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Are Nigerian Medical Students Mentored Or Bullied In Our Medical Schools? A Rejoinder....

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The Initial Article:

"JOHN NWOFIA does a reminiscence of his days as a medical student at the University of Lagos, juxtaposes that with his experience as a resident in the UK and wonders why making students go through hell is such a pleasure for so many lecturers back home. Any medical student studying in Nigeria in the 1980's and 1990's would have been exposed to intimidation and fear in the dealings and meetings with their physician teachers. This was well accepted as part of the curriculum.

I was at the College of Medicine, University of Lagos (CMUL) between 1982 and 1987; and like the rest of my peers, experienced these situations first hand. Everyone had stories to tell for every year of medical school. There were some lecturers I was convinced just enjoyed instilling fear into students, and probably bragged about it. Every department had its stories.

In the 1st year of medical school, the Anatomy department seemed to be the friendliest to students. We had a relatively young professor who enjoyed being with students. In the Biochemistry department, there was the professor whom legend had it that he had been attacked two or three times (some even said he was shot) by aggrieved former students for the unnecessary pain and suffering he put them through.

In the 2nd year of medical school we had a very amiable older professor and head of the Morbid Anatomy department who believed a medical student did not have enough time in the 12 months to become a pathologist and as such did not believe in unrealistic expectations from students. His next in command however did not subscribe to such belief. He was mostly seen as a hater of students.

Most of the more exciting stories came from the clinical years where we had such professors as the one named 'Ghadafi'. Ghadafi was so named because he ruled with such a heavy hand that it was believed some junior consultants were terrified of him. He was the head of Obstetrics and Gynecology department. It was he that threatened to resign rather than re-evaluate his scoring methods when told he could not fail over 70 percent of his students in an examination.

In the department of pediatrics, we had the likes of 'Fela'. He was so named probably because of his links with the late Afrobeat maestro. We had so many tales about him. One of this was when he was an external examiner for a neighbouring medical school. As expected, none of the students was able to impress him and after the examination he admonished them with the following words: “…you are all as bad as my students, but at least, in Lagos, my students dress well”.

Just the thought of this professor made every student nervous. But once he had this exceptional student who had to defend his distinction score in the pediatrics department. The professor had laid out a urine beaker with golden yellow liquid in it and asked the young student to tell him about the specimen. After staring at the specimen container for a while, the confused student went on to give the possible reasons why the urine would be such a color.

After his presentation, the professor reportedly took the beaker and drank the contents saying, “Now let me see what your diagnoses will do to me”. He poured beer into the container and berated the student for not smelling the specimen first. Ordinarily, this would mean that the student could not defend his distinction score and should then have his score dropped to a lower credit. But the professor would not have that. He insisted that the studentmust fail his course. It was reported that the university senate tried to intervene in this case but the professor would not budge. It was only when a very well respected professor in another department had threatened to resign if the student was failed that the university prevailed on him.

In the department of Medicine, we had a particularly terrifying professor who was dreaded by all. There was thestory of an examination candidate who on realising that this professor was going to be his examiner, stood by the doorway to the examination room and massaged both sides of his neck. When asked what he was doing, he said he was doing carotid sinus massage. Someone must have forgotten to teach him that he risked rendering himself unconscious if he was truly attempting bilateral carotid sinus massage. Or maybe he knew what he was trying to do and that unconsciousness may be better than the humiliation he was expecting to receive.

Oh God, please deliver me from this man: the prayer of many medical students?

In the department of Surgery, we had the professor who did not talk to students. He would rather talk at them. He was well known to berate students and resident doctors. Even the junior consultant in the department did not escape his humiliation. I recall my first encounter with him as a house officer. As I went to the surgery department one early morning to get my posting papers for a later shift at the surgical Accident & Emergency Unit, I did not realise I had been moved to his department and I was to resume that morning. I was helplessly ushered into his office, wearing jeans and a tee shirt. He wondered aloud who I was and I introduced myself to him. He ushered me into his inner office, shut the door, and berated me for dressing “like Fela's boy”.

He ended the berating by stating that had I been a student under him I would not have graduated from medical school, dressing the way I did. Mischief and some crazy confidence took the better part of me and I told him that not only did I pass through him as a student but that he had told my group that if anyone could be a successful doctor in the group that it would be me. This was far from the truth, but I knew he had no way of checking. He had every one on edge at his rounds; from the senior resident (SR) to the medical student and the nursing staff.

I would start my rounds at 6.00 a.m., joined by the junior resident at 06.30 and the SR at 7.00 a.m. After our rounds, we would go to the labs and radiology units to have everything ready for him in chronological order and then we'll all wait by the 1st patient's bedside at 07.55 a.m. The nurses and matrons are also ready. At exactly 08.00 a.m. the doors will swing open and 'here comes the man'! He was never late. You could set your watch by the door swing as he came in.

