Postgraduate Medical Education in Nigeria: Past, present and future

Continued from Tuesday, 8/12/2015

The primary examination is the first entry point in both Colleges, with applicants being medical graduates completing their National Youth Service Corp. No formal teaching or structured courses are featured for this examination by any of the Colleges. By contrast, candidates are expected to prepare for the examinations at their spare times, but some Specialities and Colleges sometimes organize revision courses to prepare candidates for the primary examinations. The primary examination consists largely of basic medical sciences in related disciplines, and this being the very foundation of any speciality, it is sad that the Colleges have not taken this stage of the examination seriously in terms of actual preparation of candidates.

A pass in the primary examination of either the NPMC or WAPMC is now a pre-requisite for admission into residency training in hospitals approved for training throughout the country. The entry point is usually as Senior House Officers or Junior Resident. In most hospitals, residents are expected to provide clinical services as core part of their training, with structured training almost non-existent or provided merely as an after-thought. Many hospitals do not have structured training programs or lecture schedules or seminars through which the residents are to consolidate their skills and knowledge. In attempts to correct this anomaly, both Colleges provide guidelines for training that includes structured rotations through clinical specialities and sub-specialties. These rotations in addition to submission of a book of cases (in the case of the FMCOG) are required before candidates are allowed to proceed to the Part I examination. Periods ranging between two to three years clinical training are normally required before candidates can take the Part I FMCOG examination.

Candidates who pass the Part I examination are then promoted to the post of Senior Registrars (or Senior Resident) – and this could be attained within 2 years of entry into a programme. Further progression is less structured, as the candidate is then merely required to provide a book of clinical cases (as with the WAPMC) or to conduct research and write a thesis on a sub-speciality topic (as with the NPMC) before they can be eligible for the Part II examination. This period requires a mandatory clinical exposure and maturity of up to two years, during which the candidate also supervises the clinical duties of junior residents and medical students (for those enrolled in medical schools). Upon passing the Part II (Final) Examinations, candidates are now immediately appointed Consultants in Teaching and Specialist Hospitals where appropriate vacancies exist.

A total of 2514 Fellows were admitted by examinations during the period. This figure must have grown to nearly 3,500 between 2009 and 2015 considering the fact that during the 2015 Convocation Ceremony of the College about 300 new Fellows were added to the list. Additionally, the number of Faculties in the College has risen to 15, which further adds impetus to the number of trainees that the College can produce. If the contribution of the WAPMC is added to this, and both Colleges seem to be at par in the enrolment and production of graduates, the number of specialists produced by both Colleges will be hitting the 7000 mark. This no doubt, is a major contribution to postgraduate medical education and the production of human resources for health in Nigeria. As expected, specialist obstetricians and gynaecologists are in the majority, followed by internal medicine (physicians) and then surgery (surgeons).

Strengths and Strategic Advantages of Postgraduate Training in Nigeria
Thus, a major strength of the post-graduate medical training in Nigeria is its correction of the human resource deficiency that the country suffered in the 1970s and 1980s. Before then, many Nigerian specialists who trained abroad never returned home, leaving huge gaps in key specialist areas. Specialists such as anaesthetists, radiologists, ophthalmologists and pathologists were in very short supply, and among the few that existed they preferred to remain in big hospitals in urban cities while rural and sub-urban areas remained largely under-served. Now all that is fast disappearing. With the reasonably high supply of all categories of specialists, even district hospitals in most remote areas are benefitting from this largesse of specialists.

With in-country training, the cost of PME declined, with resulting salutary effects on the national economy. Indeed, the nature of the cost-effectiveness of the training programme to the national economy needs to be systematically investigated to provide greater impetus for the promotion of postgraduate training within the country. Also, local training enabled trainees to study the nature and pattern of highly prevalent disease conditions, such that diseases that were previously poorly investigated now feature regularly in research results and interventions in the country. Indeed, the systematic decline in the prevalence and reduction in the case-fatality of many local diseases in recent times can partly be attributed to better understanding of their epidemiology and new treatment regimens, propelled largely by repeated provision of evidence-based data provided by trainees and participants in post-graduate training programmes in the country.

