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SPECIAL ARTICLE
Year : 2022 | Volume
: 29
| Issue : 4 | Page : 347-353
Striving for excellence in subspecialty medical training in Nigeria: The 6th theophilus oladapo ogunlesi lecture
Sebastian N N. Nwosu
Centre for Eye Health Research and Training, Nnamdi Azikiwe University, Awka, Nigeria
Correspondence Address:
Sebastian N N. Nwosu
Centre for Eye Health Research and Training, Nnamdi Azikiwe University, Awka
Nigeria
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/npmj.npmj_228_22
The solid foundation laid by Prof Theophilus Oladapo Ogunlesi and other founding fathers of the National Postgraduate Medical College of Nigeria (NPMCN) has consistently achieved its mandate of producing specialist medical practitioners in Nigeria. The ever-changing world requires that we have in Nigeria a critical mass of subspecialists to tackle the various old and emerging ailments that afflict the citizenry. Subspecialist training is popular among Nigerian specialists. While those who are not yet subspecialists crave for the training. Nigerian-born sub-specialists in the diaspora are willing to assist in the training. It is now left to policy makers and captains of the training institutions to seize the chance and move us forward with a view to improving the current embarrassingly low number of subspecialists in Nigeria. The NPMCN is hereby beckoned to take the lead. In doing so, it should combine excellence with relevance.
Keywords: Subspecialty, medicine, training, Nigeria
The Chairman, College President, Emeritus Professor TO Ogunlesi and his family, Fellows of the National Postgraduate Medical College of Nigeria (NPMCN), distinguished guests, ladies and gentlemen, you are welcome to this very important session of the Annual Scientific Conference and All Fellows Congress of the NPMCN.
PreambleIt gives me pleasure to deliver the 6th Theophilus Oladapo Ogunlesi Lecture in honour of our teacher and the first President, NPMCN, Emeritus Prof TO Ogunlesi [Figure 1]. I am grateful to the Faculty of Ophthalmology for nominating me for this task. I also thank the College authorities for accepting the nomination.
Figure 1: Emeritus Prof TO Ogunlesi (donning NPMCN Presidential gown). NPMCN: National Postgraduate Medical College of NigeriaThe topic of this lecture, striving for excellence in subspeciality medical training and clinical practice, was chosen for several reasons. When Prof Ogunlesi and his colleagues were teaching us at the University of Ibadan medical school, excellence was the watchword. Indeed, one of our teachers, the late iconic physician, Professor Benjamin Osuntokun once stated, 'it is excellence, not success, that counts. Success is perishable. Excellence lasts forever'.[1]
On his part, Prof Ogunlesi never settled for anything short of excellence. Thus, after a gruelling 7-year study at the Yaba Higher College school of medicine, he was not satisfied with the status of Assistant Medical Officer, as graduates of that school were then designated in the colonial civil service. Hence, he moved to the United Kingdom, where within a year, he passed the Conjoint Board examination earning MRCS and LRCP. Without wasting time, he enrolled in postgraduate training obtaining the MRCP in record time.
On returning to Nigeria, he worked at the Adeoyo Hospital, Ibadan. But still, in search of excellence, he moved to the University College/University College Hospital, Ibadan, where he was deeply involved with organising and nurturing the new medical school. Then, combining excellence with relevance, he became the first Director of the University of Ibadan's Ibarapa Community Health Development Project (Ibarapa Project, for short) – a community-oriented medicine programme that sought and indeed actualised the aim of making locally trained doctors to be conversant with the health needs within Nigerian communities.
In further search of excellence, Prof Ogunlesi along with his colleagues conceived the idea of local postgraduate medical training in Nigeria. This wonderful move gave birth to the NPMCN. He later became the first President of the college.
Excellence is not static; rather, it is dynamic. It is clear that Prof Ogunlesi recognised the dynamic nature of excellence and, in his prime, continued its relentless pursuit, milestone after milestone.
National Postgraduate Medical College of Nigeria Versus ExcellenceThe NPMCN has excellence at the bedrock of its charter – its vision and mission statements embody excellence. For over half a century, the college has pursued excellence in residency training with a view to graduating at each moment, medical and dental specialists capable of tackling the health problems of Nigerians. To a very large extent, one can safely opine and also congratulate the college for achieving a high degree of excellence in its residency training programme.
