Continuing Medical Education in the Nigerian Context: A matter of national security
– Prof. Dr. Enyeribe Anyanwu MD, PhD, FWACS, FACA,
I have chosen to concentrate on continuing medical education in the Nigerian context, because it presents a lot of facets, each providing enough data and perhaps anomalies that merit special studies. I will only concentrate on a few. The issue of continuing education is fundamental to virtually all academic disciplines. Its specifics are faculty related. Consequently, I shall take a look at the tertiary institutions in general and later concentrate on medical institutions.
With a population of about 140 million, Nigeria currently boasts of about 75 Universities and other tertiary institutions. Sixteen of these Universities have medical schools. The educational and institutional coverage varies regionally. So also is the internal governance to a large scale dictated by ethnic allegiance as verified or vilified by “the son of the soil” definition. The aftermath of this politics, which originally aimed at neutralizing or reducing ethnic dominance in an institution has been the restriction of employment of qualified members of other ethnic groups, who could have raised the academic and achievement standards of the tertiary institutions. Excellence fell prey to mediocrity, which itself finds so many allies that the battle against it became doomed to failure before it ever took off. However, this is only one aspect of the problems.
The National Universities Commission has been entrusted with making sure that minimal standards are met before an institution is recognised as a University or degree awarding tertiary institution. Directly and indirectly, she is also responsible for the quality of the academic products. But the lack of institutionalized preemptive quality management leaves every institution to its uncontrolled devices. When chaos finally breaks out it is addressed by closing down the institution followed by a commission of inquiry.
The chronic under-financing of the universities takes its toll in the quality of our educational system independent of the lofty ideals of the NUC, which has as its vision :To be a dynamic regulatory agency acting as a catalyst for positive change and innovation for the delivery of quality university education in Nigeria” and whose declared mission is “To ensure the orderly development of a well coordinated and relevant education for national development and global competitiveness” (http://www.nuc.edu.ng). Since weeks and months, the Academic Staff Union of the Universities (ASU) has been on strike, the sort that has been perennially paralyzing tertiary education. On the platform of global competitiveness, much is left to be desired. One of the yardsticks for comparison is the World Academic Universities Ranking. None of the 75 Nigerian Tertiary Institutions could be found among the first 500 of the Academic Ranking of World Universities 2008.
In the Ranking Web of World Universities July 2009, University of Benin occupied the 6.602nd. position in the world ranking and the 61st. place in the ranking for the continent of Africa giving the University of Ilorin a good margin (7.902 world/77 Africa). The University of Lagos scaled to the position 95 in the African ranking and luckily escaped being dropped out of the first 100 and managed the 8.871 position in the world ranking. Obafemi Awolowo University (7,942/78) and the University of Ibadan were just ahead of Lagos (http:// www.webometrics.info/top 6000.asp). It is pertinent to look at these figures to know where we stand.
The plight of medical students is often deplorable. They have to battle with crowded laboratories often lacking basic equipment. Many of them are bombarded with theoretical knowledge not reinforced by the apparative support, leaving them speculating about the realities of the medical world outside their reach. I remember my seminars in PH in the mid 80’s where I literally had to apply for a VCR three weeks ahead of each schedule in order to show videos on gastroscopy and ERCP. The interest of my students was so high that I could literally feel them grasping at the gastroscope. It was the same feeling, when I held seminars in cardio-thoracic surgery. During the extracurricular HIV/AIDS seminars, which awoke the students interests I could see in their lost faces the desire to know more but the HIV serology and the screening tests available at the time other than relying solely on intelligent guesses and on the clinic symptoms which were shared with malnutrition, chronic malaria, tuberculosis and other chronic debilitating illnesses.
The landscape for the specialists is not even greener. A stethoscope around the neck, a sphygmomanometer and a defective ECG machine in the office are all it takes to turn a man or woman into a Cardiologist. Unless they trained outside the country, very few of the cardiologists have ever seen a catheter laboratory or carried out an investigation in any. The same situation obtains for gastro-enterologists. On the operative sector, the situation often calls for law promulgation and enforcement. I have problems trusting a consultant orthopedic surgeon in a University teaching hospital, who immobilises a knee for 6 weeks in POP because of non-infectious effusion, or another who sees a patient with dislocation of the shoulder and kept on postponing the simple reduction for 5 weeks, in which time the patient had already developed partial paralysis of the arm. A hard look at all the specialties reveals gross inadequacies and incompetence despite the claim of specialist status!
The recognition of our under-performance and under-achievement in the country begs for answers to the perennial problems. The fact that Nigerians engaged in academics in the western world successfully compete with their peers and the academicians of similar standing in their host countries prove that Nigerians can achieve. We have very successful professionals, who have competed and won honors for their successes in their host or adopted new countries in Europe and the Americas. These performers share only one secrecy: the right environment.
Politics sets the right environment. It defines quality and standards. It makes sure that these are adhered to through institutionalized quality management.
