In a sequel to his story on how fresh doctors in Nigeria beg for posting to do their one-year compulsory housemanship even when the medical personnel in the country remain grossly inadequate, TUNDE AJAJA in this second part reveals that perhaps the personnel crisis in the health sector is worse than it seems and far from being over as doctors who want to do residency training to become specialists also spend years, begging, to get placement, while the nation grapples with its few consultants
Notably, securing a placement for housemanship has become a sort of bottleneck for many fresh doctors in Nigeria, as many spend months at home, looking for placement. And in most cases, they are left frustrated, more so that some mates and juniors would have gone ahead of those who are unable to secure placement fast.
While that is pitiable and has already made some of them regret their choice to study medicine, it seems more worrisome that most of those who were lucky to scale the housemanship hurdle and are aiming to further their career by seeking to be specialists in their desired fields are stuck and stranded due to the scarcity of placement for the residency programme. Some spend years looking for placement.
The road to residency seems more turbulent and in some cases, some give up on the dream of becoming specialists to settle for general practice.
According to the National Postgraduate Medical College of Nigeria, the institution at the apex of Medical Education in Nigeria with the responsibility of conducting professional postgraduate examinations and producing specialists in all branches of Medicine and Dentistry, there should be one consultant to about four resident doctors.
In other words, where there is one specialist (consultant), four resident doctors should be under him or her, for training and these doctors can only undergo this training in the institutions accredited by the NPMCN.
A nation ‘killing’ itself
Suffice it to say if all the consultants in Nigeria have four resident doctors attached to them and all the accredited institutions take the maximum quota allotted to them, most doctors who want to undergo the programme would have been absorbed. And some would have become specialists after some years to provide the country with the numerous specialists that it needs.
But findings show that in some of the about 200 institutions, comprising federal and state tertiary health institutions, University Teaching Hospitals, Federal Medical Centres, some state health management boards and some private institutions, the number of resident doctors employed and attached to a consultant is as low as one, instead of four. And it is very rare to see any of the institutions take the maximum number allotted to them.
This shortfall in intake, according to findings, is due to shortage of funds.
Resident doctors are paid the full salary of a doctor and the training takes five to six years. But due to lack of funds, in some hospitals, resident doctors are paid half of the salary they should be getting.
Beyond the paucity of funds, there are also allegations of sharp practices by some Chief Medical Directors, who employ below their quota and pocket the money they should have paid to the other resident doctors they fail to employ, thwarting the dreams of many doctors in the process.
No doubt, there is an obvious inadequacy in the number of resident doctors in hospitals, even as the University College Hospital Ibadan recently said it lacked enough resident doctors.
But, in spite of the obvious inability of the various hospitals to take the maximum number allotted to them, the qualifying examination for the programme, called ‘Primary’, holds twice a year, clearing more doctors for the programme, even though there is no training space for them.
And, the ‘Primary’ does not come cheap. While NPMCN charges N40,000 for the exam, the alternative, West African Postgraduate Medical College (of Physicians or Surgeons), charges N148,000, a significant increase from the N50,000 it used to charge for its own exam. And those who pass it have five years to secure placement for the residency or the result would lose validity and the person would have to retake the exam or settle for general practice.
According to international standards, there should be one consultant to 10,000 patients, and so for a country of 180 million people, it needs 18,000 specialists.
But according to the information from the NPMCN, there are 5,348 registered specialists, out of which some are retired, some others have travelled abroad and some are deceased.
This shows a shortfall of about 13,000 specialists that Nigeria needs, yet many doctors who want to become specialists could not because of space. And so many have already given up the dream of being specialists and settled for general practice.
Tales of aborted dreams
For Dr. Christopher Alade, a resident doctor undergoing his training in a teaching hospital in a south eastern state, even though he was lucky to get placement four years after searching, some of his colleagues who were not so lucky already dropped the idea and settled for general practice.
He said, “After writing and passing the qualifying exam in 2011 to do residency training, some of my colleagues and I kept searching but we couldn’t get placement. We went to many states, bought forms, took exams and did interviews but none worked.
Then in 2014, the Federal Government placed a ban on residency programme in federal institutions for about nine months. So, no government hospital was advertising, even though some were secretly recruiting, but I later got in 2015. And I would call it a miracle because I didn’t know anyone, whereas many others came in through referrals from top government officials.
“By the time that ban was lifted, there were many people on ground, looking for placement. And till the five years elapsed, they didn’t get placement. So, those who couldn’t pay again gave up on that dream and moved on.”
While Alade was lucky to get placement, Dr. Linus (surname withheld) has been in general practice since 2014 when he couldn’t get placement and his five years elapsed. He said instead of paying for another exam for placement that he wasn’t sure of, he would rather forget it and move on.
