by brahim Toli
The first three articles in this series essentially focused on the organisation of our health care delivery system, qualifications and roles of the various players in the industry. We will now examine the major problems affecting this important public sector.
The immediate problem facing the public health industry is leadership positions, which includes the office of the chief executive and the various clinical departments. The lucre attached to the office of Chief Medical Director/Medical Director (CMD/MD) in the tertiary centers is certainly the drive for such fierce battle rather than the fervor for altruistic service to humanity. Nigerias dysfunctional system attached too many privileges to the offices of the chief executives of various institutions. Therefore all other health workers felt cheated for being outliers of this coveted office, hence coming together under a bellicose umbrella of Joint Health Sector Union (JOHESU) that comprises all other health workers, except Doctors, including junior staffs (ward attendants, porters, etc for the purpose of quantity and sabotage) who have no chance of ever reaching the office, but they join the struggle anyway. Closely related to the office of CMD/MD is that of Chairman Medical Advisory Committee (CMAC) which has limited powers, but has as its advantage a chance of promotion to the higher office. There are two directorate offices in the teaching hospitals, one of which is that of the Director of Administration (DA) and the other, Director of Clinical Services, otherwise known as the Chairman, Medical Advisory Committee (CMAC). The director of administration is always an administrative staff while a medical doctor occupies that of CMAC. CMAC represents all the clinical departments, at least 17 of them, with a single vote which has the same voting power as the Director of Administration. At present Doctors occupy both the offices of CMD and CMAC by statutory laws and unless such laws are repeal, the status quo has to be maintain. To circumvent these laws and to cut corners while aiming at the CMD/MD office, elements within JOHESU want to be appointed tertiary hospital consultants and directors within the clinical setting without requisite clinical training or job descriptions. Not only that but they equally demand identical pay scale like the physicians as we shall see later. Earlier articles in this series showed the existence of the titles consultants and specialists related to other health workers, but their roles and wages are never the same with that of the physicians anywhere in the world! On the surface it will appear to any uncritical observer that Doctors are preventing such appointments to satisfy their egoistic temperament, but in reality some people want to jump professional intellectual ladder for pecuniary gains. While their colleagues over there are quietly obtaining such qualifications, our Nigerian JOHESU intends to have it through noise, insults, deceit, propaganda and blackmail.
It is true that in other countries non Doctors are appointed as chief executives of hospitals because hospitals are money generating corporate organisations and not purely portal for social services. Personally I don’t have problem with such arrangements only that we are doing it the wrong way. I am worried about how professionals like pharmacists and nurses are conscribed in to this imbroglio. I still find it difficult to believe that these professionals will be a party to a group that will switch off oxygen plant, electricity and water supply to a hospital not minding the fragile patients on mechanical ventilators or incubators. I find it absurd that nurses are being herded in to occupational black hole without them even realising it, for they are employed at CONHESS 07 while their influencers are employed at CONHESS 09 and even if FG liberalise the office of the CMD/MD, they have no chance. I find it rather strange that these professionals do not see the consequences of hastening FG’s decision on the inevitable privatisation of tertiary centres!
The next in contention is headship of laboratory departments. Laboratory medicines belong to the domain of pathology and are headed by pathologists (laboratory medicine physicians). A pathologist is a physician who has undergone postgraduate residency training in any of the fields of pathology namely: Histopathology, Hematology, Chemical Pathology or Medical Microbiology/Parasitology. As mentioned above, Doctors specialize in Lab Med comprising Histopathology and Morbid Anatomy (involves with postmortem, tissue analysis for infection or cancer, etc), Medical Microbiology and Parasitology (involves with analyzing pathogenic [infectious] microorganisms and parasites etc), Chemical Pathology (involves with analyzing body chemicals, hormones etc) or Hematology (involves with analyzing blood and its products, blood donation, blood transfusion etc). Silently in the background, but incubating is the Immunology (concerns with analyzing products of immune mediated events like antibodies, antigens, immune cells etc) and Radiology (concerns with patient evaluation using radio and non radio imaging). It is important to note that, just as the pharmacists are assisted by the pharmacy technicians; the laboratory scientists/technicians assist the pathologist. This is the standard all over the world. The dearth of man-power in this critical area of medicine has often lead in most instances laboratory technologists filling-in for a pathologists especially in primary and secondary health centers. What was intended to be an ad interim arrangement has now mutated in to something else, just