However, although some of its faculties, such as physic (internal medicine) and surgery, have subspecialist programmes, the college is yet to fully cut its teeth in subspecialist training either during residency training or post-residency training.
What is Subspecialist Training?This is a 1–2 years of further formal training by a qualified specialist to enable him/her to acquire highly specialised skills and expertise in a particular aspect of the chosen speciality. Such skills usually raise the quality of medical care rendered to patients. In developed countries, subspecialist training is usually embarked upon after residency training and thus tagged post-residency fellowship programme.
Case ReportIn most cases, Nigerians who travel abroad for medical care do so because of perceived or actual lack of requisite skills and or equipment locally. However, such overseas treatment, good as they may initially be, ultimately becomes frustrated by the lack of adequate follow-up, as this non-hypothetical case report illustrates:
A 50-year-old Nigerian male became blind in his only seeing left eye. (He had lost vision in the right eye following penetrating injury in childhood.) A diagnosis of giant retinal tear with total retinal detachment complicated by proliferative vitreo-retinopathy was made. He travelled overseas where he had sight-restoring surgery involving lensectomy, vitrectomy, membrane peel, laser and intraocular injections of heavy liquid and silicone oil. He was advised to return for follow-up and silicone oil removal. However, he was unable to do so. He continued follow-up care in several eye care facilities locally, but the silicone oil was not removed in spite of it becoming emulsified and touching the cornea. Meanwhile, his vision began to deteriorate. Four years later, the persistent silicone oil contact with the cornea led to corneal de-compensation and the patient returned to blindness.This case illustrates the drawback in obtaining highly specialised treatment overseas without facilities and skills for follow-up care in the patient's country of residence. This patient's ophthalmic disorder required care beyond the skills of a general ophthalmologist; it required the skills of a subspecialist, in this case, a vitreoretinal surgeon working with equally specialised support staff and equipment. Problems highlighted in this case report which are not uncommon in our setting, include:
Lack of requisite skills, including the surgeon and support staffLack of requisite facilities, including equipment and ancillary supportUnsustainability of overseas treatment.All these show that the bane of overseas treatment is inadequate follow-up in the patient's home country. Overcoming this difficulty will require a deliberate policy that will enable us to take our destiny in our own hands –ensure that requisite subspecialist skills and equipment are widely available in Nigeria.
In its early days, the NPMCN recognised the need for overseas exposure for its trainees and so every resident doctor that passed its Part I Fellowship examination was sent to an overseas (America or Europe) training institution for a period of at least 1 year ('the year-abroad programme'). This endured until the mid-1980s, when the programme was scrapped largely due to economic reasons. The NPMCN has, on its own tried to revive the programme through travel grants (enduring 3–6 months) to select resident doctors who had excelled in the Fellowship examinations. However, it is not clear if there has been any audit of the overseas exposure with a view to finding out its usefulness or otherwise.
In 1985 the Federal government designated Ibadan, Enugu, Maiduguri and Zaria teaching hospitals as Centres of Excellence in neuroscience, cardiovascular diseases, immunology and oncology, respectively. It will be relevant to this discourse to find out the impact of these Centres on subspeciality training, clinical service and research in their areas of designation.
National Postgraduate Medical College of Nigeria Versus National Health PolicyThe NPMCN, it should be acknowledged, has done a lot in helping direct health policy and practice in Nigeria. The most significant in recent time was its collaboration with the Federal Ministry of Health and other bodies to produce the National Surgical, Obstetrics, Anaesthesia and Nursing Plan (NSOANP) for Nigeria, 2019–2023.[2]
The document outlined the strategic priorities for surgical care which would ensure surgical equity, safety and progress in Nigeria. Looked at closely, the document is premised on the need to achieve universal health coverage by ensuring safe obstetrics, anaesthetic, surgical and nursing care, leaving no Nigerian behind. Indeed the provisions of NSOANP, if well implemented, would strengthen the primary and secondary health care levels. These levels of health care are very important in ensuring the well-being of Nigerians. In particular, primary health care is designed to reach the unreached in remote rural areas and the disadvantaged sections of urban communities. However, the tertiary (specialised) care level needs be simultaneously carried along.
Primary health care should not be emphasised to the detriment of tertiary care since the villager, the urban poor and the elite are all subject to cancer and other debilitating diseases that, in the main, require tertiary care. There is a need to strike a balance. I once posed a question to my colleagues during the Fellowship examiners' meeting: 'Do you think that if we are able to investigate cases of retinoblastoma to gene level, our resident doctors wouldn't know it?' In response, all examiners present bemoaned the lack of facilities for such investigation in almost all the training centres within the jurisdiction of our college.