The quality of postgraduate training in Nigeria has also reasonably been optimal. Especially during the earlier years of its establishment, there was no doubt that the quality of graduates in the programmes compared reasonably well with those from other parts of the world. It was for this reason that a program such as the FMCOG had reciprocity for part of its examinations with the Membership Examination of the Royal College of Obstetricians and Gynaecologists at the time. Post-graduate doctors who completed Primary Examinations of the FMCOG and the FWACS were exempted from the Part 1 MRCOG. Indeed, I was a beneficiary of this practice at the time! Additionally, reports indicated that candidates who completed their Part I examinations and were admitted into UK hospitals under the “Double Scholarship Scheme” performed excellently well, although many of such candidates have remained in the UK since then till now. The fact that two Nigerians who trained solely under the Nigerian postgraduate program were recently awarded Honorary FRCOG (ed aundem) (Professor Ekele and my humble self) by the Royal College of Obstetricians and Gynaecologists further testify to the quality and international acceptability of the Nigerian national training programs.

Challenges facing PME in Nigeria
Unfortunately, things have not always remained the same. There is evidence that the Nigerian and West African postgraduate training programs have not managed to sustain the reputation for quality and excellence that was achieved in earlier years. Not only has the “Double Sponsorship Scheme” been abated, there are reports indicating that the quality of clinical performance of specialists who trained primarily under the Nigerian program working in UK hospitals have declined over the years. Additionally, the poor attention paid to training of resident doctors in research has led to the debate of its relevance vis-à-vis PhDs and higher degrees offered by Nigerian Universities. The elements of this debate will be discussed later in this presentation. Furthermore, the almost non-participation of international trainees and trainers in the Nigerian training programs may be due to the fact that none of the Colleges or programs has yet been accredited by regional or international accreditation bodies.

Some of the challenges facing PME in Nigeria include the following:

• Poor funding. Although the National and West African Postgraduate Medical Colleges are parastatals of government, there is almost no dedicated budget for actual postgraduate training. Budgets provided are normally inclusive of salaries and overheads, but not much is dedicated to actual program implementation, teaching and research related to medical postgraduate training. The Tertiary Education Trust Fund (TETFUND) that provides funding for tertiary education in Nigeria does not include medical post-graduate training in their resource allocation, citing the non-inclusion of medical education in the law that established the Fund as reason for the exclusion. Teaching and tertiary hospitals under which PME is accommodated are funded by the Federal and State Ministries of Health or private proprietors, but often do not receive dedicated funding for postgraduate training. Thus, postgraduate training in Nigeria is almost left as an adhoc or passive service without the financial support to enable it gain the needed momentum. Indeed, it is my strongly held opinion that the recent call for the privatisation of teaching and tertiary hospitals will further de-activate PME in Nigeria.

• Informal status of PME in teaching hospitals. Unfortunately, the teaching hospitals in which PME are housed pay little or no attention to post-graduate training. Residents are treated as labourers and part-time workers, who are considered only for the clinical services they provide rather than agents to be trained to enhance improved work outputs. Some hospitals field offices such as “Directors of Postgraduate Training”, but the offices largely exist to curtail demands and excesses of resident doctors rather than to systematically support various elements in post-graduate training. Indeed, many hospitals do not have structured curricular for the training of residents. There are no didactic teaching schedules, while supervising Consultants are often too busy to conduct teaching rounds that are the time-honoured methods of training undergraduate and post-graduate students. And residents themselves are also too busy engaging in “extra-mural private practice” or planning the next round of strikes (lock-outs) to take their postgraduate training seriously.

Surely, there are lots to be written about the inadequacy and unpreparedness of teaching and tertiary hospitals to support post-graduate medical training in Nigeria. Many hospitals do not have dedicated seminar rooms, reading rooms, libraries or furnished offices for residents in training. The post-graduate learning environment is often not available in many hospitals, and support for research is non-existent. The structure of the present post-graduate medical training has weakened over the years, and would need to be rebuilt if PME in Nigeria is to rise to the next level of development.