like what is happening with those train in school of health technology that are now physicians and surgeons in the PHCs. In advance societies, just like no Coroner will accept an autopsy report from a technologist/technician, no clinician will accept a laboratory result that is not signed by a qualified pathologist. The reason is simple. Only the Doctor is equipped with the knowledge of human anatomy/physiology on one hand and disease pathophysiological process on the other that can make meaningful juxtaposition between the clinical condition and the laboratory result. Put differently, the doctor’s clinical knowledge helps in optimizing laboratory results and minimizing confounders that could be due to improper timing of sample, transportation of the sample or other factors that may alter the test result in addition to the disease. For example a technologist might think he made a mistake if he sees a WBC (white blood cell) count of 50,000/μL or 100,000/μL, but a Doctor will know it to probably represent a Leukemoid reaction or Leukemia respectively, again a PCV (packed cell volume) of 60% is not unusual in Polycythemia Vera, a technologist will heroically report serum potassium of 9 mmol/L, but a Doctor knows it is likely to be factitious as that level is incompatible with normal function of human heart etc. Can a technologist perform an autopsy or bone marrow biopsy? Will it make any sense to a technologist who cultures Staphylococcus epidermidis from cerebrospinal fluid (CSF) of a child with ventriculo-peritoneal shunt? He will certainly report it as a culture of normal skin commensal. Will a Doctor ever sign and release a result of antibiotic sensitivity test of microbial resistance to all drugs? Is it a wonder acute Leukemia, Myelodysplastic syndromes and Myeloproliferative disorders are hardly ever diagnose in time in General hospitals? That is the ultimate difference. More so Doctors dont just treat lab results rather they use the results while holistically looking at the patient clinical and or comorbid conditions. Often times they disregard a result when it conflicts with actual patient clinical condition. Because many laboratory techniques are becoming more automated making it easier to train anyone to perform, laboratory medicine has been mistranslated. However, relegating Lab Med to just clinical tests is gross ignorance and disservice to good clinical practice.
Apart from the Doctors, there are two groups of people working in the lab, the lab scientists and the lab technicians. The difference between the technician and technologist is that while the former has only basic technical training of 1-2 years, the latter spends 4-5 years to obtain a university degree. The Lab scientists have been agitating to head the departments believing they are the rightful owners. This may be convincing in the PHCs and perhaps, some General Hospitals where there are no pathologists, but in any other situation, it will be just ridiculous. Yes, the Doctors learn a lot from the technologists/technicians just like Cadets learn drills and shooting skills from other ranks, but can the other ranks volunteer to teach say theory of intelligence, VIP protection, reconnaissance, crime scene investigations etc? And yes, there are many professors of lab science, but they cannot design specific programs or mentor residents. For one they have very limited medical knowledge and for another they cannot examine the residents by statutory law. Therefore, the distinction between a teacher and a student will be distorted as the latter has disproportionately more knowledge. How can anyone then justifies a lab scientist heading a clinical laboratory in any hospital not the least tertiary health centers? The Heads of clinical laboratories are not just administrative leaders but academic ones as well. There are technologists in the university/polytechnic laboratories as well, but you don’t have them agitating to be HODs, that is unthinkable. It is a wonder then coming to our tertiary health centers a university graduate wanting to teach residents a more than equivalent of academic PhD simply because he/she has reached a certain grade level by natural passage of time. Many assume residents are university students requiring basic teaching. I am aware of the recent agitation for the establishment of post graduate college of lab science, a carbon copy of the National Post Graduate Medical College of Nigeria. Apart from cloning the former from the latter, all the courses are mere duplication of what is currently offered in our universities as MSc and PhD. But then the real reason for its establishment is to “bridge” the gap and then justify specialist allowance, call allowance, medical consultation/prescription and the position of HOD/CMD, not necessarily due to the need for adding quality to lab tests. Soon you will hear post graduate college of radiography, physiotherapy, optometry, etc. The technicians generate minimal dispute since they don’t have university degrees. Amazingly they are proficient in the technical work they do because of consistent repetition. They equally teach the lab scientists in their formative years and yet they never seem to realize their full potential of demanding equal recognition. I guess one day they will also demand such and I wonder what will happen then. The fight for minister of health and directors in Federal Ministry of Health is a well known over flogged old story. Here again the struggle is for the same reasons; recognition, privileges and a chance for vindictiveness.
Department of Internal Medicine,
Ahmadu Bello University Teaching Hospital Zaria, Kaduna State, Nigeria.