Cancer care, I should add, does not fully reside with the primary health caregiver. While the primary health-care worker could through health promotion and early detection, identify cancer cases, it is at the tertiary care level with subspecialists that definitive cancer care will be obtained. Such well-staffed and well-equipped centres would be the training and practice arena of subspecialists.
The former President of Tanzania, Julius Nyerere, had proposed that 'while white men have gone to the moon, we in Africa should get to the village'.[3] But renowned African scholar, Ali Mazrui, worried that by the time we, in Africa, get to the village, we will not be able to return to the cities. This concern was possibly based on his observation that 'all over Africa, development is distorted, priorities violated and the continent has mortgaged its soul'.[3] My submission is that we have been in the village since 1988 when Nigeria's Health Policy with primary health care as its cornerstone was launched.[4] We should sustain the progress so far achieved in primary health care by strengthening tertiary care with massive local training of subspecialists in all branches of medicine. At this juncture, it is pertinent to pay tributes to eminent Fellows of NPMCN who are regarded as the fathers of primary health care in Nigeria: Professor Adetokunbo Lucas, who chaired the committee on National Health Policy that recommended primary health care as its cornerstone and Professor Olikoye Ransome-Kuti who as Minister of Health meticulously implemented the Primary Health Care programme. May their souls rest in peace.
Local Subspeciality Training: A Luxury?Some leading medical educators in Nigeria consider subspeciality training a luxury we cannot afford in Nigeria.[5],[6] They argue that we should concentrate on our current mode of residency training until enough specialists have been produced. However, these respected colleagues have not defined the exact number that should constitute 'enough specialists'. At its 50 years anniversary and 37th Convocation ceremony in 2019, the NPMCN announced that it had graduated 7000 specialists.[7] To this number would be added those who qualified exclusively from the sister colleges of the West African College of Surgeons, West African College of Physicians and similar colleges overseas. Thus, the problem is not the number of specialists. The real problem lies with the mal-distribution of the specialists, which is skewed in favour of major urban areas, as well as with the exodus of doctors to overseas countries – a phenomenon known as 'brain drain' in local parlance.
It is instructive that the idea of local residency training was conceived by the Nigerian Medical Council in 1966 when the Council's Secretary wrote to the Federal Government requesting approval of the policy. There was progress in 1969 with the establishment of the Examination Boards in different specialties by the Nigerian Medical Council. The legal backing for the NPMCN came with the enactment of the National Medical College Network Act of 1979, which authorised the establishment of the National Medical College charged with the responsibility of conducting post-graduate examinations in various specialised branches of medicine and dentistry.[8]
By 1966 the University of Ibadan was the only tertiary institution producing medical doctors in Nigeria and its output per stream was scarcely above 50. However, this did not prevent the leading medical educators at that time, of which Prof Ogunlesi was one, from embarking on local residency training in Nigeria. Hence, the apparent fewness of general specialists should not be a hindrance to the pursuit of subspeciality training in all the faculties of the NPMCN.
Dearth of Subspecialists in NigeriaThe dearth of subspecialists in Nigeria and indeed, the West African Sub-region is worrisome. A recent survey of surgical subspecialists in West Africa showed that only 32.6% of surgeons were surgical subspecialists.[9] This translates to 0.17/100,000 population for the sub-region and for Nigeria, 0.29/100,000 population.[9] This proportion is very small compared with 7.9/100,000 population in the UK[10] and 18.5/100,000 population in the US.[11] The number of subspecialists in West Africa is also less than that in East, Central and Southern Africa;[12] this region has the College of Surgeons of East, Central and Southern Africa as the local post-graduate medical training and certifying institution.
Perhaps to tackle the embarrassingly low surgical subspecialist workforce, the West African College of Surgeons modified its curriculum devoting the last 2 years of its programme to subspecialist training. It is hereby recommended the NPMCN also institutes subspeciality training across all its faculties.
Planning Subspecialist TrainingHowever, mounting subspeciality training programme should be preceded by thoughtful planning and a clear vision of the expected outcome. Also to be addressed are issues such as funding, external co-operation and sustainability. There should be a timeline for the establishment of the programme – beginning with definite policy direction; the assemblage of the critical number of trainers and monitoring of the progress of the training. The political will of government to support and help with funding the programme should be secured. Very importantly, all stakeholders should be carried along at every stage.