• The non-involvement of universities in PME is a major problem. Universities have traditionally provided undergraduate medical education in Nigeria. Teaching hospitals were set up to provide clinical training to support the basic training offered by Universities and it was never intended that they would provide content training alone. Thus, the fact that PME is located solely within Teaching Hospitals without the inputs of Universities is an anomaly. This is further accentuated by the recognition that teaching hospitals and Universities are governed by two separate arms of government (Ministries of Education and Health), and results in post-graduate medical education located within Teaching Hospitals not benefitting from the involvement of Universities.

Involving Universities in PME is crucial in three ways. First, Universities have the required infrastructure for post-graduate training which would be useful for PME. Several Nigerian Universities have Schools of Postgraduate Studies with considerable experience in curriculum design and implementation in various fields of studies. Such a school can remove the burden of curricular planning, monitoring and review that Teaching Hospitals involved in PME have no experience to implement. Secondly, the fact that Universities often feature several disciplines means that their involvement in PME will enable medical doctors involved in PME to gain experience and exposure to other fields such as pedagogy, sociology and anthropology, statistics, public administration and law. Indeed, it is important that PME benefits from a multi-disciplinary approach since fellows trained under the programme are increasingly playing multiple roles not only in the country’s health sector, but in other fields of development as well. Finally, the involvement of Universities in PME will allow for internationalization of the training programmes as Universities provide the bedrock for postgraduate training in other parts of the world.

• Inadequate research component. PME is presently characterised by inadequate research training and low research outputs by its participants. Not only do participants not receive didactic or practical exposure in proposal writing, research methods, research design, biostatistics, computer-based learning and writing methodology, the actual outputs in terms of high quality publications that meet international standards are also limited. Although the development of a dissertation is one requirement for obtaining some of the fellowships, often the dissertations often are not purposefully designed, often depend on repetitive or retrospective data, and are not rigorous enough to enable publication in high ranking international journals. This is a challenge that needs to be overcome in efforts to improve the quality of PME in Nigeria.

• Poor monitoring and evaluation of training programmes and graduates. A major challenge facing PME in Nigeria is the lack of effective monitoring and assessment of trainees and trainers of the program. Some of the most innovative methods in teaching methodology include the integration of methods that assesses not only the students but also where students have the possibility to assess their teachers. To date, there are no known methods designed by the NPMC and the WAPMC to monitor the performance of the graduates from the programs, neither do they have an approach for assessing the teachers, trainers and even health institutions participating in the programs. Without such a system, it would be impossible for the training programs to do things differently in ways to consolidate their quality and attain regional and global relevance.

• Non-review of training curricular. Part of the weakness of PME in Nigeria includes the lack of review of training curricular by relevant Faculties. Although a lot of changes have taken place in PME internationally and in medical knowledge and skills in particular, not many changes have taken place in training curricular in this country over the last couple of years. Some attempts at revision of curricular have taken place, but this has not been radical or deep-seated enough to change the pattern of training or the orientation, knowledge and skills of trainees. Right from the beginning of the program, it has been “business as usual”, with new trainers being recruited who may not have had the required skills and knowledge to participate in training and in examinations. In particular, the training remain focussed on passing examinations without substantive efforts made to purposefully train the candidates to address the peculiar health challenges in the region.

• The lack of internationalisation of the local PME programs is a major challenge.
To date, many of the fellowship degrees offered under the NMPC and the WAPMC have not been accredited by international accreditation bodies, and this is an important challenge that needs to be addressed if our healthcare delivery system is to attain global standards. Nigeria’s health care system is presently ranked by the World Health Organization as one of the weakest (187/192) in the world, in part due to the low quality of its health services provision, propelled largely by specialists and consultants. If the country’s PME were to attain global stage in terms of its quality and propensity to adopt internationally accepted evidence-based standards and methodologies, it is possible that this will not only improve the health system, but will also enable the country to attain high global ranking in the provision of quality health services. Achieving global standards and internationalising postgraduate medical training must be one bench-mark that Nigeria’s PME must focus on in the immediate future.