“All of us cannot be resident doctors,” he said, adding, “Primary holds twice a year, but the people taking the exam yearly add to the pool of those who had passed the exam but have not got placement. Yet, hospitals are not advertising. Even when they do, at best, maybe once in two years and they only take a few; like 50 instead of 150. So, where should others go, or can the government claim not to know this abnormally?
“For many people like me, our Primary expired right under our nose but we couldn’t do anything. I can confidently tell you that many brilliant doctors have left Nigeria to continue abroad. I mean people whose brilliance can intimidate you. I know many of them. So, why won’t our health sector be in this comatose level? It’s frustrating being a doctor here.”
Throughout the discussion Dr. Adebisi Eniola had with our correspondent, she kept shaking her head in utter disgust. She is also stuck as she has not been able to secure placement four years after passing Primary.
She said, “I’ve given up. It is very traumatic seeing that merit no longer counts. Even people you are better than get placement before you. Some people even got placement without the result of their primary exam; they got it provisionally, hoping to pass within one year of starting the programme. It is that bad.”
Due to the difficulty in getting placement for his residency progamme for five years, Dr. Emeka (surname withheld), a graduate of College of Medicine, Ambrose Alli University, Ekpoma, Edo State, travelled out of the country to continue his studies.
“I couldn’t settle for anything less. I’ve always wanted to become a cardiologist and if I had waited in Nigeria, I wouldn’t achieve that dream,” he added.
Given the growing number of doctors who have difficulty in getting a placement for residency, housemanship or even getting a job, especially those who could not afford to relocate to other countries, have resorted to forming a group on both Facebook and Twitter to vent their anger and rub minds.
On Facebook, the closed group, named ‘Locum Doctors’ has 2,942 members, as of Thursday, December 22, while on Twitter, the group named ‘PIHAN’ had 507 followers. And on the twitter page is a pinned tweet; a video, saying, “Every year, about 4,000 medical interns are produced, more than six interviews per candidate, yet more than half have no placement. Help #RegulateMedicalInternship.”
Also, some of those who are bent on becoming specialists but could not secure placement have resorted to supra numery residency, in which case they do the training without being paid. And in some cases, such doctors pay as much as N500,000 to be allowed to do the training.
Residency, an ‘optional necessity’
Basically, residency is not compulsory for all doctors, as some would be in the general practice. Findings showed that, in the past, there used to be no rush for residency and only few people opted for it. But apart from those with the aspiration of becoming specialists, doctors who initially didn’t consider it now do so due to the better remuneration and prestige.
And even during the training, resident doctors are paid the full salary, which is sometimes more than what is being earned by those in general practice; thus, the drift to residency programme.
A medical doctor, Rotimi Adesanya, said the upsurge in doctors opting for residency programme could also be tied to the increase in the number of doctors produced annually, unlike when only few federal universities offered medicine. So, now, it is survival of the fittest.
He added, “On the way out, government needs to make available more centres for training of resident doctors. But we still need doctors in general practice, because a specialist is not supposed to be attending to malaria patients. So, everybody cannot be specialists. We need doctors in academics and administration.”
An avoidable misfortune
For a nation of over 180 million people and one that is facing serious shortage of medical doctors – about 250,000 deficit and in need of more specialists, about 13,000, the current situation has been described by many as unfortunate.
It is worthy of emphasis that the number of specialists in the country would have increased if more resident doctors were being absorbed into the system.
But given the situation at hand, the shortfall has been taking its toll on the millions of patients who throng hospitals daily aiming to see specialists but are often disappointed because of the queue and the shortage of the requisite professionals.
For example, at the Ophthalmology unit of the Lagos State University Teaching Hospital, there are about five consultants, and according to the guidelines of the NPMCN, which is one consultant to four resident doctors, there should be 20 resident doctors in that unit, but as of Thursday, the unit had about 10.
Given the shortage of both specialists and resident doctors, there is usually a huge number of patients in that unit, even though there are four clinic days in a week; Monday, Tuesday Thursday and Friday.
And on a typical day, there could be about 15 new cases, which are referred to the specialists, and follow-up, usually being attended to by resident doctors, which could be up to 60 patients daily.
“We have shortage of consultants and resident doctors and it makes us to work under pressure,” one of the staff in the hospital said.
Findings also reveal that at the moment, because of the shortage of personnel, the next available date to see a consultant is July 2017. And it is not for nothing that a person attended to today could have his or her next appointment in one month.
It is the same story in most other specialist hospitals in Nigeria.