No one was allowed in after him. No one! Then the junior resident (JR) would present the cases to him, he would ask the senior resident (SR) questions about the patient. He then talked at the students and would then test the JR. I do not remember him actually talking to the patients in our teaching rounds. He probably did at his own round as he seemed to know a lot about his patients.

I remember one particular case on a round. We had a patient who had come in over the weekend following a motor vehicle accident. He had sustained some chest injury with a ruptured artery. The SR, having tried unsuccessfully to contact him had gone forward to operate and save the man's life. As he walked by the bedside, the first question the professor asked was “And who is this on my bed?” The SR then went on to present the case to him.

Without acknowledging the patient, he went on to berate the SR for not trying hard enough to contact him. Then without warning, the patient interjected and said something like this: “How dare you attack and insult the man that saved my life? I have heard about you; you scare everyone and act like you are God. Well, I don't need you; I don't need to be your patient. I am the patient of the man that saved my life and you can go to hell!”

You could have heard a pin drop from a mile away. Everyone was dumbstruck; including the professor. Nothing was said for a few seconds; seconds that seemed like several minutes. The professor turned around and matched out of the ward. That was the end of the round. We were elated. I could have hugged the patient. We could all have hugged the patient but nobody dared show any outward sign of joyful emotion on this attack on the professor.

I served one month as the only intern in the unit; 30 days of calls and no time off. I went into his office to get my papers signed for completion of the rotation and the first question he asked me was “who are you?” I could not believe what I just heard. I had just slaved in this department for 30 days and completed a long ward round with him the previous day and he did not know who I was. I again re-introduced myself to the professor I had just served for 30 days. His remark was “…it means you have done nothing to impress me and nothing to incur my wrath. I think that is the best place for you guys to be”.

He signed me off as 'satisfactory'. I was livid. I had given 30 x 24 hours of service and that was all I got. I could do nothing about it and went to the administrator's office to submit the paper. And, behold, I was the first person in five months to have come out without extension added to their posting in the unit. I guess from him 'satisfactory' meant exceptional!

There are many more stories to tell about our encounters. We were terrified of the professors. You could not cough or sneeze in a ward round.

If you got a question wrong you were humiliated. Your parents and family were not free from these attacks. Tests were made to fail students not necessarily to test their competence. We were told that if you made it through Lagos you would survive anywhere else. My question had always been: “was that really necessary? Did it make us better doctors? Or did it just make us better test takers?”

I remember my first training position in England. As a matter of expectation, I addressed the consultant as “Sir”. He then advised me that he was not a knight and I should address him by his name. I was even shocked the more when one of the other consultants I later trained under requested that we address him by his initials. In the US, the director of my residency program wanted us to address her by her first name. All these were foreign to me. I was used to addressing my consultants as 'Sir' or 'Ma'.

I did not think there was anything wrong with that. At the same time I realised that while our teachers commanded a lot of fear, the ones in the UK and the US commanded a lot of respect. Make no mistake about it- I had a lot of respect for most of our teachers, and still do. We owe several of them whatever success we may have achieved in our careers. But you never forget the humiliation and unnecessary intimidation we had to go through.

At College of Medicine University of Lagos (CMUL) the pass rate was closer to 30percent for the first attempt while in the US anything short of 100 percent pass rate was considered a problem. We were not less smart in Nigeria as it can be seen that Nigerian trained doctors did better in the US. Now some can say that was a vindication of the system in Nigeria. But again, the question arises of whether it made us better doctors or better test takers. I am in support of the later, and not the former.

Medicine is a disciplined profession and not for the faint hearted. At the same time, medicine is a caring profession and you do not make caring professionals by training them in a harsh environment. I am of the opinion that an intimidated student doctor will produce an intimidated patient. We do not have to pamper the student but teach them in a caring manner. Monsters, for the most part, will create monsters while angels will create angels.

We want our doctors to be caring, respectful and engaging with their patients. Why then should we expect that when we train them in a hostile, fearful and intimidating atmosphere?"

Courtesy Nigerian Health Journal.
Rejoinder.
THE EXTENT OF THE PROBLEM.
Since I attended the same medical school as the author, may I, solemnly decrypt his comments by mentioning some names here! The encrypted bullying Professors, by no means the only inveterate bullies in those days, were...Surgery, Adebonojo; Internal Medicine, Akinyanju: Paediatrics, Olikoye Ransome- Kuti: Obstetrics and Gynaecology, Agboola, the worst of them all nicknamed Gaddaffi!.

