and available facilities.
3. Residency
Accreditation of a program presupposes the availability of physical infrastructure, equipment, and resource persons necessary for training. It is a seal or stamp of approval that what is produced meets a minimum standard qualitatively. Therefore, attention and emphasis must shift back to this area rather than the current short sight emphasis examinations.
The National Universities Commission must have an imput in the curriculum development, staffing, quality assurance and accreditation of residency programs.
There must be clearly delineated landmarks or milestones and specific deliverables to ensure a steady and progressive climb through the ranks of all candidates.
Premium must once again be placed on the 'taught' element in mentorship, didactic lectures delivered by the experts.
There must be opportunities for mutual teacher-students rating or assessment. And to achieve desirable results, teacher promotions and ratings must be tied to student achievements in specific and measurable ways.
What is good for the geese is equally good for the gander.
Part of the contribution of the National Universities Commission is to ensure that would-be trainers obtain minimum qualifications in educational methods and processes.
Residency as constituted in Nigeria now is synonymous with oppression, and servitude of the resident doctors. It is a tool of control and manipulation by those in charge for sundry benefits.
Small wonder, their products become equally egotistic, narcissistic, devoid of milk of human kindness and assume a godlike complex who needs to be appeased to attend to his responsibilities and patients.
It need not be so!
4. Assessments
These must be backed by validity and reliability studies and standardized. International best practice are another yardstick for assessments.
Besides the other assessment approaches of resident doctors, a credit or competency based model of assessment should be looked into. The beauty of this lies in its ability to identify areas of strengths, or weaknesses, and provides a framework for improvement and measuring improvements.
Credit needs to be accorded in areas of competence, whilst encouraging a strengthening of weaker areas. A wholesale or the 'all or none' discredit of individuals is unconscionable.
Membership, engagement and participation in relevant professional aassociations local and international should form one of the yardsticks for ratings.
5. Certification
Most advanced countries have a one off certification examination at the end of the specialist residential training. It is usually voluntary and its purpose is to ensure a minimum standard of practice regardless of the centre of training. It also serves to assure the public of conformity with best practices. Thus cliches like "board certified" are heard.
Not being board certified does not preclude practice and the earning of a living. What it does is to limit the opportunities for practice or the individual's earning potential as some employers and patients will require this.
There ought to be the availability of choice for all and sundry, patient and providers alike.
Certification in nigeria are currently staggered into two stages and highly punitive. Navigating them is like "salvation through fire"and have become a thing of competition rather than facilitation.
Teachers have abandoned their duty posts of facilitation for the "Examinations". These are the happiest days for these people, as they get to affirm and assert themselves.
It will be a good idea for the conduct of these examinations be supretended by independent observers.
Globally acknowledged standards of assessments equally need to be adopted.
Conflict of interest by the examiners is another problem that need be confronted. It is pertinent to note that many of the resource persons at individual centers double up as examiners centrally, and are beneficiaries of repeated examination registration by candidates. Refering to an earlier article of mine on this same subject, a professor of one of the specialities said to me "you claimed in your writeup that candidates often sit a single examination up to 8 or 9 times. If you bring your money to us 100 times, we will collect it". Need I say more?
6. Anti trust
A deliberate policy of healthy competition must be fostered and promoted by the federal government of Nigeria in and through all her rival agencies.
A policy of 'membership of only one postgraduate medical college' should be propagated, to promote healthy rivalry in practices between the two recognized Medical colleges.
Currently, most examiners of one college, say the West Africa College of Physicians double up as faculty and examiners of the National postgraduate Medical College of Nigeria. This leaves a 'monopoly' of sorts as the peoples, systems and processes between the two colleges are virtually identical.
Candidates usually have to register with both colleges in a game of lots.... If I don't scale one, I might the other.
In order to promote this healthy competition, examiners must be made to make a choice of which college to belong, the one which adequately reflects his values. The same should apply to the resident doctors.
The consequence of this will be that candidates will naturally gravitate towards that college which offers her better growth opportunities, at a reasonable costs, while the converse will be true for the other.
The colleges will thus compete for the candidate's money, and again "the customer will be king!"
The failings of monopolistic systems are well cataloged.
7. Continuing Medical Education
One of the excuses for the insensitivity of the exams is the lack of framework for continuing medical education. The reasoning is that once you escape the gulag, further control over the specialist is lost. In other words, he is no longer subject to specialized CME activities to keep track of his progress in the given field. Medicine being what it is require continual updates and review of learned information to keep abreast of current developments.
Present attempts at CMEs are at best jejune, tepid and disjointed.
Specialist CME providers, organizations that provide educational materials on various specialist subjects are practically non existent in Nigeria. Ditto the use of online platforms for delivery and tracking of CME credits.
These present an economic opportunity for our specialists if the appropriate framework is institutionalized.
In concluding, these are mere suggestions from an active participant in the medical milieu. They are by no means exhaustive, and may be a template for a global review of our system
Comments
Post a Comment