The fellowships versus PhDs controversy
The PhD versus Fellowship controversy started in 2008 when the National Universities Commission (NUC) made it mandatory that all teachers in the University system must have a PhD in order to progress in the Nigerian University system. Before then, the same NUC working in collaboration with the NPMC and the WAPMC, and in view of the peculiar nature of the training of clinical teachers, had established that Fellowship degrees are equivalent to PhDs for the purpose of career progression in the Nigerian University system. Indeed, throughout the world, especially because postgraduate clinical training embraces the same number of years of training as PhD and may even be more intensive, fellowships are accepted for entry into the University system. There has never been such a controversy in other countries; why it exists in Nigeria is still not completely clear.

The controversy became more intense when attempts were made by some Universities to make it mandatory for applicants to the post of Vice-Chancellors to possess PhD degrees. This was extremely bizarre as it meant that although a person may have risen to the post of Professor in a clinical discipline and has obtained vast experience in University administration, but because he has not previously obtained a PhD, he may not rise to the highest position in the University system. This seemed a major inequity and unfairness, which many clinical teachers justifiably rose up to challenge. Today, it is well known that there are several non-clinical, non-PhD holders who have risen to the post of Vice-Chancellors, and there have equally been several clinical Fellows, non-PhD holders who have done well as Vice-Chancellors in the Nigerian University system. Thus, it is becoming increasingly evident that the effectiveness of a Vice-Chancellor does not depend on his possession of a PhD, and so this cannot be as an argument for prioritising PhDs over clinical postgraduate training for headship of Nigerian Universities.

The real issue seems to be whether Fellowships are as rigorous as PhDs to implement high quality research and supervise undergraduate and postgraduate students and junior faculties in the implementation of research, which is a major function of Universities. In many parts of the world, evidence has shown that Fellows are as good as PhD holders in the implementation and supervision of research. However, for the Nigerian system, one way to counter this element of the controversy is to strengthen the research training component of the fellowship training programs. A counter argument has been that even the quality of PhD training has also weakened in all disciplines in Nigeria due to inadequate facilities for research. So, no one should throw the first stone as there is a need to strengthen both fellowships and PhD training in all disciplines in the country.
One way to resolve this controversy is to integrate Fellowship training with PhD training. In many developed countries, many Fellows also have PhDs, which indeed puts such “double-barrel graduates” ahead of those who possess PhDs or Fellowship degrees alone. Such a solution is possible in Nigeria, and can easily be infused into the current postgraduate training program in the country.

PME in Nigeria: Looking Forward

Arising from the above analysis, there can be no doubt that strengthening postgraduate medical education in Nigeria would need to be prioritised if the country is to succeed in improving its health system and achieve better health outcomes. Some specific recommendations include the following:

• Postgraduate Medical Education in Nigeria would need to be extensively reviewed to enable it gain momentum to overcome some of the challenges listed above, and to deepen research and training in the medical sciences in the country. The present administration of President Muhammed Buhari would do well by constituting a high level committee to undertake this review within the shortest possible period of time. The NPMC might for example need to be upgraded to a University for Postgraduate Medical Education that would incorporate the principles of didactic learning and structured administration that are normative of University systems. Alternatively, a different approach that integrates the current system of hospital-based training to Universities that offer undergraduate medical education might be developed to strengthen the academic and multi-disciplinary learning components of PME.

• Increased funding of PME is crucial if the proposed benchmarks for gaining excellence and quality are to be attained. Increased funding of the NPMC and the WAPMC as presently constituted either by adequate federal budgetary allocations or through revision of the TETFUND law to enable the organization to also target postgraduate medical education for funding would be of great importance. It is instructive that while TETFUND funds students to undertake postgraduate medical training abroad, it does not fund the local postgraduate medical training programs within the country. This is an anomaly and an ambiguity that needs to be revised and corrected.

• There is also a need to extensively review all curricular for PME to enable them meet international accreditation standards. International accreditation agencies and similar postgraduate training institutions in other parts of the world should be engaged to participate in the curriculum review process.