A bit disappointing that the author forgot to mention "Mama Anaesthesia", Professor Dorothy Ffouls- Crabbe ....who took the art of bullying to another level. She habitually gave us vicious knocks on our heads, delivered vigorous twists to our ears, before asking us to go kneel down in front of our huge lecture hall, close our eyes, and raise up our arms! My encounter with her one fateful day in the dental theatre was not funny.

You see, children are routinely given general anaesthesia before painful dental procedures including extractions.... And in her opinion, I was not careful enough with the patient's airway. With a deafening shriek, she yelled "Akindele, Akindele, you never leave the airway of the patient!"...then proceeded to turn my skull into a conga drum as she rained vicious knocks on my head!

I lost count. My eyes turned deep red. Nurses in attendance exchanged quick anxious glances. We were senior clinical students in our penultimate years of training....when our mates who did shorter courses had already graduated!. Olikoye Ransome Kuti might have gained prominence as a doctor but he was a poor teacher. The lager beer incident mentioned by the author was not the only time he demonstrated bad judgment.

I lost my cool with Professor Esho though... He was on full throttle bullying me right there in the exam "hall"...and I told him that the onus was on him to put me at ease, that an examination is a two- way process and that he should take it easy with me. I refer to practical/ clinical exams and I knew that by my restrained outburst, he was going to fail me! You fail the clinicals, then automatically fail the whole exam no matter your scores in the essay and multiple choice questions (MCQ) papers.

We had to grapple with negative marking in the MCQs in which some student scores raked in negative integers, so why should the man add to my problem! So I graduated years later, quite behind my classmates. In my whole academic career, it was only my medical school that found me "dull". A compulsive star on prize- giving days in primary and high school where I even won a full scholarship, it is as if I again rediscovered my intellect after graduation!

FACTORS THAT PERPETUATE THE PROBLEM
Though Professor Ffoules Crabbe's novel approach to bullying was deserving of psychiatric intervention, none of us had the courage to lodge an official report with the college authorities in spite of the obvious illegality of her actions....afraid that her colleagues....in solidarity with her...would fail us perpetually and prevent us from graduating! What could we do? Report the bully and have his colleagues mark us down and ensure we never graduated?

The only time I protested, I payed dearly for it in years...as I already stated! Friends and family started calling our mothers "Mama Doctor" the very day we got our admission letters from JAMB and disappointing such proud parents by withdrawing from the course was the last thing on our minds! I think there is more awareness now. But we still have a long way to go. I thought I had forgotten it all only for this author to make it all rush back!

I think the situation was rampant because there were no checks and balances. Afterall, there was a smattering of good ones among our medical teachers. As the term suggests, the good ones were abysmally few. And if these ones chose to be bad, there was practically nothing by way of sanctions anyway. And so, many academic talents were wasted....required to withdraw from the course for excuses ranging from the flimsy....through the sublime....to the ridiculous. Individual who undoubtedly, could have turned out to be brilliant doctors....perhaps much better than those of us who survived the whole mess! Besides, there is an element of ego.

How do you tell a young man who has never "carried" the second position in his academic life that he has failed an exam...often repeatedly...and for some lousy technicalities.....or lecturer idiosyncracies? How do you mend his injured ego so that he does not fail endlessly? Realising that an ego-fix might come in handy in my case, I read compulsively after graduation. I re- read all my medical books right from year one!

CONSEQUENCES OF BULLYING.
The sad thing is that, as already stated by the author, bullying has the tendency to be a generational thing. A victim of bullying may transform into one of these...

1. Become a bully to those weaker than him...
2. Become perpetually docile and unassertive....
3. Become overassertive and inanely aggressive.....

4. Become homicidal as he takes immediate carefully- orchestrated steps to kill his tormentors.

For me, it was triple tragedy....bullied by step- mother at home, bullied in high school where I probably hold the title of the most- beaten up pupil in the history of the school....then when I finally thought I had a respite, beaten up again by Professors as a clinical medical student!

SOLUTIONS PROFERRED.
Bullying or any other social vice does not just solve itself. The society at large, and the medical community in particular, must take concrete steps to solve it. The first step of course, is to recognise it as a problem....followed by a determined attempt at solutions. I hereby proffer the following solutions:

1. Victims of bullies should summon the courage to lodge official reports.

2. Responsible officials should treat such report with the seriousness it deserves.

3. Psychological and psychiatric treatment should be provided for officers who require such. Teachers at all levels must be made to undergo regular psychiatric assessment to ascertain their continuing suitability for the job of teaching.