The Nigerian Medical Council was faulted for non-inclusiveness at the inception of what is now the NPMCN.[13] Criticisms include that the Council went ahead to organise post-graduate residency training without:
Seeking the input of potential training institutionsUpgrading the facilities required for post-graduate standardsDetermining the overall financial implications and level of funding, the participating institutions would need to provide additional infrastructureAddressing benefits or possible disadvantages that may accrue to the training institutions.[13] Interviewing StakeholdersIn preparing for this lecture, questionnaires were sent out seeking the opinion of the following stakeholders in subspecialist training:
Chief Medical Directors/Medical Directors of residency training institutions and Centres of ExcellenceSpecialist medical practitioners (Fellows) in NigeriaSome Nigerian specialists/subspecialists in the diaspora. FindingsRegrettably, despite my best efforts, no response was obtained from the heads of residency training institutions and Centres of Excellence. On the other hand, specialist medical practitioners, most of who are Fellows of the NPMCN, impressively responded to the inquiry; there were 612 respondents. All respondents had their first degree in medicine or dentistry between 1974 and 2011; specialist qualifications were obtained between 1986 and 2021.
Most residency training (98.0%) was conducted in government hospitals; private and faith-based hospitals constituted 2% of the training institutions. Only 26% of the respondents had undergone subspeciality training. Among those without subspeciality training, 83.2% would like to undergo subspeciality training. Subspeciality training took place in different countries in all the continents of the world, with Africa, Asia and Europe constituting 76.0% [Figure 2]. The duration of training ranged from 2 weeks to 2 years, with 47.6% enduring for 3 months or less [Table 1]. Most of the training took place in India (18.7%), the USA (13.4%), Nigeria (12.0%), the UK (8.7%) and South Africa (6.5%).
Indeed subspeciality training is ongoing in a few disciplines in 30.8% of the training institutions in Nigeria. Of those not yet involved with subspeciality training, 47.2% were of the opinion that their hospitals were capable of subspeciality training.
Only in 64.2% did the subspecialist training involve practical hands-on experience; in the remaining 35.8%, the trainees were mainly engaged in observer-ship [Figure 3].
Of those fortunate to have hands-on training, 30.5% had hands-on guidance during only 50% or less of the training period [Figure 4].
Facilities for subspeciality practice were not optimal in all the institutions where some of the subspeciality medical practice are undertaken in Nigeria; shortage of critical team members such as specialised nurses and technicians were the obstacles most felt [Figure 5].
In 32.0% of respondents, subspecialist activities make up 50% or less of the workload [Figure 6].
Lack of trained subspecialists, lack of equipment, poor infrastructure and weak policy guidelines were the major obstacles to subspeciality training [Figure 7].
The Diaspora PerspectiveAmong the Nigerian-born specialists/subspecialists practicing outside Nigeria (all in Europe or North America) who responded to the questionnaire, were subspecialists in psychiatry, paediatrics, ophthalmology, obstetrics and gynaecology, nephrology, clinical neurophysiology and clinical oncology. While all the respondents supported mounting subspecialist training in all clinical specialties in Nigeria, 75% felt that it is feasible to undertake such training now using the existing teaching hospitals. All the respondents would like to support and indeed participate in such training if invited. They would also provide some learning resources and equipment as well as arrange overseas exposure for the trainees [Figure 8]. All the respondents would like to visit Nigeria to participate in the training for up to 2 weeks at a time, once or twice yearly; some would stay longer if the environment is secure. One respondent, a clinical neurophysiologist, had this to say:
Figure 8: Areas of support for subspeciality training by diaspora colleagues'I will like to disseminate the skills I learnt abroad to Nigerian specialists. When I was a consultant in Nigeria, we purchased equipment for Clinical Neurophysiology. Unfortunately, there was nobody skilled in Clinical Neurophysiology to give the training or use the equipment. The equipment were there ageing and getting out of date without being used appropriately. That was precisely one of the main reasons why I went abroad in the first place. As many of us who went abroad to learn subspecialist skills are getting older, we yearn to pass on the knowledge to the younger generation before we retire from practice. It would be a waste if all the skills acquired by Nigerian subspecialists abroad are not passed on to their compatriots.'
