November 20, 2014.
By: Ibrahim Toli
The part one of this article gave introduction to organisation of health care delivery system and the undergraduate medical training. This part will discuss postgraduate medical training and how it differs from the traditional postgraduate degrees.
The Nigerian specialist medical cadre is modelled after the British system. After the mandatory 1-year of clinical clerkship (internship) and another 1-year of National Youth Service (NYSC), aspiring medical specialists have to undergo residency/fellowship training.
Residency means the candidates become resident in the hospital with very limited freedom; they also face very rigorous training. The duration depends on the field of study and could be between four to six years. Admission into residency does not come on a platter of gold. The aspiring medical specialist must pass at least one Primary examination from the National Post graduate Medical College of Nigeria (NPMCN) or West African Medical College (WAC) or their equivalents before eligibility for very limited slots in accredited tertiary health centers.
Successful applicants are given temporary, non-pensionable employment for a maximum duration of six years, and failure to complete the training within this period leads to termination of employment.
The program is divided into two parts: the first which is Junior Residency (Part 1) lasting two to three years, and the second, the Senior Residency (Part 2) lasting for another two to three years. Progression at each stage is subject to passing an examination. The senior residency has a research component, and successful completion of this stage is subject to passing an exam and also successful defence of a research dissertation.
Residents doing a four-year program have a grace of one year at each stage to pass the exams, but residents in fields of Surgery and Internal Medicine whose training generally last for six years do not have this luxury. It is only after passing the part two that a doctor is appointed as Consultant/Specialist physician and function as such.
It is a unique postgraduate Medical programme for Doctors which combined study and provision of clientele medical services at the same time. A Resident has a contract with the employer to provide medical services to hospital clients while undergoing postgraduate degree. Thus the employer, mainly Federal Government, pays the Resident monthly wages for consulting patients based on reasonable balanced hours of work that ideally shall not interfere with the Resident’s study time.
Alas, in Nigeria the whole time is nearly all consumed by service delivery with very little remaining for personal academic development. How Residents here survive this carnage not only able to complete the training, but equally excelled beats my wildest imagination. Funny enough, it is this monthly wage deservedly paid to Residents for service delivery that some weird groups see as Manna and even maliciously suggested its stoppage. What then is the definition of a Consultant, a very simple word that is being mystified in Nigeria’s electrospace. According to Merriam-Webster dictionary;
: a person who gives professional advice or services to companies for a fee.
: a hospital doctor of the highest rank who is an expert in a particular area of medicine.
: a person who is skilled in the science of medicine : a person who is trained and licensed to treat sick and injured people.
: the place where a doctor works.
: a dentist.
Ironically the training institution has no obligation to retain such individual and thus a new consultant must look for where to start work afresh except if employed by the university or is a supranumerary resident with a permanent job ab inito.
Throughout residency, the rank of a university Lecturer-Resident is lecturer II and a new Lecturer-Consultant lecturer I for the few employed by the university.
The salary scale of Doctors is called Consolidated Medical Salary Structure (CONMESS) at present. The rank of a Junior Resident or Medical Officer, considered the entry point for Doctors, is CONMESS 02/02 or GL 12/02 and a Senior Resident occupies CONMESS 03/03 or GL 13/03.
It is important to note that promotion for Doctors that choose residency as their postgraduate line is tied to passing exam only and thus a Resident can remain static in one level except he/she passes the fellowship exam. Should the resident doctor be unable to pass the exam and exit the residency programme, the unlucky Doctor will still remain on GL 12 no matter the years of clinical practice. If this is not short-changing then I don’t know what it is.
Nigerian system failed to acknowledge the existence of additional medical knowledge a Resident acquired irrespective of exam outcome. The system does not differentiate Residents based on College/Board eligibility or certification. A Resident is College eligible if he has finished rotating between core clinical units, his/her medical knowledge cannot be compared with a new Resident.
Doctors choose areas of interest to specialize in spanning through many specialties. How then does residency training differs from conventional postgraduate degrees (MSc and PhD)?
There is a wide difference between these two in every aspect. The conventional university postgraduate degrees apart from being narrower in scope, lay emphasis on theoretical than clinical aspects in a specific credit unit system while the medical training and residency lay dual emphasis on both academic and clinical knowledge.
A medical student or Resident is not deemed to have passed an exam unless s/he demonstrates in clear terms both academic and clinical competence in the subject area. Reading about a disease and seeing it real, are two different ball games entirely.
Let us take one disease in the nervous system like meningitis, inflammation of the coverings of the brain and spinal cord called meninges. One cant possibly write a Doctoral thesis on the many etiology of meningitis, ranging from viruses, bacteria, fungi, parasites, aseptic etc, rather one chooses a specific cause of the disease, say viral meningitis.
Even that is too wide a topic to have a PhD on rather it may be more realistic to write on cerebrospinal fluid biochemical and cellular pattern in specific viral meningitis for example. Can you then call this person a Neurologist? Will you present yourself to him/her for treatment of any neurological disease? This is only one disease syndrome in the nervous system.
Again, suppose someone has an MSc in iron deficiency anaemia (one of the cause of low level of blood in the body) and PhD in hemoglobinopathies (abnormality in pigment of blood), will he then be appointed as a senior resident and consultant hematologist respectively?
What if someone present with hemophilia or leukemia? Ok I hear you say no big deal, there are others that will specialize in those areas. That is correct, but how many consultants are you going to have in hematology; 1000, 2000? Thus in a hospital you will need like 500,000 consultants to manage just one centre! This of course is not practicable and that is why medical postgraduate training is very different and unique.
Does having PhD in electroencephalography, electrophysiology, lung function tests, gastrointestinal endoscopy, hemodialysis, refraction, radiography and psychology qualifies one to be called and function as a Consultant Neurologist, Cardiologist, Pulmonologist, Nephrologist, Ophthalmologist, Radiologist and Psychiatrist respectively as well?
To pass part I in the case of Internal Medicine, a resident has to study all the common and rare human diseases affecting all the human biological systems. A Senior Resident is a Specialist in the making who requires additional training for 36 months after which he must write and defend a project. He is capably trained to lead the unit in the event his consultant is indisposed.
A Consultant hardly changes the diagnosis of a competent senior resident, what s/he does is to enrich the final clinical assessment and management. On the whole, all residents are in fact specialists in training when one considered the quality of their input to patient care.
In the tertiary hospital, a Consultant is the final refined touch to any patient’s management. He owns the patient and takes the ultimate responsibility for the care of the patient. He leads and teaches both medical and dental students including allied health professionals, mentors residents and above all, a good Consultant also learn from those he leads.
There is a difference between being a Consultant and being a Fellow of certain organisation; the former is achieved by academic excellence while the latter is attained by mere membership and payment of annual dues.
Department of Internal Medicine,
Ahmadu Bello University Teaching Hospital Zaria, Kaduna State, Nigeria.