4. Residents and others who are future university teachers must undergo some courses in the faculty of education. It should not be assumed that once an individual possesses a postgraduate qualification, he can teach the subject in question.

Like I often say, teaching is a profession and its skills need to be taught. Post- graduate medical students (residents) who are future medical tutors must temporise in a nearby faculty of education. We must refrain from the folly of assuming that once an individual possesses a PhD or some fellowship diploma, he can automatically function as a teacher in his core area of interest! Some persons simply lack the temperament and the gumption to teach!

5. Educational institutions must subject their students to regular mandatory evaluation of their teachers using annonymous forms so designed as to place as much emphasis on academic content as student- lecturer relationship and the attitudinal cum behavioural attributes of teachers! The worth of a teacher resides in bringing out the brilliance in his students....not in the number of students he can fail!

6. We must not forget to mention that more emphasis be placed on the fact that teachers especially in secondary schools need to be psychologically ingrained. Thank God my immediate younger brother is a professional teacher....went through all the works....Grade 2....then NCE....followed by a university degree in education. A good teacher would curiously explore the family background, family mechanisms cum dynamics and family machinations of his student....among other things.....

7. We have a culture of child abuse. This is to be discouraged! It is not uncommon for parents to inflict more beatings on kids for having the "audacity" to report to them that they were beaten by teachers at school!....a phenomenon so endemic that our university professors now strike out at their students! Steps already put in place by our state governments to curtail child abuse and battery are commendable. They should be improved upon.

8. I remember reading a book on Surgical Residency (i.e. postgraduate training in surgery) in the US. Bullying of subordinates would in the first instance, attract a verbal counselling, followed by a verbal reprimand, then caution in writing, and finally, summary dismissal from the program! We must imbibe such techniques.

9. There are three purviews of learning....cognitive, affective and psychomotor.... as you would readily recall. It is for the essence of placing more emphasis on the affective cum attitudino- behavioural domains that medical degrees are not strictly categorized into 1st class, 2nd class and so on. Everybody is given a pass degree except, occasionally, there is the need to return a candidate as having passed with distinction. The term "Pass" is in fact reserved for the final award of a medical degree. Prior to that ultimate point, our exam results bore the phrase...."Satisfied The Examiners".

Medical professors hide under this loose phrase to commit atrocities..... like visiting students with "Veto Fail" exam results. All the man needed to say was that this or that particular student, would not, in his own opinion, be worthy of being admitted into the profession! Medical teachers must be discouraged from being so disposed. Such loose terms as "satisfied the examiners" must be expunged for "pass".

10. Achaic subjective examination methodologies like The Long Case should be totally replaced with the OSCE (Objective Structured Clinical Examination). Medical teachers ought not to retain subjective exam methods so they may manipulate exam results.

Having been thoroughly bullied as a child by teachers, school principals, physically stronger classmates, parents and relatives, you can imagine what type of adult I would turn out to be. In the formative years of a child, it is like a script being written I indelible ink.

CONCLUSION (Another Panelist)
Now that you mentioned it Tosin, I might as well comment on it: I never thought we could end up 'pallying' like this. In school, I saw you as overly assertive and quite aggressive to borrow your own words. I could sense some innate anger. I remember in particular an altercation between you and a friend and how I got part of the "punch". I'm glad you've come to terms with it or we won't be having this discussion. That is a healing process.

Tosin, honestly having lived in the West for quite some time, I have come to understand the destructive nature of bullying. I have come to understand that children who exhibit rebellious traits are to be understood and helped. The problem usually goes back to the childhood. At least it was your own stepmom.

My own mum was always so quick with the slap, I became so rebellious. With hindsight it was a function of her domestic frustration. I don't even think African parents see it as abuse. Nonetheless, we can't afford to carry hate along, but we can keep on speaking out against the vice of bullying. A little bit here, a little bit there will eventually add up and hopefully make a difference in awareness.

It's a deep-rooted problem. A lecturer giving head knocks to a doctor in training! It's not even funny! Nigeria is a pretty rough terrain to grow up in, a wilderness where only the fittest survive. Consequently, aggression instinctively becomes our nature. There's so much frustration in the people and naturally it is the vulnerable who suffer. What with utterly unresponsive leaders. Very sad. Thumbs up to you for ANALYTICAL MINDS!

The Initial Article was written by Dr John Nwofia 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. John Nwofia is on the editorial board of the Nigerian Health Journal. He is an interventional phychiatrist and rehabilitation specialist and Medical Director, Pain and Spine Consultants, Tennessee, United States.

Acknowledgements to Nigerian Health Journal and ANALYTICAL MINDS.

Disclaimer: "The views/contents expressed in this article are the sole responsibility of Tosin Akindele 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