The operators of health care delivery are on a mission. A mission can only be fulfilled, if means are provided for it. Currently, health care is heavily underfinanced judged by international standards and recommendations. This affects almost all areas of the health care system. The only projects apparently doing well so far are those financed by the World Bank, foreign humanitarian organizations and Foundations.
Problems that need be addressed immediately are water supply, electricity and clean environment. The usual monthly environmental exercise is a sure sign that politics cares. But, it should be internalized as a daily exercise.
It is a matter of national security to invest heavily on medical research. Not only will the country be in the position to provide first hand answers to our health problems, but it will place her in a position to rescind the soliciting culture or please-help-me-syndrome we have been trained to accept as integral part of our life style. It is only when we have results to present to the world shall we be able to talk at the same eye level with our colleagues on international meetings and workshops. It is also a matter of national security to make sure that those employed remain at their jobs. This is only possible if consultants in the hospital and research scientists can feel secure in their jobs. By security I mean, having enough financial resources to be able to take care of their families and the education of their children, buy and maintain at least one limousine, have enough savings from their salary to be able to afford a home by the end of their professional life. Then and only then does the consultant or research scientist feel the obligation to render whole-hearted service to the country. The lack of security is a major reason why so many of the so-called “Government Hospitals” are generally inefficient. On the operative sector, the consultant’s schedule is reduced to One Theater Day in the week and one day in the week for Outpatients Clinics. What does he do for the rest of the three to 5 days? You are right! He is in his private clinic – not out of contempt for being a government employee, but he has to make enough money for his own security in as much as he does not elect to turn his back to the country and seek his fortune elsewhere! For the reason of security, most of the Nigerian professionals trained outside generally do not return to Nigeria to work in their profession, unless they have economic and political patrons there as guarantors of this security, assuming they have the right infrastructure to give them job satisfaction.
Against the background of specialization and sub specialization world wide, there is need for Nigeria to focus on the medical landscape of the future. Except for the medical schools, which should be centers of excellence in their own right attention should be paid to building specialist medical centers with good infrastructure, concentration of knowledgeable specialized manpower and provision of security to the staff so elected that they devote their attention entirely to the service of the center. Examples are multiple, of which center for men’s diseases (infertility and prostatic cancer), center for women’s diseases and cancer of the female organs, breast center, chest center, cardiac center, eye center are only examples. These can be integrated in the medical schools. Since these centers are essentially referral, the continued existence and maintenance of the basic hospital services remain mandatory. The building of such centers, however, should not be left to the federal and state governments alone. Both Government and the private sector, alone or in partnership are called upon to look seriously at the dire need for these centers.
Continuing education is crucial for the advancement of any institution, be it economic or health. It leads to the acquisition of new and advanced skills. This acquisition is almost based entirely on continuous research and the translation of its results into practice. In the era of globalization, an international exchange based on partnership is the rule. The extent to which we can profit from the research of our international partners depends on their willingness to share knowledge and resources. Currently, this is limited. We are faced with wrangles over lack of capital and intellectual ownership. The advanced countries are all too willing allow us a peep into their factories and research centers – all from the front of the closed door – for security reasons. They are also very willing to display their finished products and hope for business. For reasons of capital and affordability we are usually conducted through the used equipment sector – the product of past research and technology. This system makes sure we do not catch up really. Technology transfer actually does not take place meaningfully.
The one year abroad practice has succumbed to maximal economic restriction, unless one is lucky to get scholarship from a foreign academic exchange program. Otherwise, for continuing medical education of international standard, Nigerian medical professionals are dependent on the benevolence of centers of excellence outside their country to show them what they are actually missing: a cardiologist seeing a catheter laboratory for the first time, a radiologist-in-training observing angiography in progress, a visceral surgeon watching endoscopic gallbladder or colonic operation on the monitor. Thanks to Memorandum of Understanding between the Federal Government of Nigeria and Foreign Institutions (insert Picture here) the young medical professionals, all the same, profit from such a short exposure, which generally lasts up to three months. The stereotypical question from the participants of such a program is: “how can we get such equipments home?” I have always admired the brazen honesty of our visiting medical professionals. The question of what happens next is open.
Postscriptum: It will be a challenge to Nigerian politicians and lawmakers to actively facilitate the return to specialist centers in Nigeria of Nigerian medical professionals, who have acquired the necessary medical skills and technology. These are the only guarantors of technology transfer.
Prof. Dr. Enyeribe Anyanwu is a Consultant Thoracic & Cardiovascular Surgeon, Surgical Oncology and Angiology
Continuing Medical Education in the Nigerian Context – A matter of national security was first published in Nigerian Year Book Germany 2009 and republished as part of the ongoing debate about the comment credited to Ambassador Abdu Usman Abubakar that Germany does not have many Nigerians and the few ones available are busy fighting each other to make any meaningful contribution-Editor