Observations and DeductionsOur findings suggest that only 26% of the specialists interviewed had any form of subspecialist training. This is <32.6% documented in the West African College of Surgeons survey.[9] The quality of subspecialist training obtained by some respondents is of concern for the following reasons:
More than 30% did not have practical hands-on training,Very short training duration– <3 months in many instances (47.6%) [Table 1].Oyediran[14] had decried the situation where senior resident doctors in public health who were sent to some industries for practical experience were not given an opportunity for practical hands-on training. In emphasising the importance of hands-on subspecialist training, a Nigerian subspecialist in the diaspora stated namely:
'The most essential ingredient here is the availability of sub-specialist workforce to provide the training. Nigeria is blessed with well-trained manpower living abroad who can transfer this technology. The costs are affordable to establish a service centre that grows with time. Young trainees will gain immense practical skills which cannot be learnt by reading books alone. You cannot learn how to swim by reading a book'.
Similarly, the very short duration of training may not allow for the acquisition of relevant skills. Given the very short training duration and the high proportion of observer-ship, some of these training programmes actually fall outside what could be regarded as subspeciality training. At best, they constitute update courses! Any training enduring <6 months should not be certified as subspeciality training.
RecommendationsThe NPMCN should devise uniform minimum curriculum and accreditation requirements for subspecialist training in all its faculties. In doing so, the NPMCN should early seek the collaboration of both the government (for funding) and the training institutions (infrastructure and capacity building). To this end, it bears to re-emphasise that the Nigerian government (Federal, State) should show genuine commitment to local subspecialist training by improving the funding of teaching and specialist hospitals (which constitute the training institutions). It is only through adequate funding and careful deployment of critical human and material resources that the goals of subspecialist training can be attained. Of great importance is the need to ensure that the requisite equipment are available and critical team members (including nurses and technicians) are trained or hired and deployed for subspecialist work. It is depressing for one, after subspecialist training, not to have the necessary work tools. The lack of the requisite work tools may be the reason a third of subspecialists interviewed put in 50% or less clinical work in their subspecialties.
The NPMCN should also seek the collaboration of sister colleges and academies overseas with a view to signing with them appropriate memoranda of agreement that will allow local subspecialist trainees go for further training lasting in each case not <6 months and with specific provision for practical experience. The enthusiasm to participate in local subspeciality training expressed by the Nigerian-born medical subspecialists in the diaspora is an opportunity to be grabbed with two hands. Some of these compatriots have influence as well as resources that should be harnessed in building capacity and ensuring that we achieve excellence in subspeciality training locally.
In summary, our findings point to the fact that subspecialist training is popular among Nigerian specialists. While those who are not yet subspecialists crave for the training, Nigerian-born subspecialists in the diaspora are willing to assist in the training. It is now left to policymakers and captains of the training institutions to seize the chance and move us forward with a view to improving the current embarrassingly low number of subspecialists in Nigeria.
ConclusionThrough the solid foundation laid by Prof Ogunlesi and other founding fathers of NPMCN, the college has consistently achieved its mandate of producing specialist medical practitioners in Nigeria. However, our ever-changing world requires that we have in Nigeria a critical mass of subspecialists to tackle the various old and emerging ailments that afflict the citizenry. The NPMCN is hereby beckoned to take the lead. In doing so, it should combine excellence with relevance.
Acknowledgement
I wish to express my gratitude to all who were of assistance to me in preparation for this lecture. Let me thank the Chairman, Faculty of Ophthalmology, Dr Haroun Ajibode and all the members of the Faculty Board of Ophthalmology. All those who responded to our questionnaire are greatly appreciated. Also to be appreciated are: Professors Adesola Ogunniyi, Charles Bekibele, Bolutife Olusanya, Abdu Lawan and Abdulkadir Rafindadi. Others are my colleagues at the Nnamdi Azikiwe University Teaching Hospital: Drs. Chizoba Uba-Obiano, Adaora Onyiaorah and Chidozie Ndulue. The following colleagues in the diaspora are simply wonderful: Drs. Dele Sokunbi, Godwin Lekwauwa and Jideofor Ndulue. May God Bless you all.
The 6th Theophilus Oladapo Ogunlesi Lecture was delivered at the 16th Annual Scientific Conference and All Fellows Congress (ASCAF) of the National Postgraduate Medical College of Nigeria which held at Eko Hotel and Suites, Victoria Island, Lagos, on 9th August 2022.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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