• Training of trainers and examiners in PME is also now sorely needed. In particular, PME trainers should be trained and re-trained to use standard teaching and pedagogy methods, including ICT. Their capacity to mentor trainees should also be actively developed. Additionally, present examination procedures need to be overhauled in both Colleges to include the assessment of candidates in relevant knowledge and skills that promote the uptake of the most recent interventions in health care. In particular, examination methods should be structured to elicit the ability of candidates to be innovative and inquisitive, and must include the assessment of research results. Such research must be novel or nearly novel, must be purposefully designed, and must rely on use of research methods that were led or nearly led by the candidates.

• One of the revisions that ought to be made to PME in Nigeria is to make it possible for candidates to obtain both the Fellowship as well as the PhD degrees before they complete their training. One way to do this is first to ensure that entrance into PME is through a formal admission process into a University designated for the purpose. That means that all present Teaching Hospitals accredited for postgraduate training should be linked to Universities that offer undergraduate courses in medicine. Candidates so admitted into PME will undergo a six months to one year pre-clinical training in basic sciences, including research methods, public health, biostatistics and ICT, after which they will take the first examination (presently called Primary Examination). Those who pass the Primary Examination will then be admitted into the clinical training (intermediate) part of the program. This will include building the advanced knowledge and skills of candidates in critical clinical care, while at the same time training them to be critical and skilled in using the research principles and skills they learned in their pre-clinical basic sciences training to develop research in the clinical disciplines. The intermediate training should normally not last more than two to three years, following which candidates will undertake the Part 1 Clinical examination. Those who pass the Part 1 examination will then progress to the Part II and final part of the training. Part II training will focus on defence and implementation of a research proposal with submission of a thesis (as done for PhDs) in the discipline or in a related discipline. The supervisors would include both a clinical specialist, but also someone with a PhD working in a related discipline. The idea is that once the candidate is adjudged as passing the PhD thesis, he/she will be exempted from the Fellowship examination and will be immediately be awarded the Fellowship degree. Thus, final outputs will be both PhD and fellowship degrees for entrants into such a program. A major feature of this pattern of training will be for the candidate to registered for an MSc or/and PhD degrees training at some point during their entrance into the program, and to pursue them simultaneously. Figure 3 illustrates the suggested template for this integration.

• Going forward, monitoring, objective assessment and evaluation should feature prominently in the implementation of PME in the country. Thus, properly designed Monitoring and Evaluation frameworks should be developed along with process and outcome indicators. Reports on the agreed indicators should be provided periodically both at the institutional as well as national level as ways to measure the quality of implementation and level of success of the programs. This will allow adequate corrective measures to be put in place, and therefore allow the systemic growth and development of PME in Nigeria.

Conclusions
There can be no doubt that PME has gained considerable momentum and ascendancy in Nigeria. However, the quality of its development has not matched the enthusiasm with which it was begun several years ago. This lecture is a befitting tribute to our hero, mentor and benefactor, who with several of his colleagues championed the development and implementation of PME in Nigeria in the 1970s. The assessment undertaken in this paper suggests that while the main purposes of PME have largely been achieved in Nigeria, a lot remains to be done in propelling it beyond its original vision to enable it compare favourably with similar medical postgraduate training programs in other parts of the world. One of the greatest attributes and respects that can be paid to national icons and visionaries like Professor Linus Ajabor is to ensure that the program which they so elegantly conceived and implemented in the earlier days, grow from strength to strength and exceed their expectations and projections in terms of the quality of its outputs and impact. This lecture is therefore a call for action for all stakeholders to do everything possible and with great determination and commitment to propel the fortunes of postgraduate medical training in Nigeria.

• Professor Okonofua, the vice-chancellor, University of Medical Sciences, Ondo, Ondo State, delivered this lecture in honour of Professor L.N Ajabor (JP, FRCOG, OON, Hon DSc.)
under the Series on Frontiers In Medical Education at the International Conference of the Society of Gynaecology and Obstetrics (SOGON) in November 2015.