The True Face Of PG Medical Training In Nigeria, A Rejoinder

"The West Africa College of Physicians concluded the second diet of exams recently. The faculty of psychiatry declared a pass rate of 13.8% at its part one membership exams (8 of 58 candidates). The faculty of public and community health recorded a 32% pass rate (23 of 70 candidates)

Twice every year, candidates from all over the country converge in Ibadan and Lagos for the West Africa College of Physician and National Post Graduate Medical College exams respectively, each diet of examinations consisting of written, objective structured clinical exams, picture tests and oral/long case exams as the case may be. It is usually a very grueling and trying time for any candidate with psychological, emotional, financial and sometimes physical consequences.

A minimum of N60,000 is paid for each exam attended without consideration of transportation,feeding, and other ancillary expenses incurred. It is funded by the candidate after an initial one time sponsorship by the training hospital.

A candidate may repeat the exams as many as seven (7) times. There are records of up to 10 times and over at one stage. Usually, candidates do not scale the first stage, and even then, meeting hurdles in each subsequent stages of the OSCE, Picture test and long case stages. Each must be passed independently, usually under stifling time constraints.

It is pertinent to shed some light on the long case examination, already phased out by certain faculties of the college owing to its largely subjective nature. A candidate is assigned a patient for the purposes of the exam, and is to conduct an interview, physical examination and prescribe a course of management under harrowing time conditions. The candidate is to make an oral submission of his findings to two or more examiners who are usually less than dispassionate in their assessments. Mark you, less than 10% of these examiners have any degree in education, evaluation, assessing or any pedagogic training for that matter.

It is under this long case that a lot of examiners excise their “pound of flesh” as a candidate may be faulted in practically any and everything! Thus, a candidate who manages to scale through the first, second and third stages, is truncated at the last stage by an examiner who chooses to sleep during proceedings!

A lot of candidates have been maimed as a result of the activities of these colleges with the active connivance of some training hospitals. Failing to pass these exams, a doctor is unable to make any professional advancement; he is stuck and sooner or later shown the way out of the residency program with no lifeline. He is unemployable as a specialist, and cannot proceed as a general practitioner.

Medicine is touted to be an apprenticeship;so, if a candidate has to repeat a particular exam so many times, has he been properly mentored? Small wonder the high morbidity and mortality rates; the capital flight in medical tourism and the total loss of faith in the healthcare system. Such candidates who are frustrated out of the system for their inability to scales these exams, where do they go? Where do they start from with families and other dependants? What about the psychological toll on him? Something to which he has committed a lifetime of effort and suffered untold deprivation?

A number of questions beg for answers;
Does this “high” standard that candidates are held up to translate to favorable health indices for the country- reduced morbidity, mortality and medical tourism to India and other nations? Capital flight? Is the nation any better off from the efforts of the Postgraduate medical college?

What does a failure rate of 87% connote? The trainers are not doing their jobs? The trainers do not understand what is required of them? That candidates are so dull? Or is it simply a case of unregulated and misguided leadership?

What role does national interest play in the determination of proceedings, procedures, modus operandi and outcomes of the college? The national postgraduate medical college of Nigeria prides itself in having produced 4,000 plus specialists in over 30 years of existence and in a country of about 160 million people. Whose interest do they really serve?

What is the role of international best practice in the regulation of the colleges? Any peer review mechanism? Any validity and reliability studies on the mechanisms of these colleges?

Should each region or state not regulate its own postgraduate education, require and needs? Who oversees the activities of these colleges?

It is high time the House committee on health, the federal ministry of health, policy makers and other interest groups gave some scrutiny into the workings of these colleges in the interest of all stake holders, and the nation as a whole bearing in mind the various ramifications, dimensions and implications of the activity of these colleges on all and sundry. It is no longer acceptable that things remain the way they've always been. Indeed, the mark of humanity is the ability to adapt; to evolve; to meet challenges and peculiarities of the day, a peculiarity that once again challenges our resourcefulness."

Courtesy The Nation Newspapers
I would even exonerate the trainees....on a relative level of culpability. Remember, such trainees are already doctors. Let noone tell me that the "trainees" are unwilling to learn. Failing 80-90% of your wards or charges on the altar of "standard" and gloating over it shows that the teacher is incompetent at teaching. He lacks the skills....the temperament...or even the gumption to teach. He had no formal training in teaching. I proffer that residents as future teachers, temporize in nearby faculties of education to equip them with teaching skills. Medical teachers must also undergo periodic psychiatric assessment. The resident, (a future consultant and peer of his trainer and examiner) must not be perceived as a potential threat. The trainer thinks in terms of supply and price the fewer the merrier! The format of the exams must change! Why rewrite theory papers already passed? Passed courses need merely be credited to the candidate...till he passes the practicals, a must! Retain the OSCE.....but do away with the Long Case method....and all.....repeat all other subjective elements of the exams!

An exam that fails almost all candidates is USELESS!....since it fails to discriminate between the good and the "bad" candidates. I have read a lot about medical education....and know that relevant authorities predetermine what % of candidates they intend to pass....based on the strength cum toughness of the exam. It is all subjected to statistical analysis! This practice is global....but trust the Nigerian examiner to abuse it! Such scenario played itself out even in undegraduate medical education at the College of Medicine of the University of Lagos during my days as student. Some lecturers gloated over the failure rate they could return to the Academic Board....especially "Gadaffi" in O&G! Fela's elder brother would coyly fill up beakers with lager beer and present such in exams as urine! Some examiners slept off during exams! The scenario is worse during residency. A panelist refers to a "narrow gate".....already presumed to allow in few persons! Yet the general public is yet to grasp the true meaning of failing medical exams.....

Acknowledgements to The Nation Newspapers.
The Initial Article was written by Dr Timi Babatunde and the Rejoinder by Dr Tosin Akindele.

Dr Tosin Akindele is a Lagos-based medical practitioner, founder of ANALYTICAL MINDS, social critic and good health advocate.

Dr Timi Babatunde MD is a Lagos-based medical practitioner.

Disclaimer: "The views/contents expressed in this article are the sole responsibility of the author(s) and do not necessarily reflect those of The Nigerian Voice. The Nigerian Voice will not be responsible or liable for any inaccurate or incorrect statements contained in this article."

Articles by Tosin Akindele