At the cardiology unit of the University of Nigeria Teaching Hospital in Ituku/Ozalla, Enugu State, clinic day is Friday, and so it is entirely understandable that the crowd weekly could be frightening. Being one of the few health institutions with consultant cardiologists in the area, people come from both far and near, including those who spend about four hours from their communities to get to the hospital.
It was gathered that there are two cardiology units, with six consultants. Hence, there should be about 24 resident doctors, but at the moment, there are about five, which, as expected, is inadequate to meet the needs of the patients.
Also, out of the about 150 patients that visit the unit for medical care weekly, only 60 old patients and six new patients could be attended to, while the rest would have to come back, regardless of where they came from, because according to the standards, each patient should be given about 15 minutes.
Implications of the shortage
Speaking to our correspondent, the President, National Association of Resident Doctors, Dr. Ben Onyebueze, lamented that the ratio of consultant to resident doctors could be as low as one in some places.
He said government should ensure that the required number of resident doctors for each institution is filled up so that the ones would not be overworked.
He said the country, at the moment, had less than 6,000 resident doctors, which is grossly inadequate, given the over 4,000 doctors produced yearly.
He explained, “The impact of this is that doctors are overworked, and apart from that, they may not adequately meet the needs of the patients because of fatigue and the need to attend to as many as possible.
He said, “In the villages, we have people suffering from hypertension and diabetes who need to see specialists, like cardiologists and nephrologists, but when you don’t have this manpower sufficiently in the tertiary health institutions, then you also have a problem having them in the hinterlands and rural communities. The implications of that is obvious.
He lamented that the inadequacy of placement for residency programme had not only led to doctors relocating abroad, it has also led to medical tourism.
And according to the Minister of State for Health, Dr. Osagie Ehanire, Nigeria spends over $1bn annually on medical tourism.
Onyebueze also blamed the inability of hospitals to take their maximum quota on underfunding, saying this had forced some hospitals to dip hands into personnel emoluments for resident doctors, so as to keep the hospitals running.
And in spite of the WHO’s recommendation of 15 per cent budget allocation to the health sector, allocation to the health ministry in the 2015 budget was 6.24 per cent of the entire budget, which dropped to 4.64 per cent in 2016.
He stressed that ‘Primary’ exam should not have expiry date. He added, “We see it as greed, and a way to keep making money. Why should a certificate have an expiry date? One can imagine the trauma of taking an exam they wrote and passed five years ago.”
The NARD President said the shortage of resident doctors in the system, combined with lack of health awareness, poverty and inability to implement the National Health Act had contributed to avoidable deaths in the country.
Meanwhile, with 72 deaths in every 1,000 live births, Nigeria ranks as the 10th with infant mortality rate in the world. Meanwhile, this situation has partly been tied to inadequate access to medical care and health personnel, especially in the rural areas, where about 52 per cent of Nigeria’s population live.
According to experts, the shortfall in the number of doctors and specialists has worsened the health care system in the country.
Reacting to the difficulty by many doctors to secure placement for residency training, the Chief Medical Director, University of Ilorin Teaching Hospital, Prof. Abdulwaheed Olatinwo, said there were more doctors than the accredited health institutions could take and that paucity of funds had also been an issue.
He said there should be more training institutions to train the doctors, given the growing population. “Like in Kwara State now, we only have UITH for residency training programme, so you can imagine if there are other institutions,” he said.
When asked why most health institutions don’t take the maximum quota allotted to them, he said all the spaces available could not be filled at the same time, hence, there was need to take them in batches.
Olatinwo said, “You won’t say because you can take 30 then you want to take them all at once. That means you won’t be able to take anyone for the next six years and once they finish the programme, they all leave at once. That is not advisable. What we do is to spread it.
“You must have a number of seniors and a number of juniors, because the training is in stages. People only look at the figures, but you must look at the need to spread it to accommodate all the levels. It is better for me to have five trainees in each of the levels, say from level one to six, than take 30 at a time. That means I can always add five doctors every year, otherwise, there will be trouble.
“There is no doubt that we don’t have enough doctors in the system, neither do we have enough consultants to the resident doctors, but I believe the Federal Government is working on a modality to make things easier for all.”
On the way out, the Registrar of NPMCN, Prof. Oluwole Atoyebi, was not available for comment, but a source in the council who spoke on the condition of anonymity because he was not authorised to speak on the issue said in spite of the shortage of space, the college had the statutory responsibility to conduct the exam, noting that doctors still secure placement from time to time.
“Bankers would tell you there is no job, but higher institutions still admit and graduate students in banking and finance yearly, so it’s the same thing here; it’s our statutory responsibility,” the source added.