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Published On: Mon, Apr 28th, 2014

Physician, heal thyself

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By Timi Babatunde

About 3 or 4 years ago, the British Royal College of Physicians was involved in a peer review process with the West Africa College of Physicians. The objective was to assess areas of collaboration in medical education, evaluation and practice. The intent was also to evolve a new paradigm and approach to the training of doctors generally, bringing things to par with international best practices.

The success of that mission would have meant that physicians trained and accredited here as specialists could simply pack their belongings and move to the United kingdom, Australia, Singapore or Ireland for practice and vice versa. It would have meant our qualifications are unquestioned and at par with other ones out there. It would have facilitated practice across borders, greater international recognition and acceptance, a fluidity of processes and perhaps a restoration of confidence in a sector since relegated to the fringes.

It would have been an elixir of life in a sector bedeviled by all manner of ills, a lack of leadership (conceptual, managerial and innovative), loss of confidence by the populace, an obsolete approach to medical education, lack of general and human management approaches, inter and intra professional squabbles, this initiative would have done a lot to assuage some of these ailments.

Unfortunately, as is typical for brilliant, well intentioned and novel ideas which go against well entrenched vested interests, the initiative came dead on arrival! A cabal that eschews public scrutiny and accountability presided over the death of the initiative. Few of us continue to say that too much power is vested in the post graduate Medical Colleges which remains both the judge and prosecutor in her own cases! It determines the standards of graduate medical education, determines the standards for residency programs, determines the standards and formats for the examinations, administers these examinations and determines individuals it deems fit to qualify as specialists. She will also adjudicate in any appeals against it, an exercise in futility.

The colleges are a law unto themselves with no external checks and balances. They are not accountable to the public. They carry on as though not answerable to anyone. The reason is that, the federal government which underwrites the salaries of these resource persons has never demanded results. No one has ever challenged their methods. They resist oversight from the National Universities Commission in a battle of egos and continue to inflict unimaginable pain on multitudes of wannabe specialists through their non-evidence based methods. The tragedy is that no one is asking questions!

For each resource person maintained and millions of naira in salaries, what are the correspondent outcomes in terms of specialists produced annually? Are any quotas for training outcomes specified? Are the throughputs done with local and national needs in mind? What is been done to meet the specialist needs of the North East in five years time? Their need for pediatricians, psychiatrists, surgeons, etc.?

Indeed, the thrust of the recommendations by the Royal College was precisely in the areas of planning, resource allocation, objectivity, standardization, transparency, accountability and international best practices. These recommendations were roundly dismissed by some of the faculties (Psychiatry) and selectively adopted by others. A case of double standards, raising questions of governance and regulation.

The developed countries adopt a process which matches supply of specialists with demand, which ensure outcomes for resource allocation and which lends little opportunity for manipulations, ensuring accountability from top to bottom.

Transparency and accountability is often achieved by a process of quality assurance which articulates what the definitions, standards or measures of quality are, what needs to be done to achieve this quality and spells out the steps to achieve this end- in a dispassionate manner.

Quality assurance in graduate medical education should begin with the separation of the bodies responsible for setting and upholding the standards for graduate medical education and the body that implements these standards. In the United States of America, the Accreditation Council for Graduate Medical Education ACGME is responsible for the former, while the American Board of Medical Specialities (ABMS) is responsible for the latter.

This transparency, accountability and quality assurance continues by ensuring that each medical specialty conforms and implements the recommendations of the ACGME to the letter. Interestingly, each speciality or faculty is made to apply individually to the ABMS, and its conformity to recommended guidelines assessed before acceptance to the general board. A case of the dog wagging its tail, not the other way round.

The other way quality assurance and control is ensured is in the manner of training and evaluation. Specific criteria are laid down for the selection of program director or head of residency training. These include academic interest, exposure (local and international), experience and qualifications. Specific formats of training emphasize didactic lectures, seminars, case presentations, grand rounds, bedside teachings, lifelong learning and enquiry.

Specific timelines with associated learning objectives are clearly outlined, usually by rotations and an annual graduation from one level to the other. Thus, post graduate year one naturally gives room to PG year two through to PG years five or six as the case may be. This helps keep track of the progress of individual candidates against the learning objectives, assures promotion from class to class, enhances administration and planning and discourages a culture of impunity where no one takes responsibility for progression of resident doctors under them.

In the area of evaluation, specific methods are also adopted. The multiple choice (mcq) and extended matching question formats are important in written examinations. They replace the more subjective essay writing, and can more effectively test the breadth and depth of knowledge, including recognition. The Objective Structured Clinical Examination (OSCE) also replaces the obsolete and highly subjective clinical “long case” exams. Adoption of OSCE ensures uniformity, and standardization of clinical examinations, and all candidates get to see the same patients and examiners without the allegations of bias or nepotism.

As in other spheres of the Nigerian existence, the tendency to resist change remains significant in the healthcare sector. The sector is arguably the most troubled, partly because of the conspiracy of its elites, its highly professional nature which renders it impervious to public scrutiny, failure of her utilizers to demand change and a government lacking in will to place demands.

The sector will remain in its current sorry state unless the conceptual underpinnings of healthcare delivery is revisited, new mechanisms and processes engaged, accountability and transparency to the public made its cornerstone, and a more appropriate model for its delivery employed.


Timi Babatunde is a medical doctor.


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